Form 21.1 Survey

OMB #: 0925-0593

Expiration Date: 07/31/2013

Biospecimen Urine Collection, Phase II

Recruitment Strategy Substudy

Event Name(s):

Birth Visit Interview (LI)

Instrument Name(s) and Versions:

Birth Visit Interview (LI) – 1.1

Recruitment Groups:

Low Intensity

Birth Visit Interview (LI)

TABLE OF CONTENTS

INTERVIEW INTRODUCTION 1

INTERVIEWER-COMPLETED QUESTIONS 1

BABY CHARACTERISTICS 2

HOUSING CHARACTERISTICS 3

ENVIRONMENTAL EXPOSURES 5

INFANT FEEDING 6

INFANT SLEEP 7

WELL BABY CARE AND IMMUNIZATIONS 8

WORK AND PLANS FOR CHILDCARE 9

TRACING QUESTIONS 11

INTERVIEWER-COMPLETED QUESTIONS 17

Birth Visit Interview (LI)

INTERVIEW INTRODUCTION

(TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

VS001.Thank you for agreeing to participate in the National Children’s Study. This interview will take about 20 minutes. Your answers are important to us. There are no right or wrong answers. We will ask you about yourself, your baby’s birth, and your plans for taking care of your baby. You can skip over any question or stop the interview at any time. We will keep everything that you tell us confidential.

VS002. INTERVIEWER INSTRUCTION: IF ADDITIONAL INFORMATION IS NEEDED, SAY [You may be receiving government benefits, such as Social Security or Medicaid. Nothing will happen to those benefits if you decide to take part or not take part in this study.]

VS003. INTERVIEWER INSTRUCTION: CONTINUE UNLESS RESPONDENT ASKS QUESTIONS OR REFUSES TO PARTICIPATE. IF RESPONDENT REFUSES, DISPOSITION CONTACT AS A REFUSAL AND COMPLETE A NON-INTERVIEW REPORT.

INTERVIEWER-COMPLETED QUESTIONS

(MULTIPLE) wAS THIS A MULTIPLE BIRTH?

YES 1 (MULTIPLE_NUM)

NO 2 (BABY_NAME)

(MULTIPLE_NUM) HOW MANY BABIES WERE DELIVERED?

|___|___|

NUMBER

(CHILD_DOB) WHAT WAS THE BABY’S DATE OF BIRTH?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED ……………………………………………………………….-1

DON’T KNOW -2

Baby Characteristics

PROGRAMMER INSTRUCTIONS:

• LOOP THROUGH QUESTIONS (BABY_NAME - BABY_BWT) FOR TOTAL NUMBER OF BABIES DELIVERED

• BASED ON NUMBER OF LOOPS, DISPLAY APPROPRIATE ADJECTIVES (E.G. “FIRST” OR “NEXT,” “BABY” OR “BABIES”

BC001/ (BABY_NAME) During this interview, we would like to refer to your {baby/babies} by name.

[IF SINGLE BABY] What name would you like me to use to talk about your baby?

[IF TWIN OR OTHER MULTIPLES] Let’s start with your first [twin/triplet/higher order birth. What name would you like me to use to talk about your [first/next] baby?

NAME PROVIDED 1

INITIALS PROVIDED 2

NO OFFICIAL NAME SELECTED 3

REFUSED -1

DON’T KNOW -2

BC002. INTERVIEWER INSTRUCTION: ENTER TEXT AND CONFIRM SPELLING

_____________________

FIRST NAME

(BABY_FNAME)

REFUSED -1

DON’T KNOW -2

_____________

MIDDLE NAME

(BABY_MNAME)

REFUSED -1

DON’T KNOW -2

___________________

LAST NAME

(BABY_LNAME)

REFUSED -1

DON’T KNOW -2

BC007/(BABY_SEX) INTERVIEWER ADMINISTERED QUESTION: WHAT IS THE SEX OF THE BABY?

BOY 1

GIRL 2

REFUSED -1

DON’T KNOW -2

BC007A/(BABY_BWT_LB)/(BABY_BWT_OZ) How much did [BABY_NAME] weigh when [he/she] was born?

