Form 19.1 Survey

OMB #: 0925-0593

Expiration Date: 07/31/2013

Pregnancy Visit 1 Father Instrument, Phase II

Recruitment Strategy Substudy

Event Name(s):

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

Instrument Name(s) and Versions:

Pregnancy Visit 1 Father Instrument (EH, PB, HI) – 1.0

Recruitment Groups:

Enhanced Household, Provider-Based, and High Intensity

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

TABLE OF CONTENTS

CAPI 1

INTERVIEW INTRODUCTION 1

DEMOGRAPHICS: PART 1 1

TOBACCO USE 4

ALCOHOL USE 4

SELF RATED HEALTH 5

OCCUPATIONAL/HOBBY EXPOSURES 10

MENTAL HEALTH 11

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS: PART 2 17

SOCIAL RESOURCES 19

PATERNAL INVOLVEMENT 20

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

CAPI

INTERVIEW INTRODUCTION

(TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IN001. Thank you for agreeing to participate in this study. We are about to begin the interview portion of today’s visit, which will take about 15 minutes to complete. Your answers are important to us. There are no right or wrong answers, just those that help us to understand your situation. There are questions about where you work, your health, and your feelings during this interview and you can always refuse to answer any question or group of questions.

IN002. Are you ready to begin?

YES 1

NO 2 (END interview)

DEMOGRAPHICS: PART 1

(TIME_STAMP_2) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

I’ll begin by asking some questions about you.

IN002A/(R_FNAME) (R_LNAME) What is your full name?

_________________________ _________________________

FIRST NAME LAST NAME

(R_FNAME) (R_LNAME)

REFUSED -1 (IN003)/(DOB_CONFIRM)

DON’T KNOW -2 (IN003)/(DOB_CONFIRM)

INTERVIEWER INSTRUCTIONS:

• IF RESPONDENT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS, ASK FOR INITIALS OR SOME OTHER NAME SHE WOULD LIKE TO BE CALLED

• CONFIRM SPELLING OF FIRST NAME IF NOT PREVIOUSLY COLLECTED AND OF LAST NAME FOR ALL RESPONDENTS.

IN003A/(PERSON_DOB). What is your date of birth?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED ………………………………………………………………. -1 (AGE_ELIG)

DON’T KNOW -2 (AGE_ELIG)

INTERVIEWER INSTRUCTION:

• IF RESPONDENT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB IS REQUIRED TO DETERMINE ELIGIBILITY

• 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 INSTRUCTION:

• INCLUDE A SOFT EDIT/WARNING IF CALCULATED AGE IS LESS THAN LOCAL AGE OF MAJORITY OR GREATER THAN 50

• FORMAT PERSON_DOB AS YYYYMMDD

(AGE_ELIG)

PROGRAMMER INSTRUCTION:  BASED ON DOB_CONFIRM OR PERSON_DOB CALCULATE AGE. USING KNOWN LOCAL AGE OF MAJORITY DETERMINE IF SHE IS ELIGIBLE (AT LEAST AGE OF MAJORITY AND LESS THAN AGE 50); SET AGE_ELIG AS APPROPRIATE

RESPONDENT IS AGE-ELIGIBLE 1 (TIME_STAMP_2)

RESPONDENT IS YOUNGER THAN AGE OF MAJORITY 2 (END)

AGE ELIGIBILITY IS UNKNOWN 4 (TIME_STAMP_2)

IF VALUE IS ‘REFUSED’ OR ‘DON’T KNOW’ FLAG CASE FOR SUPERVISOR REVIEW AT SC TO CONFIRM AGE ELIGIBILITY POST-INTERVIEW.

DE001. Are you the child's…

Birth father,…... 1

Adoptive father, 2

Step father, 3

Foster father or male guardian, or 4

Do you have some other relationship to child?

Please specify, 5

_____________________________________

REFUSED -1

DON’T KNOW -2

DE003 Are you now married, widowed, divorced, separated, never married or living with a partner?

