Form 25.1 Survey

IN001 We are about to begin the interview portion of today’s home visit, which will take about 25 minutes to complete. Your answers are important to us. There are no right or wrong answers. There are questions about your child’s health and health care as well as your child’s behaviors, such as sleeping and eating. We will also ask you about some of your own experiences and feelings, as well as your day to day routines. You can skip over any question or stop the interview at any time. We will keep everything that you tell us confidential.

INTERVIEWER COMPLETED QUESTIONS

INTERVIEWER INSTRUCTIONS: DO NOT ADMINISTER THESE QUESTIONS TO THE PARTICIPANT.

IN004 (MULT_CHILD) IS THERE MORE THAN ONE CHILD OF THIS MOTHER ELIGIBLE FOR THE 6 MONTH VISIT TODAY?

YES	…………………………………………………….	1
NO	…………………………………………………….	2	(CHILD_SEX)

IN006 (CHILD_NUM) HOW MANY CHILDREN OF THIS MOTHER ARE ELIGIBLE FOR THE 6 MONTH VISIT TODAY?

|___|___|

NUMBER OF CHILDREN

PROGRAMMER INSTRUCTION: IF MULT_CHILD = 1; LOOP AND COMPLETE SEPARATE QUESTIONNAIRE FOR EACH ELIGIBLE CHILD RECORDED IN CHILD_NUM

IN009 (CHILD_QNUM) WHICH NUMBER CHILD IS THIS QUESTIONNAIRE FOR?

|___|___|

PROGRAMMER INSTRUCTION: CHILD_QNUM CANNOT BE GREATER THAN CHILD_NUM

IN011 (CHILD_SEX) IS (CHILD_QNUM) A BOY OR GIRL?

BOY	…………………………………………………….	1
GIRL	…………………………………………………….	2

PROGRAMMER INSTRUCTION: USE (CHILD_SEX) TO CODE {his/her} AND {he/she} FIELDS AS APPROPRIATE THROUGHOUT INSTRUMENT

Participant Verification

PV001 First, we’d like to make sure we have your child’s correct name and birth date.

PV004 (CNAME_CONFIRM). Is your child’s name _____[INSERT NAME]___________?

YES	…………………………………	1	(CDOB_CONFIRM)
NO	…………………………………	2	(C_FNAME)(C_LNAME)
REFUSED	…………………………………	-1	(C_FNAME)(C_LNAME)
DON’T KNOW	…………………………………	-2	(C_FNAME)(C_LNAME)

PROGRAMMER INSTRUCTION: INSERT CHILD’S NAME IF KNOWN

PV007 (C_FNAME) (C_LNAME) What is your child’s full name?

_________________________ _________________________

FIRST NAME LAST NAME

(C_FNAME) (C_LNAME)

REFUSED	…………………………………	-1	(CDOB_CONFIRM)
DON’T KNOW	…………………………………	-2	(CDOB_CONFIRM)

INTERVIEWER INSTRUCTIONS:

CONFIRM SPELLING OF FIRST NAME IF NOT PREVIOUSLY COLLECTED AND OF LAST NAME FOR ALL CHILDREN.
IF RESPONDENT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS, ASK FOR INITIALS OR SOME OTHER NAME SHE WOULD LIKE HER CHILD TO BE CALLED

PROGRAMMER INSTRUCTION: IF RESPONDENT REFUSES TO PROVIDE NAME, INITIALS OR IDENTIFIER (C_FNAME AND C_LNAME=-1), USE “YOUR CHILD” FOR “C_FNAME” In remainder of questionnaire.

PV011 (CDOB_CONFIRM). Is {C_FNAME or YOUR CHILD}’S birth date [INSERT CHILD’S DATE OF BIRTH]?

YES	…………………………………	1	(TIME_STAMP_2)
NO	…………………………………	2	(CHILD_DOB)
REFUSED	…………………………………	-1	(CHILD_DOB)
DON’T KNOW	…………………………………	-2	(CHILD_DOB)

PROGRAMMER INSTRUCTIONS:

PRELOAD CHILD’S DOB IF KNOWN AS MM/DD/YYYY

IF RESPONSE = YES, SET CHILD_DOB TO KNOWN VALUE, FORMAT AS YYYYMMDD

INTERVIEWER INSTRUCTIONS: IF RESPONDENT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB HELPS DETERMINE ELIGIBILITY

PV016 (CHILD_DOB). What is {C_FNAME or YOUR CHILD}’s date of birth?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED	…………………………………	-1	(TIME_STAMP2)
DON’T KNOW	…………………………………	-2	(TIME_STAMP2)

INTERVIEWER INSTRUCTION:

IF RESPONDENT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB IS HELPS 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 4 MONTHS OR GREATER THAN 9 MONTHS
FORMAT CHILD_DOB AS YYYYMMDD

Child Development and Parenting

CDP001 (TIME_STAMP_2) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

First, I’d like to ask about {C_FNAME or YOUR CHILD} and you. I will read you a list of things {C_FNAME or YOUR CHILD} may already do or may start doing when {he/she} gets older. Does {C_FNAME or YOUR CHILD }…

CDP003 (EYES_FOLLOW) … Follow you with {his/her} eyes?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP004 (SMILE) … Smile when you smile at {him/her}?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP005 (REACH_1) … Try to get a toy that is out of reach?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP006 (FEED) … Feed {him/herself} a cracker or cereal?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP007 (WAVE) … Wave goodbye?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP008 (REACH_2) … Reach for toys or food held to {him/her}?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP009 (GRAB) … Grab an object like a block or rattle from you?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP010 (SWITCH_HANDS) … Move a toy or block from one hand to the other?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP011 (PICKUP) … Pick up a small object like a Cheerio or raisin?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP012 (HOLD) … Hold two toys or blocks at a time, one in each hand?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP013 (SOUND_2) … Turn towards a sound?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP014 (SOUND_3) … Turn toward someone when they’re speaking?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP015 (SPEAK_1) … Make sounds as though {he/she} is trying to speak?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP016 (SPEAK_2) … Say mama or dada?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP017 (HEADUP) … Keep head steady when sitting or held up?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP018 (ROLL_1) … Roll over from stomach to back?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP019 (ROLL_2) … Roll from back to stomach?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP020 (SITUP) … Sit up by {him/herself}?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP021 (STAND) … Stand while holding onto something?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

Sleep

SL001 (TIME_STAMP_3) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Now I’ll ask you about {C_FNAME or YOUR CHILD}’s sleeping.