POUNDS: |___|___|

P P

OUNCES: |___|___|

O O

REFUSED ……………………………………………………………….-1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: IF MULTIPLE BIRTHS, PRE-FILL EITHER “your babies” OR ACTUAL NAMES – SEPARATED BY “and” AS APPROPRIATE THROUGHOUT QUESTIONNAIRE

BC008/(LIVE_MOM) Does {[BABY’S NAME]/your babies} live with you? ALT – IF BABY STILL IN HOSPITAL: When {[BABY’S NAME]/your babies} leave the hospital, will [he/she/they] live with you?

YES 1 (RECENT_MOVE)

NO 2

REFUSED -1

DON’T KNOW -2

BC009. (LIVE_OTH) With whom does [he/she/they] live? ALT – IF BABY STILL IN HOSPITAL: With whom will [he/she/they] live?

BABY’S FATHER 1

BABY’S GRANDPARENT(S) 2

OTHER FAMILY MEMBER 3

PLACING IN FOSTER CARE 4

PLACING FOR ADOPTION 5

REFUSED -1

DON’T KNOW -2

BC010/(TIME_STAMP_2) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HOUSING CHARACTERISTICS

HC001/ (RECENT_MOVE) Have you moved or changed your housing situation since we contacted you last?

YES 1

NO 2 (TIME_STAMP_3)

REFUSED -1 (TIME_STAMP_3)

DON’T KNOW -2 (TIME_STAMP_3)

HC004/(OWN_HOME) Is your current home…

Owned or being bought by you or someone in your household 1

Rented by you or someone in your household, or 2

SOME OTHER ARRANGEMENT (OWN_HOME_OTH) -5

REFUSED -1

DON’T KNOW -2

HC005. (OWN_HOME_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

HC006/(AGE_HOME) Can you tell us when your home or building was built? Was it between…

2001 to present, 1

1981 to 2000, 2

1961 to 1980, 3

1941 to 1960, or 4

1940 or before 5

REFUSED -1

DON’T KNOW -2

HC007/(LENGTH_RESIDE)/(LENGTH_RESIDE_UNIT) How long have you lived in this home?

|___|___|

NUMBER

WEEKS 1

MONTHS 2

YEARS 3

REFUSED -1

DON’T KNOW -2

HC009/INTERVIEWER INSTRUCTION: ENTER IN NUMERIC VALUE AND SELECT ASSOCIATED UNIT OF TIME

PROGRAMMER INSTRUCTION: INCLUDE SOFT EDIT IF VALUE > 18 YEARS

HC010/(TIME_STAMP_3) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

ENVIRONMENTAL EXPOSURES

EE001/(RENOVATE) The next few questions ask about any recent additions or renovations to your home.

Since our last contact, have any additions been built onto your home to make it bigger or renovations or other construction been done in your home? Include only major projects. Do not count smaller projects such as painting or wallpapering, carpeting, or refinishing floors..

YES 1

NO 2 (DECORATE)

REFUSED -1 (DECORATE)

DON’T KNOW -2 (DECORATE)

EE002/(RENOVATE_ROOM) Which rooms were renovated?

INTERVIEWER INSTRUCTION: SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

BABY’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER (RENOVATE_ROOM_OTH) - 5

REFUSED -1

DON’T KNOW -2

EE003. (RENOVATE_ROOM_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

EE004/(DECORATE) Since our last contact, were any smaller projects done in your home, such as painting, wallpapering, refinishing floors, or installing new carpet?

YES 1

NO 2 (SMOKE)

REFUSED - 1 (SMOKE)

DON’T KNOW -2 (SMOKE)

EE005/(DECORATE_ROOM) In which rooms were these smaller projects done?

INTERVIEWER INSTRUCTION: SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

BABY’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER (DECORATE_ROOM_OTH) - 5

REFUSED -1

DON’T KNOW -2

EE006. (DECORATE_ROOM_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

EE007/(SMOKE) Currently, do you or others in your household smoke cigarettes, cigarillos, cigars, pipes or other tobacco products?

YES 1

NO 2 (TIME_STAMP_4)

REFUSED -1 (TIME_STAMP_4)

DON’T KNOW -2 (TIME_STAMP_4)

EE008/(SMOKE_LOCATE) Do those who smoke usually smoke indoors, outdoors, or both indoors and outdoors?