MARRIED....................................................................................... 1

WIDOWED...................................................................................... 2

DIVORCED..................................................................................... 3

SEPARATED.................................................................................. 4

NEVER MARRIED...................................................................................... 5

LIVING WITH PARTNER................................................................ 6

REFUSED....................................................................................... 7

DON'T KNOW................................................................................. 9

DE004. Do you consider yourself to be Hispanic, or Latino?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DE006. What race do you consider yourself to be? You may select one or more.

PROBE: Anything else?

SELECT ALL THAT APPLY.

White, 1

Black or African American, 2

American Indian or Alaska Native, 3

Asian, or 4

Native Hawaiian or Other Pacific Islander? 5

SOME OTHER RACE? (SPECIFY): 6

REFUSED -1

DON’T KNOW -2

DE007. What is the highest degree or level of school that you have completed?

LESS THAN A HIGH SCHOOL DIPLOMA OR GED 1

HIGH SCHOOL DIPLOMA OR GED 2

SOME COLLEGE BUT NO DEGREE 3

ASSOCIATE DEGREE 4

BACHELOR’S DEGREE (e.g., BA, BS) 5

POST GRADUATE DEGREE (e.g., Masters or Doctoral) 6

REFUSED -1

DON’T KNOW -2

TOBACCO USE

(TIME_STAMP_3) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

The next question is about your use of cigarettes.

TA001. Currently do you smoke cigarettes?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

ALCOHOL USE

(TIME_STAMP_4) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Now I am going to ask about your use of alcohol.

AU001. Do you drink any type of alcoholic beverage?

YES	………………………………………	1
NO	………………………………………	2	(TIME_STAMP_5)
REFUSED	………………………………………	-1	(TIME_STAMP_5)
DON’T KNOW	………………………………………	-2	(TIME_STAMP_5)

AU002 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

REFUSED -1 (TIME_STAMP_5)

DON’T KNOW -2 (TIME_STAMP_5)

AU003. 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, or 3

About once a day 4

Less than once a month 5

Never 6

REFUSED -1 (TIME_STAMP_5)

DON’T KNOW -2 (TIME_STAMP_5)

SELF RATED HEALTH

(TIME_STAMP_5) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Now, I have questions about your health and about medical conditions or health problems you have or have had.

HE005. How would you rate your overall physical health at the present time? Would you say it is excellent, very good, good, fair or poor?

EXCELLENT 1

VERY GOOD 2

GOOD 3

FAIR 4

POOR 5

REFUSED -1

DON’T KNOW -2

MC002. Have you ever been told by a doctor or other health care provider that you had asthma?

YES 1

NO 2

REFUSED 9--97

DON’T KNOW 9--98

MC003. (Have you ever been told by a doctor or other health care provider that you had:)

Eczema or atopic dermatitis?

YES 1

NO 2

REFUSED 9--97

DON’T KNOW 9--98

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

Seasonal allergies?

YES 1

NO 2

REFUSED 9--97

DON’T KNOW 9--98

MC007. (Have you ever been told by a doctor or other health care provider that you had:)

Hypertension or high blood pressure?

YES 1

NO 2

REFUSED 9--97

DON’T KNOW 9--98

MC008. (Have you ever been told by a doctor or other health care provider that you had:)

Diabetes?

YES 1

NO 2

REFUSED 9--97

DON’T KNOW 9--98

MC013. (Have you ever been told by a doctor or other health care provider that you had:)

High cholesterol?

YES 1

NO 2

REFUSED 9--97

DON’T KNOW 9--98

MC014. (Have you ever been told by a doctor or other health care provider that you had:)

Any type of cancer?

YES 1

NO 2 (MC016)

REFUSED 9--97 (MC016)

DON’T KNOW 9--98 (MC016)

MC015. What type or types of cancer were you diagnosed with?

SELECT ALL THAT APPLY.

BRAIN 1

BREAST 2

COLON 3

HODGKIN’S LYMPHOMA 4

LEUKEMIA 5

LIVER 6

LUNG 7

NON-HODGKIN’S LYMPHOMA 8

PROSTATE (MALE ONLY) 9

SKIN 10

TESTICULAR (MALE ONLY) 11

THYROID 12

UTERINE (FEMALE ONLY) 13

OTHER (SPECIFY): 96

REFUSED 9--97

DON’T KNOW 9--98

MC016. (Have you ever been told by a doctor or other health care provider that you had:)

Sickle cell anemia or sickle cell trait?

