Formative - Developmental

ATTACHMENT B.3.8 EXEMPLAR TAKE-HOME PACKET OMB #: 0925-0593

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

Measurement of Maternal Life Experience Study

Take-Home Packet

Study ID: _______________________

PLEASE CIRCLE THE NUMBER OF THE APPROPRIATE RESPONSE OR FILL IN THE BLANK FOR EACH QUESTION

Current Family Profile

Family Member	Age (Completed Years)	Height (Feet and Inches)	Weight (Pounds)
You
Partner/Husband
Child #1
Child #2
Child #3
Child #4
Child #5
Your Mother
Your Father

Your History

1. What is your birth order?

1…….Oldest

2…….Middle

3…….Youngest

4…….Only Child

2. How old were you/will you be when you gave/give birth to your first child? _______ years old

3. How many times have you given birth? Please count multiple births as one birth and also include stillbirths. _______ times

4. What is the lowest weight you have ever reached as an adult? As an adult, we mean 18 years of age or older. _______ pounds

5. How old were you when you were at your lowest weight? _______ years old

6. How long were you at your lowest weight? _______ years

7. What is the highest weight you have ever reached as an adult? _______ pounds

8. How old were you when you were at your highest weight? _______ years old

9. How long were you at your highest weight? _______ years

10. Excluding pregnancy, has your body weight changed (lost or gained more than 20 pounds) since you became an adult?

1…….Yes (Continue to Q11)

2…….No (Skip to Q12)

11. IF YES: How many times in your adult life has this occurred? _______ times

12. How old were you when you got your first period? _______ years old

13. How much did you weigh the day you found out you were pregnant? _______ pounds

14. Do you know what your own birth weight was?

1…….Yes (Continue to Q15)

2…….No (Skip to Q18)

15. IF YES: What was it? _______ lbs. _______ oz.

16. What is the source of this information? ______________

17. How confident are you about the accuracy of this information?

1……Not at all Confident

2……Somewhat/Moderately Confident

3……Very Confident

Your Mother’s History

18. What was your mother’s birth weight? _______ lbs. _______ oz.

I do not know this information

19. How old was your mother when she got her first period? _______ years old

I do not know this information

20. How old was your mother when she gave birth to her first child? _______ years old

I do not know this information

21. How many times has your mother given birth? Please count multiple births as one birth and also include stillbirths. _______ times

I do not know this information

Questions about Family Background

We are going to ask you about your family’s racial and ethnic backgrounds. Ethnicity and race are two separate issues, so please answer each question independently.

22. How would your mother best describe her ethnicity? Please select one of the following two choices.

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

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

I do not know this information

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

1…….American Indian or Alaska Native

2…….Asian

3…….Black or African American

4…….Native Hawaiian or Other Pacific Islander

5…….White

I do not know this information

24. Was your mother born in the United States?

1…….Yes (Skip to Q26)

2…….No (Continue to Q25)

I do not know this information (Skip to Q26)

25. IF NO: What was your mother’s country of birth? ______________________

I do not know this information

26. How would your father best describe his ethnicity? Please select one of the following two choices.

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

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

I do not know this information

27. How would your 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

2…….Asian

3…….Black or African American

4…….Native Hawaiian or Other Pacific Islander

5…….White

I do not know this information

28. Was your father born in the United States?

1…….Yes (Skip to Q30)

2…….No (Continue to Q29)

I do not know this information (Skip to Q30)

29. IF NO: What was your father’s country of birth? ______________________

I do not know this information

30. How would your baby’s paternal grandmother (biological father’s mother) best describe her ethnicity? Please select one of the following two choices:

1…….Of Hispanic, Latino or Spanish origin

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

I do not know this information

31. How would your baby’s paternal grandmother (biological father’s mother) best describe her race? Please select one or more of the following five choices. Select all that apply.

1…….American Indian or Alaska Native

2…….Asian

3…….Black or African American

4…….Native Hawaiian or Other Pacific Islander

5…….White

I do not know this information

32. Was your baby’s paternal grandmother born in the United States?

1…….Yes (Skip to Q34)

2…….No (Continue to Q33)

I do not know this information (Skip to Q34)

33. IF NO: What was your baby’s paternal grandmother’s country of birth? ____________

I do not know this information

34. How would your baby’s paternal grandfather (biological father’s father) best describe his ethnicity? Please select one of the following two choices:

1…….Of Hispanic, Latino or Spanish origin

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

I do not know this information

35. Which of the following races does your baby’s paternal grandfather (biological father’s father) consider himself to be? Please select one or more of the following five choices. Select all that apply.

1…….American Indian or Alaska Native

2…….Asian

3…….Black or African American

4…….Native Hawaiian or Other Pacific Islander

5…….White

I do not know this information

36. Was your baby’s paternal grandfather born in the United States?

1…….Yes (Skip to Q38)

2…….No (Continue to Q37)

I do not know this information (Skip to Q38)

37. IF NO: What was your baby’s paternal grandfather’s country of birth? ______________________

I do not know this information

Questions about Your Housing History

To better understand maternal-child health, we are collecting information about the physical context of a pregnant woman’s life. The places you have lived since birth will tell us some information about the physical and social characteristics you have experienced over the course of your life. Please try to fill in the following table with as much detail as you can. List the residences where you have lived since birth through your current address. If you need more space, please feel free to write on the back or attach additional pages.

