ATTACHMENT B.3.7 EXEMPLAR VISIT 1 STRESS QUESTIONNAIRE 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
Visit 1 Stress Survey
Self-Esteem, Mastery, Optimism (Rosenberg)
INTERVIEWER:
I am going to read a number of statements that people sometimes use
to describe themselves, or the way they think about themselves.
After I read each statement to you, please select the number that
best describes the extent to which you disagree or agree with each
item. Please turn to Card 1 of the Stress Survey Response Cards.
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Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
Do Not Know/ Refused |
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INTERVIEWER:
Now I am going to ask you about the various kinds of support, or
help from others, that is available to you. For this section,
please think about the time since
you became pregnant.
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INTERVIEWER:
People sometimes look to others for companionship, assistance, or
other types of support. Please tell me how often each of the
following kinds of support has been available to you if you needed
it. Remember to think about how you have felt since
you became
pregnant.
Please turn to Card 2.
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A Little of the Time |
Some of the Time |
Most of the Time |
All of the Time |
Do Not Know/ Refused |
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Social Problems Questionnaire
INTERVIEWER:
In this section, I will ask you some questions about general issues
related to your current housing, work, finances, social contacts,
and domestic life. Please turn to Card 3 and select the most
appropriate answer for each question.
1…….Adequate 2…….Slightly Inadequate 3…….Moderately Inadequate 4…….Severely Inadequate Do not know/Refused
INTERVIEWER: Please turn to Card 4. |
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1…….Satisfied 2…….Slightly Dissatisfied 3…….Moderately Dissatisfied 4…….Severely Dissatisfied Do not know/Refused |
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1……..Yes (Skip to Q5) 2……..No (Continue to Q4) Do not know/Refused
1……Satisfied 2……Slightly Dissatisfied 3……Moderately Dissatisfied 4……Severely Dissatisfied Do not know/Refused |
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(AFTER PARTICIPANT ANSWERS Q4, SKIP TO Q7)
1…….Satisfied 2…….Slightly Dissatisfied 3…….Moderately Dissatisfied 4…….Severely Dissatisfied Do not know/Refused
INTERVIEWER: Please turn to Card 5.
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1……None 2……Slight Problems 3……Many Problems 4……Severe Problems Do not know/Refused |
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INTERVIEWER: Please turn to Card 6.
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1……Adequate 2……Slightly Inadequate 3……Moderately Inadequate 4……Severely Inadequate Do not know/Refused
INTERVIEWER: Please turn to Card 7.
1……None 2……Slight Difficulties 3……Many Difficulties 4……Severe Difficulties Do not know/Refused |
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INTERVIEWER: Please turn to Card 8.
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1……Satisfied 2……Slightly Dissatisfied 3……Moderately Dissatisfied 4……Severely Dissatisfied Do not know/Refused |
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1……Satisfied 2……Slightly Dissatisfied 3……Moderately Dissatisfied 4……Severely Dissatisfied Do not know/Refused
INTERVIEWER: Please turn to Card 9.
1……None 2……Slight Difficulties 3……Many Difficulties 4……Severe Difficulties Do not know/Refused
1……None 2……Slight Difficulties 3……Many Difficulties 4……Severe Difficulties Do not know/Refused
INTERVIEWER: Please turn to Card 10.
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1……Satisfied 2……Slightly Dissatisfied 3……Moderately Dissatisfied 4……Severely Dissatisfied Do not know/Refused
INTERVIEWER: Please turn to Card 11.
1……None 2……Slight Difficulties 3……Many Difficulties 4……Severe Difficulties Do not know/Refused
INTERVIEWER: Please turn to Card 12.
1……Satisfied 2……Slightly Dissatisfied 3……Moderately Dissatisfied 4……Severely Dissatisfied Do not know/Refused |
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1…….Yes (Continue to Q17) 2…….No (Skip to Q22) Do not know/Refused |
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INTERVIEWER: Please turn to Card 13.
1…..None 2…..Slight Difficulties 3…..Many Difficulties 4…..Severe Difficulties Do not know/Refused |
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INTERVIEWER: Please turn to Card 14.
1……None 2……Slight Problems 3……Many Problems 4……Severe Problems Do not know/Refused |
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1……None 2……Slight Problems 3……Many Problems 4……Severe Problems Do not know/Refused |
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INTERVIEWER: Please turn to Card 15.
1……Satisfied 2……Slightly Dissatisfied 3……Moderately Dissatisfied 4…....Severely Dissatisfied Do not know/Refused
INTERVIEWER: Please turn to Card 16.
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1…..No 2…..Sometimes 3…..Often 4…..Yes Do not know/Refused |
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1……Yes (Continue to Q23) 2……No (Skip to Q26) Do not know/Refused |
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INTERVIEWER: Please turn to Card 17.
1……None 2……Slight Difficulties 3……Many Difficulties 4……Severe Difficulties Do not know/Refused
INTERVIEWER: Please turn to Card 18.
