15.2 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/2013

Pregnancy Visit 1 SAQ Instrument, Phase II

Event Name(s):

Pregnancy Visit 1 Instrument (EH, PB, HI) – SAQ

Instrument Name(s) and Versions:

Pregnancy Visit 1 Instrument (EH, PB, HI) – SAQ – 2.0

Recruitment Groups:

Enhanced Household, Provider-Based, and High Intensity

Pregnancy Visit 1 SAQ Instrument (EH, PB, HI)

TABLE OF CONTENTS

PREGNANCY INTENTIONS AND HISTORY 1

TOBACCO AND ALCOHOL USE 5

EVALUATION QUESTIONS 8

Pregnancy Visit 1 SAQ Instrument (EH, PB, HI)

SELF-ADMINISTERED QUESTIONAIRE

NOTE: THE SAQS MAY BE COMPLETED IN EITHER A PAPI OR CASI MODE

FIELD INTERVIEWER INSTRUCTION:

• IF COMPLETED AS A PAPI, ENTER THE PARTICIPANT ID ON TOP OF INSTRUMENT

(TIME_STAMP_18) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

IN001. Thank you for agreeing to participate in this study. This self-administered questionnaire will take about 10 minutes to complete. There are questions about your pregnancy and your lifestyle. We will also ask you about your satisfaction with our visit with you today.

Your answers are important to us. 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.

PREGNANCY INTENTIONS AND HISTORY

PIH002/(PLANNED). Regarding this pregnancy, were you trying to become pregnant?

Yes 1

No 2 (WANTED)

REFUSED -1 (WANTED)

DON’T KNOW -2 (WANTED)

PIH003/(MONTH_TRY). For about how many months were you trying to become pregnant?

INTERVIEW INSTRUCTION:

• If 1 month or less, enter 1.

|___|___|

Months

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• DISPLAY SOFT EDIT IF RESPONSE > 24

PIH006/(WANTED). When you became pregnant, did you yourself actually want to have a baby at sometime?

Yes 1

No 2 (TIME_STAMP_19)

REFUSED -1 (TIME_STAMP_19)

DON’T KNOW -2 (TIME_STAMP_19)

PIH007/(TIMING). Would you say you became pregnant too soon, at about the right time, or later than you wanted?

Too Soon 1

Right Time 2

Later 3

Didn’t Care 4

REFUSED -1

DON’T KNOW -2

PIH008/(FATHER_NAME). Part of the National Children’s Study includes a planned study visit with the baby’s father. What is the first and last name of your baby’s father?

FIRST NAME: _________________________________(F_F_NAME)

LAST NAME: _________________________________ (F_L_NAME)

REFUSED -1

DON’T KNOW -2

PIH009/(FATHER_SAME_HH). Is the father of your baby/[FIRST NAME OF FATHER] living in the same household as you?

Yes 1

No 2

REFUSED -1

DON’T KNOW -2

PIH010/(FATHER_KNOW_PREG). Is the father/[FIRST NAME OF FATHER] aware of your pregnancy?

Yes 1 (CONTACT_F_NOW)

No 2 (CONTACT_F_LATER)

REFUSED -1 (CONTACT_F_NOW)

DON’T KNOW -2 (CONTACT_F_NOW)

PIH011/(CONTACT_F_NOW). May we have your permission to contact the father/[FIRST NAME OF FATHER] and invite him to participate in the Study?

Yes 1 (TIME_STAMP_19)

No 2 (TIME_STAMP_19)

REFUSED -1 (TIME_STAMP_19)

DON’T KNOW -2 (TIME_STAMP_19)

PIH011/CONTACT_F_LATER). Once you have shared the information about your pregnancy with the father/[FIRST NAME OF FATHER], may we have your permission to contact him and invite him to participate in the Study?

Yes 1

No 2 (TIME_STAMP_19)

REFUSED -1 (TIME_STAMP_19)

DON’T KNOW -2 (TIME_STAMP_19)

PIH012/(SHARE_PREG_F). The next time we follow up with you, we will ask if you have shared the information about your pregnancy with the father/[FIRST NAME OF FATHER] so that we know if it is the right time to contact him.

PROGRAMMER INSTRUCTION:

• IF FATHER_SAME_HH = 2 AND CONTACT_F_NOW = 1, GO TO F_ADDR. OTHERWISE, GO TO TIME_STAMP_19.

PIH013/(F_ADDR). What is the father’s/[FIRST NAME OF FATHER’s] home address?

INTERVIEWER INSTRUCTIONS:

• PROMPT AS NECESSARY TO COMPLETE INFORMATION

_____________________________________________________

STREET (F_ADDR1_2)/(F_ADDR_2_2)/(F_UNIT_2)

_____________________________________________________

CITY (F_CITY_2)

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

STATE ZIP CODE

(F_STATE_2) (F_ZIPCODE_2) (F_ZIP4_2)

REFUSED -1

DON’T KNOW -2

PIH014/(F_PHONE). What is the father’s/[FIRST NAME OF FATHER’s] telephone number?