INDOORS 1

OUTDOORS 2

BOTH 3

REFUSED -1

DON’T KNOW -2

EE009. (TIME_STAMP_4) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

INFANT FEEDING

IF001/(FED_BABY) - SKIP THIS QUESTION UNLESS BABY HAS NOT BEEN RELEASED FROM HOSPITAL Have you fed {[BABY’S NAME]/your babies} since [his/her/their] birth?

YES 1

NO 2 (PLAN_FEED)

REFUSED -1

DON’T KNOW -2

IF002/(HOW_FED) How have you fed {[BABY’S NAME]/your babies}? Did you breast or bottle feed?

BREAST 1

BOTTLE 2

BOTH BREAST AND BOTTLE 3

REFUSED -1

DON’T KNOW -2

IF003/(PLAN_FEED) Have you fed the {baby/babies} breast milk, formula or both?

BREAST MILK 1

FORMULA 2

BOTH BREAST MILK AND FORMULA 3

REFUSED -1

DON’T KNOW -2

IF004/(TIME_STAMP_5) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

INFANT SLEEP

IS001/(POS_HOSP) SKIP THIS QUESTION UNLESS BABY HAS NOT BEEN RELEASED FROM THE HOSPITAL Do the nurses here in the hospital usually put {[BABY’S NAME]/your babies} to sleep on [his/her/their] stomach(s), back(s), or side(s)?

STOMACH 1

BACK 2

SIDE 3

REFUSED -1

DON’T KNOW -2

IS002/(POS_HOME) In what position do you usually put {[BABY’S NAME]/your babies} to sleep at home? [ALT – IF BABY HAS NOT BEEN RELEASED FROM HOSPITAL ASK: In what position do you plan to put {[BABY’S NAME]/your babies} to sleep at home?]

STOMACH 1

BACK 2

SIDE 3

REFUSED -1

DON’T KNOW -2

IS003/(SLEEP_ROOM) [Does/Do] {[BABY’S NAME/your babies}] sleep… [ALT – IF BABY HAS NOT BEEN RELEASED FROM HOSPITAL ASK: When you go home from the hospital do you plan for {[BABY’S NAME/your babies}] to sleep…]

In [his/her/their] own room, 1

In a room with other children, 2

In your bedroom, or 3

Another location? 4

REFUSED -1

DON’T KNOW -2

IS004/(BED) … [Does/Do] {[BABY’S NAME/your babies}] sleep in… [ALT – IF BABY HAS NOT BEEN RELEASED FROM HOSPITAL ASK: When you go home from the hospital do you plan for {[BABY’S NAME]/your babies} to sleep in …]

A bassinette, 1

A crib, 2

A co-sleeper, 3

An adult bed alone, 4

An adult bed with you, 5

An adult bed with another child, or 6

Something else (BED_OTH) -5

REFUSED -1

DON’T KNOW -2

IS005. (BED_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

IS006/(TIME_STAMP_6) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

WELL BABY CARE AND IMMUNIZATIONS

WB00.5 (HCARE_YET) Have you taken your new {baby/babies} for any well-baby checkups?

Yes 1

No 2

REFUSED -1

DON’T KNOW -2

WB001/ (HCARE) Where [have you taken/do you plan to take] your new {baby/babies} for well-baby checkups?

Hospital clinic 1

Health department clinic 2

Private doctor’s office or HMO 3

Other (HCARE_OTH) -5

REFUSED -1

DON’T KNOW -2

WB002/ (HCARE_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

WB003.5 (HCARE_YET) Have you taken your new {baby/babies} to have any well-baby shots or vaccinations?

Yes 1 (SKIP TO TIME_STAMP_7)

No 2

REFUSED -1

DON’T KNOW -2

WB003/ (VACCINE) Do you plan for your new {baby/babies} to have well-baby shots or vaccinations?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

WB004/ (TIME_STAMP_7) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

WORK AND PLANS FOR CHILDCARE

CC001/(EMPLOY2) Are you currently employed?

YES 1

NO 2 (CHILDCARE)

REFUSED -1

DON’T KNOW -2

CC002.2 /(RETURN_JOB_YET) Have your returned to your current job?