YES 1

NO 2

REFUSED 9--97

DON’T KNOW 9--98

MC018. (Have you ever been told by a doctor or other health care provider that you had:)

An autoimmune disorder such as rheumatoid arthritis, lupus, or scleroderma?

YES 1

NO 2 (MC019a)

REFUSED 9--97 (MC019a)

DON’T KNOW 9--98 (MC019a)

MC019. What type of autoimmune disorder were you diagnosed with?

RHEUMATOID ARTHRITIS 01

LUPUS 02

SCLERODERMA 03

MULTIPLE SCLEROSIS 04

GRAVES’ DISEASE 05

OTHER (SPECIFY): 96

REFUSED 9--97

DON’T KNOW 9--98

MC019a(Have you ever been told by a doctor or other health care provider that you had:)

A birth defect?

YES 1

NO 2 (MC023)

REFUSED 9—97 (MCO23)

DON’T KNOW 9—98 (MCO23)

MC019b What birth defect were diagnosed with?

(SPECIFY): 96

REFUSED 9--97

DON’T KNOW 9—98

MC023. (Have you ever been told by a doctor or other health care provider that you had:)

Blindness or any severe vision impairment?

YES 1

NO 2

REFUSED 9--97

DON’T KNOW 9--98

MC024. (Have you ever been told by a doctor or other health care provider that you had:)

Deafness or any severe hearing impairment?

YES 1

NO 2

REFUSED 9--97

DON’T KNOW 9--98

MC025. (Have you ever been told by a doctor or other health care provider that you had:)

Attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)?

YES 1

NO 2

REFUSED 9--97

DON’T KNOW 9--98

MC026. (Have you ever been told by a doctor or other health care provider that you had:)

Autism, Asperger syndrome, or any other autism spectrum disorder?

YES 1

NO 2

REFUSED 9--97

DON’T KNOW 9--98

MC027. (Have you ever been told by a doctor or other health care provider that you had:)

Bipolar disorder?

YES 1

NO 2

REFUSED 9--97

DON’T KNOW 9--98

MC028. (Have you ever been told by a doctor or other health care provider that you had:)

Depression, other than bipolar disorder?

YES 1

NO 2

REFUSED 9--97

DON’T KNOW 9--98

MC029. (Have you ever been told by a doctor or other health care provider that you had:)

An anxiety disorder, such as generalized anxiety disorder or obsessive compulsive disorder (OCD)?

YES 1

NO 2 (MC031)

REFUSED 9--97 (MC031)

DON’T KNOW 9--98 (MC031)

MC033. (Have you ever been told by a doctor or other health care provider that you had:)

Any other chronic or long lasting conditions?

YES 1

NO 2 (EOS)

REFUSED 9--97 (EOS)

DON’T KNOW 9--98 (EOS)

MC034. What other chronic condition or conditions were you diagnosed with?

(SPECIFY): 96

REFUSED 9--97

DON’T KNOW 9—98

OCCUPATIONAL/HOBBY EXPOSURES

(TIME_STAMP_5) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Now I’d list to ask some questions about work and income.

MB004. Are you currently working any full or part-time jobs?

YES 1

NO 2 (INCOME)

REFUSED -1 (INCOME)

DON’T KNOW -2 (INCOME)

MB008 (WORK_HRS) How many hours per week do you work?

|___|___|

HOURS

REFUSED -1

DON’T KNOW -2

OH009. All in all, how satisfied are you with your job? Would you say very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?

VERY SATISFIED 1

SOMEWHAT SATISFIED 2

SOMEWHAT DISSATISFIED 3

VERY DISSATISFIED 4

REFUSED -1

DON’T KNOW -2

DE009.Now I’m going to ask a few questions about your income. Family income is important in analyzing the data we collect and is often used in scientific studies to compare groups of people who are similar. Please remember that all the information you provide is confidential.

Please think about your total combined family income during [CURRENT YEAR – 1] for all members of the family.

