9.2 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/2013

Pre-Pregnancy SAQ Instrument, Phase II

Event Name(s):

Pre-Pregnancy Self-Administered Questionnaire (EH, PB, HI)

Instrument Name(s) and Versions:

Pre-Pregnancy Self-Administered Questionnaire (EH, PB, HI) – 1.1

Recruitment Groups:

Enhanced Household, Provider-Based, and High Intensity

Pre-Pregnancy SAQ Instrument(EH, PB, HI)

TABLE OF CONTENTS

INTERVIEW EVALUATION 1

SELF-ADMINISTERED QUESTIONNAIRE

INTERVIEW EVALUATION

(TIME_STAMP_13). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

ev001. We would now like to take a few minutes to ask some questions about your experience in the study. There are no right or wrong answers. You can always refuse to answer any question or group of questions, and your answers will be kept confidential.

EV002. How important was each of the following in your decision to take part in the National Children’s Study?

EV003/(LEARN). (How important was…) Learning more about my health or the health of my child?

NOT AT ALL IMPORTANT 1

SOMEWHAT IMPORTANT 2

VERY IMPORTANT 3

EV004/(HELP). (How important was…) Feeling as if I can help children now and in the future?

NOT AT ALL IMPORTANT 1

SOMEWHAT IMPORTANT 2

VERY IMPORTANT 3

EV005/(INCENT). (How important was…) Receiving money or gifts for taking part in the study?

NOT AT ALL IMPORTANT 1

SOMEWHAT IMPORTANT 2

VERY IMPORTANT 3

EV006/(RESEARCH). (How important was…) Helping doctors and researchers learn more about children and their health?

NOT AT ALL IMPORTANT 1

SOMEWHAT IMPORTANT 2

VERY IMPORTANT 3

EV007/(ENVIR). (How important was…) Helping researchers learn how the environment may affect children’s health?

NOT AT ALL IMPORTANT 1

SOMEWHAT IMPORTANT 2

VERY IMPORTANT 3

EV008/(COMMUNITY). (How important was…) Feeling part of my community?

NOT AT ALL IMPORTANT 1

SOMEWHAT IMPORTANT 2

VERY IMPORTANT 3

EV009/(KNOW_OTHERS). (How important was…) Knowing other women in the study?

NOT AT ALL IMPORTANT 1

SOMEWHAT IMPORTANT 2

VERY IMPORTANT 3

EV010/(FAMILY). (How important was…) Having family members or friends support my choice to take part in the study?

NOT AT ALL IMPORTANT 1

SOMEWHAT IMPORTANT 2

VERY IMPORTANT 3

EV011/(DOCTOR). (How important was…) Having my doctor or health care provider support my choice to take part in the study?

NOT AT ALL IMPORTANT 1

SOMEWHAT IMPORTANT 2

VERY IMPORTANT 3

EV012/(STAFF). (How important was…) Feeling comfortable with the study staff who come to my home?

NOT AT ALL IMPORTANT 1

SOMEWHAT IMPORTANT 2

VERY IMPORTANT 3

EV013. How negative or positive do each of the following people feel about you taking part in the National Children’s Study?

EV014/(OPIN_SPOUSE). Your spouse or partner

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable 6

PROGRAMMER INSTRUCTIONS:

• IF ADMINISTERED AS A CASI, SKIP OPIN_SPOUSE IF MARISTAT = 3, 4, 5, 6, -1 or -2

EV015/(OPIN_FAMILY). Other family members

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable 6

EV016/(OPIN_FRIEND). Your friends

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable 6

EV017/(OPIN_DR). Your doctor or health care provider

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable 6

EV019/(EXPERIENCE). In general, has your experience with the National Children’s Study been

Mostly negative 1

Somewhat negative 2

Neither negative nor positive 3

Somewhat positive 4

Mostly positive 5

EV020/(IMPROVE). In your opinion, how much do you think the National Children’s Study will help improve the health of children now and in the future?

Not at all 1

A little 2

Some 3

A lot 4

EV021/(INT_LENGTH). Did you think the interview was

Too short 1

Too long, or 2

Just about right? 3

EV022/(INT_STRESS). Do you think the interview was

Not at all stressful 1

A little stressful 2

Somewhat stressful, or 3

Very stressful? 4

EV023/(INT_REPEAT). If you were asked, would you participate in an interview like this again?

Yes 1

No 2

EV024. Thank you for participating in the National Children’s Study and for taking the time to complete this survey.

[IF SAQ IS COMPLETED AS A PAPI, SCs MUST PROVIDE INSTRUCTIONS AND A BUSINESS REPLY ENVELOPE FOR PARTICIPANT TO RETURN]

(TIME_STAMP_14). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 20 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.