YES 1

NO 2 (CC002)

REFUSED -1

DON’T KNOW -2

CC002.5 /(RETURN_JOB_DT)When did you return to your job?

|___|___|/|___|___|/|___|___|

DATE

REFUSED -1

DON’T KNOW -2

GO TO CC004

CC002/(RETURN_JOB) When do you plan to return to your current job?

|___|___|

NUMBER

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DOESN’T PLAN TO RETURN TO WORK 5

REFUSED -1

DON’T KNOW -2

CC003. INTERVIEWER INSTRUCTION: ENTER IN NUMERIC VALUE AND SELECT ASSOCIATED UNIT OF TIME

PROGRAMMER INSTRUCTION: INCLUDE SOFT EDIT IF VALUE > 1 YEAR

CC004/ (CHILDCARE) Next I would like to ask you a few questions about your plans for childcare.

Does {(BABY’S NAME)/your babies} or will [he/she/they] receive regularly scheduled care from someone other than you or the {baby’s/babies’} father?

YES 1

NO 2 (TIME_STAMP_8)

REFUSED -1

DON’T KNOW -2

CC005/(CCARE_TYPE) Please describe the type of setting in which most of the childcare [occurs/will occur].

PARTICIPANT’S HOME 1

OTHER PRIVATE HOME 2

CHILD CARE CENTER 3

OTHER (CCARE_TYPE_OTH) -5

REFUSED -1

DON’T KNOW -2

CC006. (CCARE_TYPE_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

CC007/ (CCARE_WHO) Which best describes the person who [cares/will be caring] for {[BABY’S NAME]/your babies}?

YOUR MOTHER 1

YOUR FATHER 2

YOUR MOTHER IN-LAW 3

YOUR FATHER IN-LAW 4

GUARDIAN 5

OTHER RELATIVE (REL_CARE_OTH) 6

FRIEND 7

NANNY 8

PROFESSIONAL IN HOME DAYCARE 9

PROFESSIONAL CENTER BASED DAYCARE 10

OTHER (CCARE_WHO_OTH) - 5

REFUSED -1

DON’T KNOW -2

CC008. (REL_CARE_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

CC009. (CCARE_WHO_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

CC010/ (TIME_STAMP_8) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TRACING QUESTIONS

TR001. These next few questions will help us to contact you again in the future.

TR002/ (R_FNAME)/(R_LNAME) What is your full name?

INTERVIEWER INSTRUCTION: CONFIRM SPELLING OF FIRST NAME IF NOT PREVIOUSLY COLLECTED AND OF LAST NAME FOR ALL RESPONDENTS.

_____________________ ___________________

FIRST NAME LAST NAME

REFUSED -1

DON’T KNOW -2

TR003/ (PHONE_NBR) What is the best phone number to reach you?

INTERVIEWER INSTRUCTION: ENTER PHONE NUMBER AND CONFIRM.

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

RESPONDENT HAS NO TELEPHONE 1 (HOME_PHONE)

REFUSED -1 (HOME_PHONE)

DON’T KNOW -2 (HOME_PHONE)

TR004/ INTERVIEWER INSTRUCTION: IF RESPONDENT DOES NOT HAVE A TELEPHONE NUMBER, ASK WHERE RESPONDENT RECEIVES TELEPHONE CALLS, EVEN IF THEY DO NOT HAVE THEIR OWN PHONE. ASK FOR AND RECORD THAT NUMBER.

TR005/(PHONE_TYPE) Is that your home, work, cell, or another phone number?

INTERVIEWER INSTRUCTION: CONFIRM IF KNOWN.

HOME 1 (CELL_PHONE_1)

WORK 2

CELL 3

FRIEND/RELATIVE 4 (FRIEND_PHONE_OTH)

OTHER -5 (PHONE_TYPE_OTH)

REFUSED -1

DON’T KNOW -2

TR006. (FRIEND_PHONE_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

TR007. (PHONE_TYPE_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

TR008/(HOME_PHONE) What is your home phone number?

INTERVIEWER INSTRUCTION: ENTER PHONE NUMBER AND CONFIRM.

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

NO HOME NUMBER 1

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: IF (PHONE_TYPE)/TR005 = 3 (CELL) THEN SKIP (CELL_PHONE_1)/TR00X AND GO TO (CELL_PHONE_2)/TR106.