DE010 (HH_MEMBERS) How many household members are supported by your total combined family income?

|___|___| (NUM_CHILD)

NUMBER

REFUSED -1 INCOME)

DON’T KNOW -2 (INCOME)

PROGRAMMER INSTRUCTION: RESPONSE MUST BE > 0; INCLUDE A SOFT EDIT IF RESPONSE IS > 15

DE010 (NUM_CHILD) How many of those people are children? Please include anyone under 18 years or anyone older than 18 years and in high school.

|___|___|

NUMBER (INCOME)

REFUSED -1 (INCOME)

DON’T KNOW -2 (INCOME)

PROGRAMMER INSTRUCTIONS:

• INCLUDE HARD EDIT IF RESPONSE > HH_MEMBERS

• INCLUDE SOFT EDIT IF RESPONSE > 10

DE011 (INCOME) Of these income groups, which category best represents your total combined family income during the last calendar year?

Less than $30,000 1

$30,000-$49,999 2

$50,000-$99,999 3

$100,000 or more 4

REFUSED -1

DON’T KNOW -2

MENTAL HEALTH

(TIME_STAMP_6) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PM001. Now, I will read a list of the ways you might have felt or behaved. Please look at this card, and tell me how often you have felt this way during the past week.

PM002. I was bothered by things that usually don’t bother me.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM003. I did not feel like eating; my appetite was poor.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM004. I felt that I could not shake off the blues even with help from my family or friends.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM005. I felt that I was just as good as other people.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM006. I had trouble keeping my mind on what I was doing.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM007. I felt depressed.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM008. I felt that everything I did was an effort.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM009. I felt hopeful about the future.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM010. I thought my life had been a failure.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM011. I felt fearful.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM012. My sleep was restless.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM013. I was happy.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM014. I talked less than usual.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM015. I felt lonely.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM016. People were unfriendly.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM017. I enjoyed life.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM018. I had crying spells.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM019. I felt sad.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM020. I felt that people dislike me.

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

PM021. I could not get “going.”

SHOW CARD PM1.

RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1

SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2

OCCASIONALLY OR A MODERATE AMOUNT OF TIME

(3-4 DAYS) 3

MOST OR ALL OF THE TIME (5-7 DAYS) 4

REFUSED -1

DON’T KNOW -2

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS: PART 2

(TIME_STAMP_7) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

DM001. These next questions are about your background and culture.

DM002. Were you born in the United States?

YES 1 (DM005)

NO 2

REFUSED -1 (DM005)

DON’T KNOW -2 (DM005)

DM004. About how long have you lived in the United States?

INTERVIEWER INSTRUCTION:

IF LESS THAN ONE YEAR, ENTER “00”.

|___|___|

YEARS

REFUSED -1

DON’T KNOW -2

DM005. Was your mother born in the United States?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DM007. Was your father born in the United States?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DM012. Now I’m going to switch the subject and ask about health insurance.

DM013. Do you currently have insurance through a current or former employer or union (of yourself or another family member)?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DM014. (Do you currently have):

Insurance purchased directly from an insurance company (by yourself or another family member)?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DM015. (Do you currently have:)

Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DM016. (Do you currently have:)

TRICARE, VA, or other military health care?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DM017. (Do you currently have:)

Indian Health Service?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DM018. (Do you currently have:)

Medicare, for people 65 and older, or people with certain disabilities?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DM019. (Do you currently have:)

Any other type of health insurance or health coverage plan?

YES (SPECIFY): 1

NO 2

REFUSED -1

DON’T KNOW -2

SOCIAL RESOURCES

(TIME_STAMP_9) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

SOCIAL NETWORK:

I’d like to ask you about your contact with other people.

SR001. On a normal day, how many people do you communicate with? (including nodding, saying hi, talking, calling, writing, through the Internet, acquaintances or not, all added together).

|___|___|

NUMBER OF PEOPLE

REFUSED -1

DON’T KNOW -2

SR002. How often do you see, write or talk on the telephone with family or relatives who do not live with you? Would you say nearly everyday, at least once a week, a few times a month, at least once a month, a few times a year, hardly ever or never?