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

PHONE NUMBER

REFUSED -1

DON’T KNOW -2

FATHER HAS NO TELEPHONE -7

INTERVIEWER INSTRUCTION:

• IF FATHER HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

PIH015/(F_AGE). What is the father’s/[FIRST NAME OF FATHER’s] age?

|___|___|

AGE IN YEARS

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_19) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PIH015A. These next questions are about any previous pregnancies you may have had.

PIH016/(PAST_PREG). Before this pregnancy, have you ever been pregnant? Please include live births, miscarriages, stillbirths, ectopic pregnancies, abortions and pregnancy terminations.

Yes 1

No 2 (TIME_STAMP_20)

REFUSED -1 (TIME_STAMP_20)

DON’T KNOW -2 (TIME_STAMP_20)

RPIH0016A/(NUM_PREG). Including this pregnancy, how many times total have you been pregnant?

|___|___|

NUMBER

REFUSED -1

DON’T KNOW -2

NO ONE IN HOUSEHOLD IS PREGNANT/NOT APPLICABLE -7

PROGRAMMER INSTRUCTIONS:

• DISPLAY SOFT EDIT IF RESPONSE > 5

PIH017/(AGE_FIRST). How old were you when you became pregnant for the first time?

|___|___|

AGE IN YEARS

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• DISPLAY SOFT EDIT IF RESPONSE < 13

PIH018/(PREMATURE). Did any of your previous pregnancies end in the birth of a child more than 3 weeks early, before his or her due date?

Yes 1

No 2

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTIONS:

• INCLUDE ALL INFANTS WHO WERE ALIVE AT THE TIME OF BIRTH. DO NOT INCLUDE MISCARRIAGES, STILLBIRTHS OR ABORTIONS.

PIH019/(MISCARRY). Did any of your previous pregnancies end in a miscarriage or stillbirth?

Yes 1

No 2

REFUSED -1

DON’T KNOW -2

TOBACCO AND ALCOHOL USE

(TIME_STAMP_20) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

TAA001. The next questions are about your use of cigarettes and alcohol just before your current pregnancy.

TA002/(CIG_PAST). In the 3 months before you knew you were pregnant, did you smoke any cigarettes?

Yes 1

No 2 (CIG_NOW)

REFUSED -1 (CIG_NOW)

DON’T KNOW -2 (CIG_NOW)

TA003/(CIG_PAST_FREQ). Did 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

TA004/(CIG_PAST_NUM). On days that you smoked, how many cigarettes did you smoke per day? If you smoked 1 cigarette or less each day, please enter “1.”

|___|___|

NUMBER PER DAY

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• DISPLAY SOFT EDIT IF RESPONSE > 60

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

TA011/(CIG_NOW). Currently, do you smoke cigarettes?

Yes 1

No 2 (DRINK_PAST)

REFUSED -1 (DRINK_PAST)

DON’T KNOW -2 (DRINK_PAST)

T012/(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

TA013/(CIG_NOW_NUM). On days that you smoke, how many cigarettes do you smoke per day? If you smoke 1 cigarette or less each day, please enter “1.”

|___|___|

NUMBER PER DAY

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

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

• DISPLAY SOFT EDIT IF RESPONSE > 60

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

TA023/(DRINK_PAST). In the 3 months before you knew you were pregnant, how often did you drink alcoholic beverages including wine, beer, drinks containing hard liquor, wine coolers, hard lemonade, or hard cider?

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 (DRINK_NOW)

REFUSED -1 (DRINK_NOW)

DON’T KNOW -2 (DRINK_NOW)

TA024/(DRINK_PAST_NUM). In the 3 months before you knew you were pregnant, on days that you drank alcoholic beverages, how many did you have per day? If you had one drink or less, please enter “1.”

|___|___|

NUMBER OF DRINKS

REFUSED -1

DON’T KNOW -2

TA025/(DRINK_PAST_5). In the 3 months before you knew you were pregnant, how often did 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

TA027/(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_21)

REFUSED -1 (TIME_STAMP_21)

DON’T KNOW -2 (TIME_STAMP_21)

TA028/(DRINK_NOW_NUM). Currently, on days that you drink alcoholic beverages, how many did you have per day? If you have one drink or less, please enter “1.”

|___|___|

NUMBER OF DRINKS

REFUSED -1

DON’T KNOW -2

TA029/(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.

EVALUATION QUESTIONS

(TIME_STAMP_21) 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

EV012/(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

EV013/(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

EV0014. How negative or positive do each of the following people feel about you taking part in the National Children’s Study?

EV014A/(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

EV014B/(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

EV014C/(OPIN_FRIEND). Your friends

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable 6

EV014D/(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

EV014E/(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

EV0144F/(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

EV014G/(INT_LENGTH). Did you think the interview was

Too short 1

Too long, or 2

Just about right? 3

EV0014H/(INT_STRESS). Do you think the interview was

Not at all stressful 1

A little stressful 2

Somewhat stressful, or 3

Very stressful? 4

EV0144I/(INT_REPEAT). If you were asked, would you participate in an interview like this again?

Yes 1

No 2

(END_EVAL). 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_22) 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.