Form 12.1 Survey

OMB #: 0925-0593

Expiration Date: 07/31/2013

Low-Intensity Questionnaire (Non- & Pregnant), Phase II

Recruitment Strategy Substudy

Event Name(s):

Low-Intensity Questionnaire

Instrument Name(s) and Versions:

Low-Intensity Questionnaire (Non- & Pregnant)

Recruitment Groups:

Low Intensity

Low-Intensity Questionnaire (Non- & Pregnant)

TABLE OF CONTENTS

INTERVIEWER-COMPLETED QUESTIONS 1

CURRENT PREGNANCY INFORMATION 4

MEDICAL HISTORY 9

HEALTH INSURANCE 12

HOUSING CHARACTERISTICS 14

TOBACCO AND ALCOHOL USE 15

EVALUATION QUESTIONS 17

CONCLUSION 20

Low-Intensity Questionnaire (Non- & Pregnant)

CATI

INTERVIEWER-COMPLETED QUESTIONS

[COMPLETION OF LOW-INTENSITY CONSENT MUST BE OBTAINED FIRST; ASSUME COMPLETION OF LOW-INTENSITY CATI PREGNANCY SCREENER OR RETURN OF PPG SELF-ADMINISTERED QUESTIONNAIRE]

(TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

[IF ADMINISTRATION OF QUESTIONNAIRE OCCURS DURING A SEPARATE EVENT FROM THE CONSENT ADMINISTRATION, ADD INTRODUCTORY STATEMENTS APPROPRIATE FOR INCOMING OR OUTGOING CALLS]

OPTION 1: INBOUND CALL TO STUDY CENTER FROM CONSENTED PARTICIPANT

Thank you for calling the National Children’s Study. (TIME_STAMP_2)

OPTION 2: OUTBOUND CALL FROM STUDY CENTER TO CONSENTED PARTICIPANT

(FEMALE_1) Hello, my name is [DATA COLLECTOR’S NAME]. I’m calling from the [LOCAL STUDY CENTER NAME]. I’d like to speak with [NAME OF CONSENTED WOMAN]. Is she available?

YES 1 (TIME_STAMP_2)

NO 2 (BEST_TTC1)

REFUSED -1 (BEST_TTC1)

DON’T KNOW -2 (BEST_TTC1)

PROGRAMMER INSTRUCTION: PRELOAD NAME OF CONSENTED PARTICIPANT

(BEST_TTC_1) What would be a good time to reach her?

INTERVIEWER INSTRUCTIONS: ENTER IN HOUR AND MINUTE VALUES; AND SELECT AM OR PM

|___|___| : |___|___|

H H M M

REFUSED -1

DON’T KNOW -2

(BEST_TTC_2)

AM 1

PM 2

REFUSED -1

DON’T KNOW -2

(BEST_TTC_3)

AFTER TIME REPORTED 1

BEFORE TIME REPORTED 2

REFUSED -1

DON’T KNOW -2

(PHONE) Is this a good phone number to reach [NAME]?

YES 1 (END_UNAVAIL)

NO 2 (PHONE_NBR)

REFUSED -1 (PHONE_NBR)

DON’T KNOW -2 (PHONE_NBR)

PROGRAMMER INSTRUCTION: PRELOAD NAME OF CONSENTED PARTICIPANT

(PHONE_NBR) Would you please tell me a telephone number where she can be reached?

|___|___|___| - |___|___|___| - |___|___|___|___|

REFUSED -1 DON’T KNOW -2

RESPONDENT HAS NO TELEPHONE/NOT APPLICABLE -7

(END_UNAVAIL) Thank you again for speaking with me today. Please ask her to call us at [LOCAL SC TOLL-FREE NUMBER].

INTERVIEWER INSTRUCTION: END INTERVIEW AND DISPOSITION CASE AS APPROPRIATE

(TIME_STAMP_2) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

[WHEN SPEAKING TO CONSENTED PARTICIPANT]

PS002.We are asking women of childbearing age a few questions about pregnancy. Not all women who answer these questions will be able to take part in the National Children’s Study now, but almost every woman who answers these questions will have a chance to take part in some way in the future. We first want to know….

PS004.(PREGNANT) IF ADULT IS KNOWN TO BE PREGNANT, ADD [Just to confirm,] Are you pregnant now?

