Formative - Developmental

ATTACHMENT B.3.6 EXEMPLAR DEMOGRAPHIC AND HEALTH SURVEY OMB #: 0925-0593

LOI3-QUEX-01 EXPIRATION DATE: 07/31/2013

STUDY ID NUMBER: __________

DATE OF INTERVIEW: __________

INTERVIEWER’S INITIALS: __________

DATE OF DATA ENTRY: __________

Measurement of Maternal Life Experience Study

Demographics Survey

INTERVIEWER: I would like to start by asking you some questions about yourself. Please open the binder and turn to Card 1. As you answer these questions, I will indicate when you need to turn the page to the next card to find answer choices to the question I am asking. Please remember that if, at any time, you feel uncomfortable answering a question, you may decline to answer.

1. Are you currently:

1…….Single

2…….Married

3…….Widowed

4…….Divorced

5…….Separated

Do not know/Refused

INTERVIEWER: Please turn to Card 2.

2. Do you currently have a spouse or partner?

1…….Yes (Continue to Q3)

2…….No (Skip to Q5)

Do not know/Refused

3. IF YES: Does this spouse or partner currently live with you in your home?

1…….Yes

2…….No

Do not know/Refused

4. IF YES: Is your current spouse/partner the father of your baby?

1…….Yes

2…….No

Do not know/Refused

INTERVIEWER: Please turn to Card 3.

5. What is the highest level of formal education you have completed? How far did you go in school?

1.....None

2……Primary, Elementary, or Middle School

3……High School or GED

4……Technical or Vocational School

5……Some College, but no degree (Number of years ___)

6……Associate’s Degree

7……Bachelor’s Degree

8……Graduate Degree (Masters, Doctorate, Medical, Law)

9……Certificate (Specify: ______________________________)

10….Other (Specify: __________________________________)

Do not know/Refused

INTERVIEWER: Please turn to Card 4.

6. Are you currently working at a paid full or part time job?

1…….Yes (Continue to Q7)

2…….No (Skip to Q23)

Do not know/Refused (Skip to Q23)

7. About how many hours per week do you usually work for pay? ____ hours per week

Do not know/Refused

INTERVIEWER: Please turn to Card 5.

8. I’ll show you a list of industries where people often work; which one category fits your work the best?

Retail & Retail Trade

1…….Retail

2…….Wholesale

Services

3…….Educational Services

4…….Health Care and Social Assistance

5…….Accommodation and Food Services

6…….Private Household Services

7…….Personal Services except Private Household

8…….Information

9…….Professional, Scientific, and Technical Services

10…..Administrative and Support Services

11……Other Services (except Public Administration)

Other

12…….Public Administration

13…….Finance and Insurance

14…….Real Estate and Rental and Leasing

15…….Manufacturing

16…….Arts, Entertainment, and Recreation

17…….Management of Companies and Enterprises

18…….Agriculture, Forestry, Fishing, and Hunting

19…….Mining

20…….Utilities

21…….Construction

22…….Transportation and Warehousing

23…….Waste Management and Remediation Services

Do not know/Refused

INTERVIEWER: I am going to read you a set of statements concerning your attitudes and beliefs about your work activities. Please indicate how much you disagree or agree with each statement using the following responses. 1 = Strongly Disagree; 2 = Disagree; 3 = Agree; 4 = Strongly Agree. Please turn to Card 6.

9. What is your job title? ________________________________________

Do not know/Refused

	Strongly Disagree	Disagree	Agree	Strongly Agree	Do Not Know/ Refused
My job requires a lot of repetitive work.	1	2	3	4
My job requires me to be creative.	1	2	3	4
I have very little freedom to decide how I do my work.	1	2	3	4
I have a lot of say about what happens on my job.	1	2	3	4
I have an opportunity to develop my own special abilities.	1	2	3	4
My job requires my undivided attention.	1	2	3	4
My job requires working very hard.	1	2	3	4
I have enough time to get the job done.	1	2	3	4
I am free from conflicting demands that others make.	1	2	3	4
My coworkers are friendly.	1	2	3	4
My coworkers are helpful in getting the job done.	1	2	3	4
My supervisor is concerned about the welfare of those under him or her.	1	2	3	4
My supervisor pays attention to what I’m saying.	1	2	3	4

INTERVIEWER: Please turn to Card 7.