NEARLY EVERYDAY (4 OR MORE TIMES A WEEK) 01

AT LEAST ONCE A WEEK (1 TO 3 TIMES) 02

A FEW TIMES A MONTH (2 TO 3 TIMES) 03

AT LEAST ONCE A MONTH 04

A FEW TIMES A YEAR 05

HARDLY EVER 06

NEVER 08

REFUSED -1

DON’T KNOW 9—98

SOCIAL SUPPORT:

Now, I’m going to ask about your feelings and thoughts.

SR003. How often do you get the social and emotional support you need?

INTERVIEWER INSTRUCTION: If asked, read “Please include support from any source.

SHOW CARD SR02.

ALWAYS 01

USUALLY 02

SOMETIMES 03

RARELY 04

NEVER 05

REFUSED -1

DON’T KNOW -2

INVOLVEMENT

(TIME_STAMP_10) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

GENERAL INVOLVEMENT:

PI001. Now I'd like to ask about your spouse or partner's current pregnancy. Did you feel that she became pregnant sooner than you wanted, later than you wanted or at about the right time?

SOONER 1

LATER 2

AT ABOUT THE RIGHT TIME 3

REFUSED -1

DON’T KNOW -2

PI003. Have you done any of the following? {FOR EACH ITEM, FATHERS SHOULD INDICATE YES/NO. THE SIX ITEMS ARE SUMMED WITH HIGHER SCORES INDICATING GREATER INVOLVEMENT}

PI004. Discussed the pregnancy with spouse/partner?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PI005. Seen a sonogram/ultrasound?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PI006. Listened to baby’s heartbeat?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PI007. Felt baby move?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PI008. Attended childbirth or Lamaze classes?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PI008. Bought things for the baby?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

GENERAL COMMITMENT:

PI014. Do you plan to be present at the birth?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PI014. Will the {baby/babies} have your last name?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PI014. Do you want the {baby/babies} to have your last name?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PI017. Will any of your family members be present for the birth?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PI018. Do you want any of your family members to be present for the birth?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

BELIEFS ABOUT INVOLVEMENT:

PI021. Here are some statements that men have made about their role as fathers. For each of the following statements, please indicate whether you strongly agree, agree, disagree, or strongly disagree with the statement.?

PI022. It is essential for the child's well being that fathers spend time playing with their children.

SHOW CARD PI01.

STRONGLY AGREE 1

AGREE 2

DISAGREE 3

STRONGLY DISAGREE 4

REFUSED -1

DON’T KNOW -2

PI023. It is difficult for men to express affectionate feelings toward babies.

SHOW CARD PI01.

STRONGLY AGREE 1

AGREE 2

DISAGREE 3

STRONGLY DISAGREE 4

REFUSED -1

DON’T KNOW -2

PI024. A father should be as heavily involved as the mother in the care of the child.

SHOW CARD PI01.

STRONGLY AGREE 1

AGREE 2

DISAGREE 3

STRONGLY DISAGREE 4

REFUSED -1

DON’T KNOW -2

PI025. The way a father treats his baby has long-term effects on the child.

SHOW CARD PI01.

STRONGLY AGREE 1

AGREE 2

DISAGREE 3

STRONGLY DISAGREE 4

REFUSED -1

DON’T KNOW -2

PI026. The activities a father does with his children don't matter. What matters more is whether he provides for them.

SHOW CARD PI01.

STRONGLY AGREE 1

AGREE 2

DISAGREE 3

STRONGLY DISAGREE 4

REFUSED -1

DON’T KNOW -2

PI027. One of the most important things a father can do for his children is to give their mother encouragement and emotional support.

SHOW CARD PI01.

STRONGLY AGREE 1

AGREE 2

DISAGREE 3

STRONGLY DISAGREE 4

REFUSED -1

DON’T KNOW -2

PI028. All things considered, fatherhood is a highly rewarding experience.

SHOW CARD PI01.

STRONGLY AGREE 1

AGREE 2

DISAGREE 3

STRONGLY DISAGREE 4

REFUSED -1

DON’T KNOW -2

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.