YES 1

GO TO (TIME_STAMP_3);

SET (PPG_FIRST) = 1

NO, NO ADDITIONAL INFORMATION PROVIDED 2

GO TO (TIME_STAMP_5)

(IF VOLUNTEERED BY RESPONDENT)

NO, RECENTLY LOST PREGNANCY (MISCARRIAGE/ABORTION) 3

GO TO (TIME_STAMP_3);

SET (PPG_FIRST) = 3

NO, RECENTLY GAVE BIRTH 4

GO TO (TIME_STAMP_11);

SET (PPG_FIRST) = 4

NO, UNABLE TO HAVE CHILDREN (HYSTERECTOMY, TUBAL LIGATION) 5

GO TO (TIME_STAMP_11);

SET (PPG_FIRST) = 5

REFUSED -1 (TIME_STAMP_5)

DON’T KNOW -2 (TIME_STAMP_5)

CURRENT PREGNANCY INFORMATION

(TIME_STAMP_3) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS:

• IF (PPG_FIRST) = 1 THEN GO TO (CP000) THEN TO (DUE_DATE)

• IF (PPG_FIRST) = 3 THEN GO TO (CP001A)

CP000. We’ll begin by asking some questions about you, your health, and your health history.

First, I’ll ask about your current pregnancy.

CP001A. I’m so sorry to hear that you’ve lost your baby. I know this can be a hard time.

INTERVIEWER INSTRUCTIONS: USE SOCIAL CUES AND PROFESSIONAL JUDGMENT IN RESPONSE

PROGRAMMER/INTERVIEWER INSTRUCTION:

• IF SC HAS PREGNANCY LOSS INFORMATION TO DISSEMINATE, OFFER TO RESPONDENT AND GO TO CP001C/(LOSS_INFO).

• OTHERWISE GO TO CS007/(END2).

CP001C/(LOSS_INFO). DID RESPONDENT REQUEST ADDITIONAL INFORMATION ON COPING WITH PREGNANCY LOSS?

YES 1 (CS007) /(END2).

NO 2 (CS007) /(END2).

CP002/(DUE_DATE).. What is your current due date?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1 (DATE_PERIOD).

DON’T KNOW -2 (DATE_PERIOD).

INTERVIEWER INSTRUCTION:

• ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR

• IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE

PROGRAMMER INSTRUCTIONS:

• CHECK REPORTED DUE DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:

  • IF DATE IS MORE THAN 9 MONTHS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 9 MONTHS FROM TODAY. RE-ENTER DATE.”

  • IF DATE IS MORE THAN 1 MONTH BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT OCCURRED MORE THAN A MONTH BEFORE TODAY. RE-ENTER DATE.”

  • IF VALID DUE DATE WAS PROVIDED, SET (DUE_DATE) = YYYYMMDD AS REPORTED ; GO TO (KNOW_DATE)

  • IF NO VALID DATE IS GIVEN  GO TO CP004 (DATE_PERIOD)

CP003/(KNOW_DATE).. How did you find out your due date?

FIGURED IT OUT MYSELF 1 (DATE_PERIOD)

HAD AN ULTRASOUND TO FIGURE IT OUT 2 (DATE_PERIOD)

DOCTOR OR OTHER PROVIDER TOLD ME

WITHOUT AN ULTRASOUND 3 (DATE_PERIOD)

REFUSED -1 (DATE_PERIOD)

DON’T KNOW -2 (DATE_PERIOD)

CP004/(DATE_PERIOD). What was the first day of your last menstrual period?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1 (TIME_STAMP_4)

DON’T KNOW -2 (TIME_STAMP_4)

INTERVIEWER INSTRUCTION:

• ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR

• CODE DAY AS “15” IF RESPONDENT IS UNSURE/UNABLE TO ESTIMATE DAY.

• IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE

PROGRAMMER INSTRUCTIONS:

• CHECK REPORTED MENSTRUAL DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:

  • IF DATE IS MORE THAN 10 MONTHS BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 10 MONTHS BEFORE TODAY. CONFIRM DATE. IF DATE IS CORRECT, ENTER ‘DON’T KNOW’.”