1……Satisfied 2……Slightly Dissatisfied 3……Moderately Dissatisfied 4…....Severely Dissatisfied Do not know/Refused
INTERVIEWER: Please turn to Card 19.
1……None 2……Slight Problems 3……Many Problems 4……Severe Problems Do not know/Refused
INTERVIEWER: To some women, certain aspects of pregnancy are uncomfortable or upsetting, although other women may not be bothered by the same things. Please indicate your own feelings about each statement. Please turn to Card 23.
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Not at All |
A Little |
Moderately |
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Extremely |
Do Not Know/ Refused |
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CES-D Scale (Radloff)
INTERVIEWER:
I am going to read a list of the ways you might feel. For each
description that I read to you, please tell me how often you have
felt this way during the past 2
weeks—the
past 14 days. Please turn to Card 24.
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Rarely or None of the Time |
Some or a Little of the Time |
Occasionally or a Moderate Amount of the Time |
Most or All of the Time |
Do Not Know/ Refused |
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Perceived Stress Scale
INTERVIEWER:
Now I am going to ask about your feelings or thoughts regarding
problems or difficulties that may have occurred during the past
month. In each
case, you will be asked to indicate how often you felt or thought a
certain way. Please turn to Card 25.
During the past month… |
Never |
Almost Never |
Sometimes |
Fairly Often |
Very Often |
Do Not Know/ Refused |
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INTERVIEWER:
The following questions relate to your usual sleep habits during
the past month
only. Your
answers should describe your average sleep habits for the days and
nights of the past
month.
When have you usually gone to bed? __________________________
Do not know/Refused
How long (in minutes) has it taken you to fall asleep each night? __________________________
Do not know/Refused
When have you usually gotten up in the morning? _________________________
Do not know/Refused
How many hours of actual sleep did you usually get? (This may be different than the number of hours you spent in bed) _______________________
Do not know/Refused
INTERVIEWER:
Please turn to Card 26. During the past month, how often have you
had trouble sleeping because you…
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Not During Past Month |
Less than Once a Week |
Once or Twice a Week |
Three or More Times a Week |
Do Not Know/ Refused |
5. Cannot get to sleep within 30 minutes. |
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6. Wake up in the middle of the night or early morning. |
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INTERVIEWER: Please turn to Card 27.
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Very Good |
Fairly Good |
Fairly Bad |
Very Bad |
Do Not Know/ Refused |
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Questions about Your Childhood
INTERVIEWER: This set of questions asks you about certain things related to your childhood and your family’s resources when you were a child. By childhood, we mean age 16 and younger. Please turn to Card 28.
When you were growing up, did you get regular medical check-ups?
1…….Yes
2…….No
Do not know/Refused
INTERVIEWER: Please turn to Card 29.
When you were growing up, was your family able to obtain medical services when needed?
1…….Yes, Always |
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2…….Yes, Usually |
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3…….Yes, Sometimes |
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4…….Rarely or Never Do not know/Refused |
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INTERVIEWER: Please turn to Card 30.
How would you rate the quality of the medical services you received while growing up, taking into account the competency of the providers and the convenience of the facilities and services?
1…….Poor 2......Fair |
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3…….Good |
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4…….Excellent Do not know/Refused
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INTERVIEWER: Please turn to Card 31.
Did your family ever receive any form of public assistance, such as food stamps, AFDC (Aid to Families with Dependent Children), Medicaid, or SSI (Supplemental Security Income) when you were a child?
1…….Yes
2…….No
Do not know/Refused
How many people lived in your household including yourself when you were growing up? ____________________
Do not know/Refused
INTERVIEWER: When you were growing up, did your family…
Own a home?
1……. Yes (Continue to Q7)
2……..No (Skip to Q8)
Do not know/Refused
IF YES: Did your family own property in addition to your home, such as a vacation or summer home, rental property or commercial real estate?
1……Yes
2……No
Do not know/Refused
Own a car?
1…….Yes (Continue to Q9)
2…….No (Skip to Q10)
Do not know/Refused
IF YES: Did your family have more than 1 car?
1……Yes
2……No
Do not know/Refused
Take regular family vacations?
1…….Yes
2…….No
Do not know/Refused
Have a savings account, college fund, or investments?
1……Yes
2……No
Do not know/Refused
Have a television?
1……Yes (Continue to Q13)
2……No (Skip to Q14)
Do not know/Refused
IF YES: Did your family have more than 1 television?
1……Yes
2……No
Do not know/Refused
Have a stereo system?
1…….Yes
2…….No
Do not know/Refused
Have a telephone most or all of the time?
1…….Yes (Continue to Q16)
2…….No (Skip to Q17)
Do not know/Refused
IF YES: Did your family have more than one telephone line?
1……Yes
2……No
Do not know/Refused
Own a washer and dryer?
1…….Yes
2…….No
Do not know/Refused
Go out to eat in restaurants often?