	Approximate Dates of Residence (month, year)	Address (Street, City, State, Zip Code)
38.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
39.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
40.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
41.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
42.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
43.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
44.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
45.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
46.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
47.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y

Questions about Yourself

Listed below are statements describing how people sometimes think of themselves. Please read each statement carefully and then indicate the extent to which you feel it applies to you by circling the corresponding number. Remember, there are no “right” or “wrong” answers.

	Statements	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1	I am not a worrier.	1	2	3	4	5
2	I like to have a lot of people around me.	1	2	3	4	5
3	I don't like to waste my time daydreaming.	1	2	3	4	5
4	I try to be courteous to everyone I meet.	1	2	3	4	5
5	I keep my belongings neat and clean.	1	2	3	4	5
6	I often feel inferior to others.	1	2	3	4	5
7	I laugh easily.	1	2	3	4	5
8	Once I find the right way to do something, I stick to it.	1	2	3	4	5
9	I often get into arguments with my family and co-workers	1	2	3	4	5
10	I'm pretty good about pacing myself so as to get things done on time.	1	2	3	4	5
	Statements	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
11	When I’m under a great deal of stress, sometimes I feel like I’m going to pieces.	1	2	3	4	5
12	I don't consider myself especially "light-hearted."	1	2	3	4	5
13	I am intrigued by the patterns I find in art and nature.	1	2	3	4	5
14	Some people think I'm selfish and egotistical.	1	2	3	4	5
15	I am not a very methodical person.	1	2	3	4	5
16	I rarely feel lonely or blue.	1	2	3	4	5
17	I really enjoy talking to people.	1	2	3	4	5
18	I believe letting students hear controversial speakers can only confuse and mislead them.	1	2	3	4	5
19	I would rather cooperate with others than compete with them.	1	2	3	4	5
20	I try to perform all the tasks assigned to me conscientiously.	1	2	3	4	5
21	I often feel tense and jittery.	1	2	3	4	5
22	I like to be where the action is.	1	2	3	4	5
23	Poetry has little or no effect on me.	1	2	3	4	5
24	I tend to be cynical and skeptical of others' intentions.	1	2	3	4	5
25	I have a clear set of goals and work toward them in an orderly fashion.	1	2	3	4	5
26	Sometimes I feel completely worthless.	1	2	3	4	5
27	I usually prefer to do things alone.	1	2	3	4	5
28	I often try new and foreign foods.	1	2	3	4	5
29	I believe that most people will take advantage of you if you let them.	1	2	3	4	5
30	I waste a lot of time before settling down to work.	1	2	3	4	5
31	I rarely feel fearful or anxious.	1	2	3	4	5
32	I often feel as if I'm bursting with energy.	1	2	3	4	5
33	I seldom notice the moods or feelings that different environments produce.	1	2	3	4	5
34	Most people I know like me.	1	2	3	4	5
35	I work hard to accomplish my goals.	1	2	3	4	5
36	I often get angry at the way people treat me.	1	2	3	4	5
37	I am a cheerful, high-spirited person.	1	2	3	4	5
38	I believe we should look to our religious authorities for decisions on moral issues.	1	2	3	4	5
	Statements	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
39	Some people think of me as cold and calculating.	1	2	3	4	5
40	When I make a commitment, I can always be counted on to follow through.	1	2	3	4	5
41	Too often, when things go wrong, I get discouraged and feel like giving up.	1	2	3	4	5
42	I am not a cheerful optimist.	1	2	3	4	5
43	Sometimes when I am reading poetry or looking at a work of art, I feel a chill or wave of excitement.	1	2	3	4	5
44	I am hard-headed and tough-minded in my attitudes.	1	2	3	4	5
45	Sometimes I'm not as dependable or reliable as I should be.	1	2	3	4	5
46	I am seldom sad or depressed.	1	2	3	4	5
47	My life is fast-paced.	1	2	3	4	5
48	I have little interest in speculating on the nature of the universe or the human condition.	1	2	3	4	5
49	I generally try to be thoughtful and considerate.	1	2	3	4	5
50	I am a productive person who always gets the job done.	1	2	3	4	5
51	I often feel helpless and want someone else to solve my problems.	1	2	3	4	5
52	I am a very active person.	1	2	3	4	5
53	I have a lot of intellectual curiosity.	1	2	3	4	5
54	If I don't like people, I let them know it.	1	2	3	4	5
55	I never seem to be able to get organized.	1	2	3	4	5
56	At times I have been so ashamed I just want to hide.	1	2	3	4	5
57	I would rather go my own way than be a leader of others.	1	2	3	4	5
58	I often enjoy playing with theories or abstract ideas.	1	2	3	4	5
59	If necessary, I am willing to manipulate people to get what I want.	1	2	3	4	5
60	I strive for excellence in everything I do.	1	2	3	4	5

Thank you for taking the time to fill out the Measurement of Maternal Life Experience Study Take-Home Packet. Your responses will help us learn more about how women’s experiences affect pregnancy.

Please mail the take-home packet in the provided, pre-addressed, stamped envelope to the following address:

Kristina Nelson

Northwestern University

750 N. Lake Shore Drive, 10^th Floor

Chicago, IL 60611

Public reporting burden for this collection of information is estimated to average 30 minutes 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.