  • IF DATE IS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT HAS NOT OCCURRED YET. RE-ENTER DATE.”

  • IF VALID DATE WAS PROVIDED, CALCULATE DUE DATE FROM THE FIRST DATE OF LAST MENSTRUAL PERIOD AND SET (DUE_DATE) (YYYYMMDD) = (DATE_PERIOD) + 280 DAYS; GO TO (KNEW_DATE)

CP004a/(KNEW_DATE). DID RESPONDENT GIVE DATE?

RESPONDENT GAVE COMPLETE DATE 1

INTERVIEWER ENTERED 15 FOR DAY 2

(TIME_STAMP_4) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

CP005/(HOME_TEST). Did you use a home pregnancy test to help find out you were pregnant?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CP008/(BIRTH_PLAN). Where do you plan to deliver your baby?

In a hospital, 1

A birthing center, 2

At home, or 3 (CP010) /(PN_VITAMIN)

Some other place? 4

REFUSED -1 (CP010) /(PN_VITAMIN)

DON’T KNOW -2 (CP010) /(PN_VITAMIN)

CP009. What is the name and address of the place where you are planning to deliver your baby?

_____________________________________________________

NAME OF BIRTH HOSPITAL/BIRTHING CENTER (BIRTH_PLACE)

_____________________________________________________

STREET ADDRESS (B_ADDRESS_1)/(B_ADDRESS_2)

_____________________________________________________

CITY (B_CITY)

|___|___||___|___|___|___|___|

STATE ZIP CODE

(B_STATE) (B_ZIPCODE)

REFUSED -1

DON’T KNOW -2

CP010/(PN_VITAMIN). In the month before you became pregnant, did you regularly take multivitamins, prenatal vitamins, or folic acid?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CP012/(PREG_VITAMIN). Since you’ve become pregnant, have you regularly taken multivitamins, prenatal vitamins, or folic acid?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DV003/(DATE_VISIT). What was the date of your most recent doctor’s visit or checkup since you’ve become pregnant?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1

DON’T KNOW -2

HAVE NOT HAD A VISIT/NOT APPLICABLE -7

DV013. At this visit or at any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?

INTERVIEWER INSTRUCTIONS: RE-READ INTRODUCTORY STATEMENT AS NEEDED

(DIABETES_1) Diabetes?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

[At this visit or] at any time during your pregnancy, did the doctor or other health care provider tell you that you had…]

(HIGHBP_PREG) High blood pressure?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(URINE) Protein in your urine?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(PREECLAMP) Preeclampsia or toxemia?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(EARLY_LABOR) Early or premature labor?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(ANEMIA) Anemia or low blood count?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(NAUSEA) Severe nausea or vomiting (hyperemesis)?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(KIDNEY) Bladder or kidney Infection?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(RH_DISEASE) Rh disease or isoimmunization?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(GROUP_B) Infection with a bacteria called Group B strep?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(HERPES) Infection with a Herpes virus?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(VAGINOSIS) Infection of the vagina with bacteria ( bacterial vaginosis?)

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(OTH_CONDITION) Any other serious condition?

YES 1 (CONDITION_OTH)

NO 2

REFUSED -1

DON’T KNOW -2

DV014. (CONDITION_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

MEDICAL HISTORY

(TIME_STAMP_5) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

MC001. This next question is about your health when you are not pregnant.

MC002./(HEALTH). Would you say your health in general is . . .

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

REFUSED -1

DON’T KNOW -2

MC103./(HEIGHT_FT) ./(HT_INCH). How tall are you without shoes?

|___| |___|___|

Feet Inches

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• INCLUDE A SOFT EDIT IF HEIGHT_FT > 7 OR < 4

• IF HEIGHT_FT IS PROVIDED INCLUDE A SOFT EDIT IF HT_INCH > 12

• IF HEIGHT_FT IS NOT PROVIDED INCLUDE A SOFT EDIT IF HT_INCH > 84 OR < 48

MC104./(WEIGHT). What was your weight just before you became pregnant?

|___|___|___|

Pounds

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: INCLUDE A SOFT EDIT IF WEIGHT < 90 OR > 400

MC110. The next questions are about medical conditions or health problems you might have now or may have had in the past.