23. Was the total income for all people in your household last year:

1…….Below $15,000

2…….$15,000 - $29,999

3…….$30,000 – $49,999

4…….$50,000 – $100,000

5…….Over $100,000

Do not know/Refused

INTERVIEWER: Please turn to Card 8.

Highest Standing

24. Where do you stand in your community? Think of this ladder as representing where people stand in their communities. People define community in different ways; please define it in whatever way is most meaningful to you. At the top of the ladder are the people who have the highest standing in their community. At the bottom are the people who have the lowest standing in their community. Where would you place yourself on this ladder?

Rung A

Rung B

Rung C

Rung D

Rung E

Rung F

Rung G

Rung H

Rung I

Rung J

Lowest Standing

Do not know/Refused

INTERVIEWER: Please turn to Card 9.

25. Where do you stand in the United States? Think of this ladder as representing where people stand in the United States. At the top of the ladder are the people who are best off – those who have the most money, the most education, and the most respected jobs. At the bottom are the people who are the worst off – who have the least money, the least education, and the least respected jobs or no job. The higher up you are on this ladder, the closer you are to the people at the very top; the lower you are, the closer you are to the people at the very bottom. Where would you place yourself on this ladder?

Best Off

Rung A

Rung B

Rung C

Rung D

Rung E

Rung F

Rung G

Rung H

Rung I

Rung J

Worst Off

Do not know/Refused

INTERVIEWER: Please turn to Card 10.

26. Are you currently covered by health insurance, including public aid?

1…….Yes (Skip to Q28)

2…….No (Continue to Q27)

Do not know/Refused (Continue to Q27)

27. IF NO: During the past 12 months, have you been covered at any time by any kind of health insurance, including public aid?

1…….Yes (Continue to Q28)

2…….No (Skip to Q29)

Do not know/Refused (Skip to Q29)

INTERVIEWER: Please turn to Card 11.

28. IF YES: During the past 12 months, what best describes the kind of health insurance or healthcare coverage you had?

1…….Private Health Insurance

2…….Medicare / Medicaid

3…….Other (Specify: ________________________)

Do not know/Refused

How many people live in your house, including yourself?

29. Children under 18 ___________

Do not know/Refused

30. Adults 18 and over __________

Do not know/Refused

31. How many bedrooms are there in your house? ________ bedrooms

Do not know/Refused

INTERVIEWER: Please turn to Card 12.

31. Were you born in the United States?

1…….Yes (Skip to Q35)

2…….No (Continue to Q33)

Do not know/Refused (Skip to Q35)

31. IF NO: How long have you lived in the United States? ________ years

Do not know/Refused

31. IF NO: What is your country of birth? __________________

Do not know/Refused

INTERVIEWER: I am now going to ask you some questions regarding how you typically identify yourself in terms of your ethnicity and your race. Ethnicity and race are two separate issues, so try to answer each question independently. Please turn to Card 13.

31. How would you best describe your ethnicity? Please select one of the following two choices.

1……. Of Hispanic, Latino, or Spanish origin

(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race).

2……..Not of Hispanic, Latino, or Spanish origin

Do not know/Refused

INTERVIEWER: Please turn to Card 14.

31. How would you best describe your race? Please select one or more of the following five choices. Select all that apply.

1…… American Indian or Alaska Native

(A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliations or community attachment).

2…….Asian

(A person having origins in any of the original peoples of Far East, Southwest Asia, or the Indian subcontinent including: Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam).

3…….Black or African American

(A person having origins in any of the black racial groups of Africa).

4…….Native Hawaiian or Other Pacific Islander

(A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands).

5…….White

(A person having origins in any of the original peoples of Europe, the Middle East, or North Africa).

Do not know/Refused

INTERVIEWER: Please turn to Card 15.

31. How would the baby’s biological father best describe his ethnicity? Please select one of the following two choices.

1……. Of Hispanic, Latino, or Spanish origin

(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race).

2……..Not of Hispanic, Latino, or Spanish origin

Do not know/Refused

INTERVIEWER: Please turn to Card 16.

31. How would the baby’s biological father best describe his race? Please select one or more of the following five choices. Select all that apply.

1…… American Indian or Alaska Native

(A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliations or community attachment).

2…….Asian

(A person having origins in any of the original peoples of Far East, Southwest Asia, or the Indian subcontinent including: Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam).

3…….Black or African American

(A person having origins in any of the black racial groups of Africa).

4…….Native Hawaiian or Other Pacific Islander

(A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands).

5…….White

(A person having origins in any of the original peoples of Europe, the Middle East, or North Africa).