TR00X/(CELL_PHONE_1). Do you have a personal cell phone?

YES 1

NO 2 (TIME_STAMP_9)

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

TR106./(CELL_PHONE_2). May we use your personal cell phone to make future study appointments or for appointment reminders?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

TR107/(CELL_PHONE_3). Do you send and receive text messages on your personal cell phone?

YES 1

NO 2 (CELL_PHONE)

REFUSED -1 (CELL_PHONE)

DON’T KNOW -2 (CELL_PHONE)

TR108/(CELL_PHONE_4). May we send text messages to make future study appointments or for appointment reminders?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: IF (PHONE_TYPE)/TR005 = 3 (CELL) AND VALID NUMBER PROVIDED IN (PHONE_NBR) SKIP (CELL_PHONE)/TR109.

TR109/(CELL_PHONE). What is your personal cell phone number?

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

PHONE NUMBER

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_9) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTION: IF (RECENT_MOVE) = 1 (YES) THEN GO TO HC002/(MOVE_INFO) ELSE GO TO TR009/(SAME_ADDR).

HC002/(MOVE_INFO) What is the address of your [new] home?

ADDRESS KNOWN 1

OUT OF THE COUNTRY 2 (SAME_ADDR)

PO BOX ADDRESS ONLY 3

REFUSED -1 (SAME_ADDR)

DON’T KNOW -2 (SAME_ADDR)

HC003/(NEW ADDRESS VARIABLES) INTERVIEWER INSTRUCTION: PROBE AND ENTER AS MUCH INFORMATION AS R KNOWS.

_____________________________________________________

(NEW_ADDRESS1) ADDRESS 1 - STREET/PO BOX

_____________________________________________________

(NEW_ADDRESS2) ADDRESS 2

_____________________________________________________

(NEW_UNIT) UNIT

____________________________________________________

(NEW_CITY) CITY

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

STATE ZIP CODE ZIP+4

(NEW_STATE) (NEW_ZIP) (NEW_ZIP4)

REFUSED -1

DON’T KNOW -2

TR009/(SAME_ADDR) Is your mailing address the same as your street address?

YES 1/ (HAVE_EMAIL)

NO 2 (MAILING ADDRESS VARIABLES)

REFUSED -1(HAVE_EMAIL)

DON’T KNOW -2(HAVE_EMAIL)

TR010/ (MAILING ADDRESS VARIABLES) What is your mailing address?

INTERVIEWER INSTRUCTION: PROMPT AS NECESSARY TO COMPLETE INFORMATION

_____________________________________________________

(MAIL_ADDRESS1) ADDRESS 1 - STREET/PO BOX

_____________________________________________________

(MAIL_ADDRESS2) ADDRESS 2

_____________________________________________________

(MAIL_UNIT) UNIT

____________________________________________________

(MAIL_CITY) CITY

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

STATE ZIP CODE ZIP+4

(MAIL_STATE) (MAIL_ZIP) (MAIL_ZIP4)

REFUSED -1

DON’T KNOW -2

TR011/(HAVE_EMAIL) Do you have an email address?

YES 1

NO 2 (PLAN_MOVE)

REFUSED -1 (PLAN_MOVE)

DON’T KNOW - 2 (PLAN_MOVE)

TR012/(EMAIL) What is the best email address to reach you?

ENTER E-MAIL ADDRESS: ___________________________ (EMAIL_TYPE)

REFUSED -1 (PLAN_MOVE)

DON’T KNOW -2 (PLAN_MOVE)

PROGRAMMER INSTRUCTION: SHOW EXAMPLE OF VALID EMAIL ADDRESS SUCH AS [email protected]

TR013/(EMAIL_TYPE) Is that your personal e-mail, work e-mail, or a family or shared e-mail address?

PERSONAL 1

WORK 2

FAMILY/SHARED 3 (EMAIL_SHARE)

REFUSED -1

DON’T KNOW -2

TR014/(EMAIL_SHARE)

PROGRAMMER INSTRUCTIONS: IF RESPONDENT REPORTED A SHARED EMAIL ADDRESS IN (EMAIL_TYPE), SET (EMAIL_SHARE) AS APPROPRIATE THEN GO TO (PLAN_MOVE)

YES 1 (PLAN_MOVE)

NO 2 (PLAN_MOVE)

TR015/(PLAN_MOVE) Do you plan on moving from your present address in the next few months?