MC003/(ASTHMA). Have you ever been told by a doctor or other health care provider that you had asthma?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC004/(HIGHBP_NOTPREG). (Have you ever been told by a doctor or other health care provider that you had)

Hypertension or high blood pressure when you’re not pregnant?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC005/(DIABETES_NOTPREG).. (Have you ever been told by a doctor or other health care provider that you had)

High blood sugar or Diabetes when you’re not pregnant?

YES 1 (DIABETES_2)

NO 2 (THYROID_1)

REFUSED -1 (THYROID_1)

DON’T KNOW -2 (THYROID_1)

MC005a/(DIABETES_2).. Have you taken any medicine or received other medical treatment for diabetes in the past 12 months?

YES 1 (DIABETES_3)

NO 2 (DIABETES_3)

REFUSED -1 (DIABETES_3)

DON’T KNOW -2 (DIABETES_3)

MC005b/(DIABETES_3) Have you ever taken insulin?

YES 1 (THYROID_1)

NO 2 (THYROID_1)

REFUSED -1 (THYROID_1)

DON’T KNOW -2 (THYROID_1)

MC006/(THYROID_1).. (Have you ever been told by a doctor or other health care provider that you had) Hypothyroidism, that is, an under active thyroid?

YES 1 (THYROID_2)

NO 2

REFUSED -1

DON’T KNOW -2

MC006a/(THYROID_2).. Have you taken any medicine or received other medical treatment for a thyroid problem in the past 12 months?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC012A. This next question is about where you go for routine health care.

MC012/(HLTH_CARE). What kind of place do you usually go to when you need routine or preventive care, such as a physical examination or check-up?

Clinic or health center 1

Doctor's office or Health Maintenance Organization

(HMO) 2

Hospital emergency room 3

Hospital outpatient department 4

Some other place 5

DOESN'T GO TO ONE PLACE MOST OFTEN 6

DOESN'T GET PREVENTIVE CARE ANYWHERE 7

REFUSED -1

DON'T KNOW -2

HEALTH INSURANCE

(TIME_STAMP_6) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HI000. Now I’m going to switch to another subject and ask about health insurance.

HI001/(INSURE) Are you currently covered by any kind of health insurance or some other kind of health care plan?

YES 1

NO 2 (TIME_STAMP_7)

REFUSED -1 (TIME_STAMP_7)

DON’T KNOW -2 (TIME_STAMP_7)

HI002. Now I’ll read a list of different types of insurance. Please tell me which types you

currently have.

INTERVIEWER INSTRUCTIONS: RE-READ INTRODUCTORY STATEMENT AS NEEDED

(Do you currently have…)

(INS_EMPLOY) Insurance through an employer or union either through yourself or another family member?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_MEDICAID) Medicaid or any government-assistance plan for those with low incomes or a disability?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTIONS: PROVIDE EXAMPLES OF LOCAL MEDICAID PROGRAMS

(INS_TRICARE) TRICARE, VA, or other military health care?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_IHS) Indian Health Service?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_MEDICARE) Medicare, for people with certain disabilities?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_OTH) Any other type of health insurance or health coverage plan?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HOUSING CHARACTERISTICS

(TIME_STAMP_7) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HC004/(AGE_HOME). Can you tell us, which of these categories do you think best describes when your home or building was built?

2001 TO PRESENT 1

1981 TO 2000 2

1961 TO 1980 3

1941 TO 1960 4

1940 OR BEFORE 5

REFUSED -1

DON’T KNOW -2

HC007/(MAIN_HEAT)... Which of these types of heat sources best describes the main heating fuel source for your home? Is it…

Electric 1

Gas – Propane or LP 2

Oil 3

Wood 4

Kerosene or Diesel 5

Coal or Coke 6

Solar Energy 7

Heat Pump 8

NO HEATING SOURCE 9 (HC012) /(COOL)

OTHER -5 (MAIN_HEAT_OTH)

REFUSED -1 (HC012) /(COOL)

DON’T KNOW -2 (HC012) /(COOL)

HC007A. (MAIN_HEAT_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC012 /(COOL). Not including fans, which of the following kinds of cooling systems do you regularly use?

SELECT ALL THAT APPLY.