Do not know/Refused

INTERVIEWER: Please turn to Card 17.

31. Is English the main language spoken in your home?

1…….Yes

2…….No

Do not know/Refused

INTERVIEWER: The next set of questions is about health history. I will ask you whether you or your partner has a history of these conditions, and whether someone in your immediate family (grandparents, parents, siblings, and children) or your partner’s immediate family have the following medical conditions. Please turn to Card 18.

Medical Condition	Occurrence?			Yourself	Your Partner	Your Immediate Family	Your Partner's Immediate Family
	Yes	No	Do Not Know/ Refused
Autoimmune Disorders	1	2		1	2	3	4
41. Cancer	1	2		1	2	3	4
42. Clotting Disorders	1	2		1	2	3	4
43. Diabetes: Type I or II	1	2		1	2	3	4
44. Epilepsy	1	2		1	2	3	4
45. Heart Disease	1	2		1	2	3	4
46. Hypertension	1	2		1	2	3	4
47. Kidney Disease	1	2		1	2	3	4
48. Liver Disease	1	2		1	2	3	4
49. Polycystic Ovarian Syndrome	1	2		1	2	3	4
50. Psychological Disorders	1	2		1	2	3	4
51. Stroke	1	2		1	2	3	4
52. Thyroid Dysfunction	1	2		1	2	3	4

INTERVIEWER: I am now going to ask you some questions regarding your pregnancy history. Please turn to Card 19.

53. How did you become pregnant?

1……..Natural

2……..Assisted Reproductive Technology (ovulation induction, in vitro fertilization, intracytoplasmic sperm injection, donor sperm, donor egg)

Do not know/Refused

INTERVIEWER: Please turn to Card 20.

53. Thinking back to the twelve months just before you found out that you were pregnant this time, were you or your partner using any contraceptives, or practicing any preventative measures so you would not get pregnant?

1………Yes

2………No

Do not know/Refused

53. Including this pregnancy, how many times have you been pregnant (include miscarriage, stillbirth, etc)? ­____­

Do not know/Refused

53. How many times have you given live birth? (IF 0: Skip to Q67)____________

Do not know/Refused

53. Birth weights of prior children (lbs., oz.):

1	2	3	4	5	6	7

Do not know/Refused

53. Have any of your children died?

1…….Yes (Continue to Q59)

2…….No (Skip to Q60)

Do not know/Refused (Skip to Q60)

53. IF YES: Why did your child(ren) die? Record Reasons.

Reason Date of Birth Month/Day/Year

Child #1 / /

Child #2 / /

Child #3 / /

Child #4 / /

Do not know/Refused

(IF ALL CHILDREN DIED, SKIP TO Q61)

53. How old are your children? Record age and date of birth.

Age Month/Day/Year

Child #1 / /

Child #2 / /

Child #3 / /

Child #4 / /

Child #5 / /

Child #6 / /

Child #7 / /

Child #8 / /

Do not know/Refused

53. How many of your pregnancies delivered before 20 weeks of gestation? _____

Do not know/Refused

53. Thinking only of your live births, how many of your babies were born full term? By full term, we mean at 37 weeks of pregnancy or after. ________________

Do not know/Refused

53. Again, thinking only of your live births, were any of your babies born too early or too soon? By too soon, we mean before 37 weeks of pregnancy. (Do not count miscarriages (delivery before 20 weeks) or stillbirths).

1…….Yes (Continue to Q64)

2…….No (Skip to Q67)

Do not know/Refused (Skip to Q67)

53. Did a doctor or nurse tell you that any of these early births were caused by preterm labor or by early rupture of membranes - your bag of water broke too early?

1…….Yes

2…….No

Do not know/Refused

53. Did a doctor or nurse tell you that your baby had to be delivered early by induction of labor or scheduled cesarean delivery because of a problem with you or the baby?

1…….Yes (Continue to Q66)

2…….No (Skip to Q67)

Do not know/Refused (Skip to Q67)

INTERVIEWER: Please turn to Card 21.

53. IF YES: What was the reason a doctor or nurse told you your baby had to be delivered early?

1…..Preeclampsia

2…..Growth Restriction/Problems with Growth

3…..Other (Specify: _____________________)

Do not know/Refused

INTERVIEWER: I am now going to ask you some questions about your personal habits regarding physical activity and diet. Remember that your answers are not linked to your name. Please turn to Card 22.