YES 1 (WHERE_MOVE)

NO (TIME_STAMP_10)

REFUSED (TIME_STAMP_10)

DON’T KNOW (TIME_STAMP_10)

TR016/ (WHERE_MOVE) Do you know where you will be moving?

YES 1 (MOVE_INFO)

NO 2 (WHEN_MOVE)

REFUSED -1 (WHEN_MOVE)

DON’T KNOW -2 (WHEN_MOVE)

TR017/(MOVE_INFO) What is the address of your new home?

ADDRESS KNOWN 1 (NEW ADDRESS VARIABLES)

OUT OF THE COUNTRY 2 (WHEN_MOVE)

PO BOX ADDRESS ONLY 3 (NEW ADDRESS VARIABLES)

REFUSED -1 (WHEN_MOVE)

DON’T KNOW -2 (WHEN_MOVE)

TR018/(NEW ADDRESS VARIABLES) ENTER ADDRESS

INTERVIEWER INSTRUCTION: PROBE AND ENTER AS MUCH INFORMATION AS R KNOWS.

_____________________________________________________

(NEW_ADDRESS1) ADDRESS 1 - STREET/PO BOX

_____________________________________________________

(NEW_ADDRESS2) ADDRESS 2

_____________________________________________________

(NEW_UNIT) UNIT

____________________________________________________

(NEW_CITY) CITY

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

STATE ZIP CODE ZIP+4

(NEW_STATE) (NEW_ZIP) (NEW_ZIP4)

REFUSED -1

DON’T KNOW -2

TR019/ (WHEN_MOVE) Do you know when you will be moving?

YES 1 (DATE_MOVE)

NO 2

REFUSED -1

DON’T KNOW -2

TR020/(DATE_MOVE) When will you move?

MONTH: |___|___|

M M

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: FORMAT DATE_MOVE AS YYYYMM

TR021/(TIME_STAMP_10) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TR022/(END_OF_INTERVIEW) Thank you for participating in the National Children’s Study and for taking the time to answer our questions.

INTERVIEWER-COMPLETED QUESTIONS

IC001. (TIME_STAMP_11) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IC002/ (RESPONDENT) WAS THE INTERVIEW COMPLETED WITH THE BIRTH MOTHER OR A PROXY?

BIRTH MOTHER 1

PROXY 2

IC003/ (CONTACT_TYPE) IN WHAT MODE WAS THE QUESTIONNAIRE ADMINISTERED?

IN-PERSON 1

TELEPHONE 2

MAIL 3

WEB 4

IC004/(ENGLISH) WAS THIS DATA COLLECTION SESSION CONDUCTED IN ENGLISH?

YES 1 (INTERPRET)

NO 2 (CONTACT_LANG)

IC005/ (CONTACT_LANG) WHAT OTHER LANGUAGE WAS USED TO CONDUCT THIS SESSION?

SPANISH 1

ARABIC 2

CHINESE 3

FRENCH 4

FRENCH CREOLE 5

GERMAN 6

ITALIAN 7

KOREAN 8

POLISH 9

RUSSIAN 10

TAGALOG 11

VIETNAMESE 12

URDU 13

PUNJABI 14

BENGALI 15

FARSI 16

OTHER (CONTACT_LANG_OTH) -5

IC006. (CONTACT_LANG_OTH)

SPECIFY ________________________

IC007/(INTERPRET) WAS AN INTERPRETER USED?

YES 1 (CONTACT_INTERPRET)

NO 2 (TIME_STAMP_12)

IC008/(CONTACT_INTERPRET) WHAT TYPE OF INTERPRETER WAS USED?

BILINGUAL INTERVIEWER 1

IN-PERSON PROFESSIONAL INTERPRETER 2

IN-PERSON FAMILY MEMBER INTERPRETER 3

LANGUAGE-LINE INTERPRETER 4

VIDEO INTERPRETER 5

SIGN LANGUAGE INTERPRETER 6

OTHER (CONTACT_INTERPRET_OTH) - 5

IC009. (CONTACT_ INTERPRET_OTH)

SPECIFY ________________________

IC010. (TIME_STAMP_12) 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.