Window or wall air conditioners, 1

Central air conditioning, 2

Evaporative cooler (swamp cooler), or 3

NO COOLING OR AIR CONDITIONING REGULARLY

USED 4

Some other cooling system -5 (COOl_OTH)

REFUSED -1

DON’T KNOW -2

HC012A/(COOL_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC033. Now I’d like to ask about the water in your home.

HC034/(WATER_DRINK). What water source in your home do you use most of the time for drinking:

Tap water, 1

Filtered tap water, 2

Bottled water, or 3

Some other source? -5 (WATER_DRINK_OTH)

REFUSED -1

DON’T KNOW -2

HC034A/(WATER_DRINK_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

TOBACCO AND ALCOHOL USE

(TIME_STAMP_8) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

DA011/(CIG_NOW). Currently, do you smoke cigarettes?

YES 1

NO 2 (DA027)/(DRINK_NOW)

REFUSED -1 (DA027)/(DRINK_NOW)

DON’T KNOW -2 (DA027)/(DRINK_NOW)

DA012/(CIG_NOW_FREQ). Do you smoke cigarettes…

Every day 1

5 or 6 days a week 2

2-4 days a week 3

Once a week 4

1-3 days a month 5

Less than once a month 6

REFUSED -1

DON’T KNOW -2

DA013/(CIG_NOW_NUM ). On days that you smoke, how many cigarettes do you smoke per day?

|___|___|

NUMBER PER DAY

REFUSED -1

DON’T KNOW -2

INTERVIEWER/PROGRAMMER INSTRUCTIONS:

• IF RESPONDENT ANSWERS 1 OR LESS PER DAY, ENTER “1.”

• INCLUDE SOFT EDIT IF RESPONSE > 60

• IF RESPONSE IS IN PACKS, CALCULATE 20 CIGARETTES PER PACK.

DA027/(DRINK_NOW). How often do you currently drink alcoholic beverages?

5 or more times a week 1

2-4 times a week 2

Once a week 3

1-3 times a month 4

Less than once a month 5

Never 6 (TIME_STAMP_9)

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

DA028/(DRINK_NOW_NUM). Currently, on days that you drink alcoholic beverages, how many did you have per day?

|___|___|

NUMBER OF DRINKS

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTIONS:

• IF RESPONDENT ANSWERS LESS THAN 1 PER DAY, ENTER “1.”

DA029/(DRINK_NOW_5). Currently, how often do you have 5 or more drinks within a couple of hours?

Never 1

About once a month 2

About once a week 3

About once a day 4

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTIONS: FOLLOW LOCAL MANDATORY REPORTING REQUIREMENTS.

(TIME_STAMP_9) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

EVALUATION QUESTIONS

(TIME_STAMP_10) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

EV000. We would now like to take a few minutes to ask some questions about your experience in the study.

EV001. How important was each of the following in your decision to take part in the National Children’s Study?

(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

(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

(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

(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

(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

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

Not at all important 1

Somewhat important 2

Very important 3

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

Not at all important 1

Somewhat important 2

Very important 3

(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

(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

EV004. How negative or positive do each of the following people feel about you taking part in the National Children’s Study?

(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 -7

(OPIN_FAMILY) Other family members

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable -7

(OPIN_FRIEND) Your friends

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable -7

(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 -7

EV005/(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

EV007/(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

EV008./(INT_LENGTH) Did you think the interview was

Too short 1

Too long, or 2

Just about right? 3

EV009./(INT_STRESS) Do you think the interview was

Not at all stressful 1

A little stressful 2

Somewhat stressful, or 3

Very stressful? 4

EV010./(INT_REPEAT) If you were asked, would you participate in an interview like this again?

YES 1

NO 2

CONCLUSION

(TIME_STAMP_11) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCITONS:

• IF PPG_FIRST = 3 GO TO (END2) ELSE GO TO (END1)

CO001/(END1). Thank you for participating in the National Children’s Study and for taking the time to answer our questions. We will contact you in about 6 months to ask you some more questions. If there are any other women in your household age [LOCAL AGE OF MAJORITY] - 49, (please have her | she may) contact us at [STUDY CENTER TOLL-FREE NUMBER].

CS007/(END2). Thank you for taking the time to answer these questions. Based on what you’ve told me, you are not eligible to take part in the study.

(TIME_STAMP_12) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 15 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.