53. Do you currently do any type of regular exercise to keep in shape?

1…….Yes

2…….No

Do not know/Refused

INTERVIEWER: Please turn to Card 23.

53. In a typical day, how many servings of fruit do you eat?

A serving is equal to:

• 1 small piece of fresh fruit - about the size of a tennis ball

• ½ cup of cut fruit

• ¼ cup of raisins, apricots, or other dried fruit

• ½ cup of 100% orange, apple, or grapefruit juice

*Do NOT count fruit punch, lemonade, Gatorade, Sunny Delight, or fruit drinks

1………None

2........1 serving

3..…....2 servings

4……….3 servings

5……….4 or more servings

Do not know/Refused

INTERVIEWER: Please turn to Card 24.

53. In a typical day, how many servings of vegetables do you eat?

A serving is equal to:

• 1 medium carrot or other fresh vegetable

• 1 cup of green salad

• 1 cup of raw or ½ cup cooked vegetables

• ½ cup of vegetable juice

*Do NOT count french fries, onion rings, potato chips, or fried okra

1……….None

2.........1 serving

3..……..2 servings

4………..3 servings

5………..4 or more servings

Do not know/Refused

INTERVIEWER: Please turn to Card 25.

53. In a typical day, how many servings of dairy - milk, cheese, soy, and yogurt - do you eat?

A serving is equal to:

• 1 cup of milk or soy milk

• 1 slice of cheese

• 1 cup of yogurt

1………None

2........1 serving

3..…….2 servings

4……….3 servings

5……….4 or more servings

Do not know/Refused

INTERVIEWER: Please turn to Card 26.

53. In a typical month, how many servings of fish do you eat?

A serving is equal to:

• 3 oz. of cooked fish - the size of a deck of cards or the palm of your hand

1…….None

2…….1 serving

3…….2 servings

4…….3 servings

5…….4 or more servings

INTERVIEWER: I am now going to ask you some questions about your neighborhood. Please turn to Card 27.

Do not know/Refused

53. How satisfied are you with your neighborhood? Would you say you are:

1…….Very Dissatisfied

2…….Dissatisfied

3…….Satisfied

4…….Very Satisfied

Do not know/Refused

INTERVIEWER: Please turn to Card 28.

How would you rate your neighborhood on the following items? Please use these responses: Bad (1) Not So Good (2) Good (3) Very Good (4)

(Do Not Know/Refused (88))

53. Overall____

54. Police protection_____

55. Safety of property_____

56. Personal safety_____

57. Friendliness______

58. Delivery of city services (garbage pick-up, road repair, etc.)____

59. Cleanliness_____

60. Quietness_____

61. Schools______

INTERVIEWER: To provide the most accurate information, it is important to know as much as possible about your pregnancy. In this section, we are going to ask about your use of vitamins and supplements, prescription medications, over-the-counter medications, caffeinated beverages, alcohol, tobacco, and recreational drugs. First, we will ask if you have used any of these items in the 3 months prior to becoming pregnant. Then, we will ask if you have used any of these items since you became pregnant. For you, 3 months before you became pregnant covers the time period from _______ to _______ (CALCULATE FOR THE PARTICIPANT). Please turn to Card 29.

53. In the 3 months before you became pregnant, did you take any vitamins, vitamin supplements, or herbal preparations?

1…….Yes (Continue to Q83)

2…….No (Skip to Q86)

Did you take…	Medication taken?			How Often?				What was the dosage?
	Yes	No	Do Not Know/ Refused	Everyday	A Few Days a Week	A Few Days a Month	Less than Once a Month
General Multi-Vitamins	1	2		1	2	3	4
Supplements (Vitamin D, Fish Oil, etc.)	1	2		1	2	3	4
Herbal Preparations (St. John's Wort)	1	2		1	2	3	4

INTERVIEWER: Please turn to Card 30.

53. Are you currently taking a daily prenatal vitamin or folic acid supplement?

1…….Yes (Continue to Q87)

2…….No (Skip to Q88)

Do not know/Refused (Skip to Q88)

INTERVIEWER: Please turn to Card 31.

53. IF YES: When did you start taking them?

1…….After you found out that you were pregnant

2…….Less than 1 month before you got pregnant

3…….1-3 months before you got pregnant 

4…….3-6 months before you got pregnant

5…….Greater than 6 months before you got pregnant

Do not know/Refused

INTERVIEWER: Please turn to Card 32.