1…….Yes
2…….No
Do not know/Refused
INTERVIEWER: As a child, did you.....
Attend private schools?
1…….Yes
2…….No
Do not know/Refused
Take music, dance, or art lessons?
1…….Yes
2…….No
Do not know/Refused
Take classes or lessons in sports, like gymnastics or tennis, outside of school?
1……Yes
2……No
Do not know/Refused
As a child, did your family regularly buy new clothes for school or special occasions?
1…….Yes
2…….No
Do not know/Refused
Childhood Trauma Questionnaire
INTERVIEWER:
Please turn to Card 32. Thinking again about your childhood,
please answer the following questions. When I was growing up….
When I was growing up… |
Never True |
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Often True |
Very Often True |
Do Not Know/ Refused |
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Williams Discrimination Scale
INTERVIEWER:
I am now going to ask you some questions about discrimination that
you may or may not experience in your day-to-day
life. By
discrimination, we mean being treated unfairly because of your race,
ethnicity, income level, social class, sex, gender, age, sexual
orientation, physical appearance, or religion. In your day-to-day
life, please indicate how often any of the following things have
happened to you as well as the reason you believe they happened.
Please turn to Card 33.
(FILL IN THE APPROPRIATE REASON CODE INTO THE REASON CODE COLUMN USING THE TABLE BELOW. IF THE PARTICIPANT SAYS, “OTHER,” ENTER THE CODE AND A SHORT DESCRIPTION.)
REASON CODES |
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1 |
Ethnicity |
2 |
Gender |
3 |
Race |
4 |
Age |
5 |
Religion |
6 |
Physical Appearance |
7 |
Sexual Orientation |
8 |
Income Level/Social Class |
9 |
Other |
88 |
Do Not Know/Refused |
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Never |
Less than Once a Year |
A Few Times a Year |
A Few Times a Month |
At Least Once a Week |
Almost Everyday |
Do Not Know/ Refused |
Reason Code |
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INTERVIEWER: Please turn to Card 34.
For unfair reasons, do you think that you have ever not been hired for a job?
1……No (Skip to Q12)
2……Yes (Continue to Q11)
Do not know/Refused
What do you think the main reason was for not hiring you?
Reason Code: __________
IF OTHER: Please specify: _____________________________________________________
Have you ever been unfairly stopped, searched, questioned, physically threatened, or abused by the police?
1……No
2……Yes
Do not know/Refused
What do you think was the main reason the police treated you that way?
Reason Code: __________
IF OTHER: Please specify: _____________________________________________________
Abuse Assessment Screen (McFarlane)
INTERVIEWER:
The last set of questions refers to events that may have taken
place at any
point in your life.
Some of these are personal or even uncomfortable, but remember your
answers are confidential. Please turn to Card 35.
Have you ever been emotionally or physically abused by your partner or someone important to you?
1……Yes
2……No
Do not know/Refused
Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
1…..Yes (Continue to Q3)
2…..No (Skip to Q5)
Do not know/Refused
IF YES: By whom? (select all that apply)
1…..Husband
2…..Ex-husband
3…..Partner
4…..Stranger
5…..Other (Specify) _______________
Do not know/Refused
How many times did they physically hurt you? _________
Do not know/Refused
Since you have been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
1……Yes (Continue to Q6)
2……No (Skip to Q10)
Do not know/Refused
IF YES: By whom? (select all that apply)
1…..Husband
2…..Ex-husband
3…..Partner
4…..Stranger
5…..Other (Specify) __________
Do not know/Refused
How many times did they physically hurt you? _________
Do not know/Refused
Can you point to the location on your body where they physically hurt you? ______________
Do not know/Refused
INTERVIEWER: Please turn to Card 36.
Please indicate the most severe incident:
1……Threats of abuse, including use of a weapon
2……Slapping, pushing; no injuries and/or lasting pain
3……Punching, kicking, bruises, cuts and/or continuing pain
4……Beaten up, severe contusions, burns, broken bones
5……Head, internal, and/or permanent injury
6……Use of weapon, wound from weapon
Do not know/Refused
INTERVIEWER: Please turn to Card 37.
Within the past year, has anyone forced you to do sexual activities?
1……Yes (Continue to Q11)
2……No (Skip to Q13)
Do not know/Refused
IF YES: By whom?
1…..Husband
2…..Ex-husband
3…..Partner
4…..Stranger
5…..Others (specify) __________
Do not know/Refused
How many times did they force you to do sexual activities? _________
Do not know/Refused
Are you afraid of your partner or anyone else?
1…..Yes (Continue to Q14)
2…..No (End Survey)
Do not know/Refused
INTERVIEWER: Do you want us to reveal this information to:
The obstetricians looking after you?
1….Yes
2….No
Do not know/Refused
The medical social worker for further management?
1….Yes
2….No
Do not know/Refused
Public reporting burden for this collection of information is estimated to average one 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.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Kristina Nelson |
File Modified | 0000-00-00 |
File Created | 2021-01-31 |