53. In the 3 months before you became pregnant, did you take any prescription medications?

1…….Yes (Continue to Q89)

2…….No (Skip to Q102)

Did you take…	Medication taken?			How Often?				What was the dosage?
	Yes	No	Do Not Know/ Refused	Everyday	A Few Days a Week	A Few Days a Month	Less than Once a Month
Medication for Anxiety/Depression	1	2		1	2	3	4
Medication for Sleep	1	2		1	2	3	4
Medication for Indigestion/ Heartburn	1	2		1	2	3	4
Medication for Asthma	1	2		1	2	3	4
Antibiotics	1	2		1	2	3	4
Medication for Severe Headaches/ Migraines	1	2		1	2	3	4
Medication for Blood Sugar	1	2		1	2	3	4
Medication for Blood Pressure	1	2		1	2	3	4
Medication for Fertility (clomid, letrasol)	1	2		1	2	3	4
Other	1	2		1	2	3	4
Other	1	2		1	2	3	4
Other	1	2		1	2	3	4
Other	1	2		1	2	3	4

INTERVIEWER: Please turn to Card 33.

53. In the 3 months before you became pregnant, did you take any over-the-

counter medications?

1…….Yes (Continue to Q103)

2…….No (Skip to Q112)

Did you take…	Medication taken?			How Often?				What was the dosage?
	Yes	No	Do Not Know/ Refused	Everyday	A Few Days a Week	A Few Days a Month	Less than Once a Month
Ibuprofen (Advil, Motrin)	1	2		1	2	3	4
Tylenol (Acetaminophen)	1	2		1	2	3	4
Medication for Allergies/Cold/ Decongestants	1	2		1	2	3	4
Medication for Indigestion/Heartburn (Pepcid/Zantac)	1	2		1	2	3	4
Medication for Sleep (Unisom, Tylenol PM)	1	2		1	2	3	4
Other	1	2		1	2	3	4
Other	1	2		1	2	3	4
Other	1	2		1	2	3	4
Other	1	2		1	2	3	4

INTERVIEWER: Please turn to Card 34.

53. In the 3 months before you became pregnant, did you drink caffeinated

beverages and/or alcohol?

1…….Yes (Continue to Q113)

2…….No (Skip to Q116)

Did you drink...	Did participant drink?			How Often?
	Yes	No	Do Not Know/ Refused	Everyday	A Few Days a Week	A Few Days a Month	Less than Once a Month
Caffeinated Beverages	1	2		1	2	3	4
Energy Drinks	1	2		1	2	3	4
Alcohol	1	2		1	2	3	4

INTERVIEWER: Please turn to Card 35.

53. In the 3 months before you became pregnant, did you use any nicotine products

such as cigarettes, cigars, smokeless tobacco, or nicotine replacements like a patch, gum, or spray?

1…….Yes (Continue to Q117)

2…….No (Skip to Q121)

Did you use…	Used?			How Often?
	Yes	No	Do Not Know/ Refused	Everyday	A Few Days a Week	A Few Days a Month	Less than Once a Month
Cigarettes	1	2		1	2	3	4
Cigars	1	2		1	2	3	4
Smokeless Tobacco	1	2		1	2	3	4
Nicotine Replacement (patch, gum, spray)	1	2		1	2	3	4

INTERVIEWER: Please turn to Card 36.

53. In the 3 months before you became pregnant, did you use recreational drugs

such as marijuana, cocaine, or heroin?

1…….Yes (Continue to Q122)

2…….No (Skip to Q127)

Did you use…	Used?			How Often?
	Yes	No	Do Not Know/ Refused	Everyday	A Few Days a Week	A Few Days a Month	Less than Once a Month
Marijuana	1	2		1	2	3	4
Cocaine	1	2		1	2	3	4
Heroin	1	2		1	2	3	4
Other	1	2		1	2	3	4
Other	1	2		1	2	3	4

INTERVIEWER: Now, let’s go over the same items since you became pregnant. This covers the time period from ________ onward. (CALCULATE FOR THE PARTICIPANT) Please turn back to Card 29.

53. During your pregnancy, have you taken any vitamins, vitamin supplements, or

herbal preparations?

1…….Yes (Continue to Q128)

2…….No (Skip to Q131)

Have you taken…	Medication taken?			How Often?				Start Date?	End Date?	What is the dosage?
	Yes	No	Do Not Know/ Refused	Everyday	A Few Days a Week	A Few Days a Month	Less than a Month
General Multi-Vitamins	1	2		1	2	3	4
Supplements (Vitamin D, Fish Oil, etc.)	1	2		1	2	3	4
Herbal Preparations (St. John's Wort)	1	2		1	2	3	4

INTERVIEWER: Please turn to Card 32.

53. During your pregnancy, have you taken any prescription medications?

1…….Yes (Continue to Q132)

2…….No (Skip to Q145)

Have you taken…	Medication taken?			How Often?				Start Date?	End Date?	What is the dosage?
	Yes	No	Do Not Know/ Refused	Everyday	A Few Days a Week	A Few Days a Month	Less than Once a Month
Medication for Anxiety/Depression	1	2		1	2	3	4
Medication for Sleep	1	2		1	2	3	4
Medication for Indigestion/ Heartburn	1	2		1	2	3	4
Medication for Asthma	1	2		1	2	3	4
Antibiotics	1	2		1	2	3	4
Medication for Severe Headaches/ Migraines	1	2		1	2	3	4
Medication for Blood Sugar	1	2		1	2	3	4
Medication for Blood Pressure	1	2		1	2	3	4
Medication for Fertility (clomid, letrasol)	1	2		1	2	3	4
Other	1	2		1	2	3	4
Other	1	2		1	2	3	4
Other	1	2		1	2	3	4
Other	1	2		1	2	3	4

INTERVIEWER: Please turn to Card 33.

53. During your pregnancy, have you taken any over-the-counter medications?

1…….Yes (Continue to Q146)

2…….No (Skip to Q155)

Have you taken…	Medication taken?			How Often?				Start Date?	End Date?	What is the dosage?
	Yes	No	Do Not Know/ Refused	Everyday	A Few Days a Week	A Few Days a Month	Less than Once a Month
Ibuprofen (Advil, Motrin)	1	2		1	2	3	4
Tylenol (Acetaminophen)	1	2		1	2	3	4
Medication for Allergies/Cold/ Decongestants	1	2		1	2	3	4
Medication for Indigestion/ Heartburn (Pepcid/Zantac)	1	2		1	2	3	4
Medication for Sleep (Unisom, Tylenol PM)	1	2		1	2	3	4
Other	1	2		1	2	3	4
Other	1	2		1	2	3	4
Other	1	2		1	2	3	4
Other	1	2		1	2	3	4

INTERVIEWER: Please turn to Card 34.

53. During your pregnancy, have you consumed caffeinated beverages and/or

alcohol?

1…….Yes (Continue to Q156)

2…….No (Skip to Q159)

Have you consumed...	Consumed?			How Often?				Start Date?	End Date?
	Yes	No	Do Not Know/ Refused	Everyday	A Few Days a Week	A Few Days a Month	Less than Once a Month
Caffeinated Beverages	1	2		1	2	3	4
Energy Drinks	1	2		1	2	3	4
Alcohol	1	2		1	2	3	4

INTERVIEWER: Please turn to Card 35.

53. During your pregnancy, have you used any nicotine products such as

cigarettes, cigars, smokeless tobacco, or nicotine replacements like a patch,

gum, or a spray?

1…….Yes (Continue to Q160)

2…….No (Skip to Q164)

Have you used…	Used?			How Often?				Start Date?	End Date?
	Yes	No	Do Not Know/ Refused	Everyday	A Few Days a Week	A Few Days a Month	Less than Once a Month
Cigarettes	1	2		1	2	3	4
Cigars	1	2		1	2	3	4
Smokeless Tobacco	1	2		1	2	3	4
Nicotine Replacement (patch, gum, spray)	1	2		1	2	3	4

INTERVIEWER: Please turn to Card 37.

53. Does anyone in your household smoke?

1…….Yes (Continue to Q165)

2…….No (Skip to Q166)

Do not know/Refused

53. IF YES: Are you routinely exposed?

1…….Yes

2…….No

Do not know/Refused

INTERVIEWER: Please turn back to Card 36.

53. During your pregnancy, have you used recreational drugs such as marijuana,

cocaine or heroin?

1…….Yes (Continue to Q167)

2…….No (End Survey)

Have you used…	Used?			How Often?				Start Date?	End Date?
	Yes	No	Do Not Know/ Refused	Everyday	A Few Days a Week	A Few Days a Month	Less than Once a Month
Marijuana	1	2		1	2	3	4
Cocaine	1	2		1	2	3	4
Heroin	1	2		1	2	3	4
Other	1	2		1	2	3	4
Other	1	2		1	2	3	4

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address.