SL003 (SLEEP_PLACE_1) Does {C_FNAME or YOUR CHILD} usually sleep in your bedroom or in a different room at night?

IN RESPONDENT’S ROOM ……………………………………………... 1

IN A DIFFERENT ROOM ………………………………………………… 2

BOTH IN RESPONDENT’S ROOM AND A DIFFERENT ROOM…….. 3

REFUSED…………………………………………………………………. -1

DON’T KNOW……………………………………………………………… -2

SL005 (SLEEP_PLACE_2) What does {C_FNAME or YOUR CHILD} sleep in at night?

A bassinette ………………………………………………………………. 1

A crib……………………………………………………………………….. 2

A co-sleeper……………………………………………………………….. 3

In the bed or other place with you……………………………………….. 4

In something else……………………………………………...-5 (SLEEP_PLACE_2_OTH)

REFUSED………………………………………………………………….. -1

DON’T KNOW………………………………………………………………. -2

SL006 (SLEEP_PLACE_2_OTH) OTHER SPECIFY

REFUSED………………………………………………………………….. -1

DON’T KNOW………………………………………………………………. -2

SL008 (SLEEP_POSITION_NIGHT) In what position do you most often lay {C_FNAME or YOUR CHILD} down to sleep at night? On the

Stomach……………………………………………………………………. 1

Back…………………………………………………………………………. 2

Side…………………………………………………………………………. 3

REFUSED…………………………………………………………………... -1

DON’T KNOW……………………………………………………………… -2

SL010 (SLEEP_POSITION_NAP) In what position do you most often lay {C_FNAME or YOUR CHILD} down for naps? On the

Stomach……………………………………………………………………. 1

Back…………………………………………………………………………. 2

Side…………………………………………………………………………. 3

REFUSED…………………………………………………………………... -1

DON’T KNOW……………………………………………………………… -2

SL012 (SLEEP_ROUTINE) Does {C_FNAME or YOUR CHILD} have a regular sleeping routine now?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

SL014 (SLEEP_HRS_DAY) Approximately how many hours does {C_FNAME or YOUR CHILD} sleep during the day?

|___|___|

HOURS

REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

SL016 (SLEEP_HRS_NIGHT) Approximately how many hours does {C_FNAME or YOUR CHILD} sleep at night?

|___|___|

HOURS

REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

SL018 (SLEEP_TIME_NIGHT) On a normal day, what time in the evening does {C_FNAME or YOUR CHILD} go to sleep?

|___|___|:|___|___|

TIME

REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

SL020 (SLEEP_TIME_WAKE) On a normal day, what time does {C_FNAME or YOUR CHILD} wake up in the morning?

|___|___|:|___|___|

TIME

REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

SL022 (SLEEP_DIFFICULT) How often is {C_FNAME or YOUR CHILD} difficult when {he/she} is put to bed?

Most of the time ……………………………………………………………. 1

Often ………………………………………………………………………… 2

Sometimes …………………………………………………………………. 3

Rarely ……………………………………………………………………….. 4

Never ……………………………………………………………………….. 5

REFUSED ………………………………………………………………… -1

DON’T KNOW……………………………………………………………… -2

SL024(SLEEP_THROUGH) How often does {C_FNAME or YOUR CHILD} wake at night?

Never ……………………………………………………………………….. 1

Occasionally ……………………………………………………………….. 2

Most nights ………………………………………………………………… 3

Every night …………………………………………………………………. 4

More than once per night …………………………………………………. 5

REFUSED ………………………………………………………………… -1

DON’T KNOW …………………………………………………………….. -2

Health and Medical Conditions

MC001 (TIME_STAMP_4) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Now I’d like to change the subject and ask about {C_FNAME or YOUR CHILD}’s health and about some medical conditions {he/she} may have had.

MC003 (C_HEALTH) Since {C_FNAME or YOUR CHILD} was born, would you say {his/her} health has been poor, fair, good, excellent?

POOR……………………………………………………………………….. 1

FAIR ………………………………………………………………………… 2

GOOD ………………………………………………………………………. 3

EXCELLENT ………………………………………………………………. 4

REFUSED …………………………………………………………………. -1

DON’T KNOW ……………………………………………………………… -2

MC005 (COLD) Has {C_FNAME or YOUR CHILD} ever had a runny nose, cough, or cold?

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

MC007 (COLD_AGE) How old was {he/she or YOUR CHILD} when {he/she or YOUR CHILD} first had a runny nose, cough, or cold?

|___|___| (COLD_AGE_UNIT)

NUMBER

REFUSED…………………………………………………………. -1

DON’T KNOW…………………………………………………….. -2

MC009 (COLD_AGE_UNIT)

DAYS ……………………………………………………………… 1

WEEKS ……………………………………………………………. 2

MONTHS ………………………………………………………….. 3

REFUSED…………………………………………………………. -1

DON’T KNOW…………………………………………………….. -2

MC011 (EAR_INFECTION) Has {C_FNAME or YOUR CHILD} ever had an ear infection?

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

MC013 (EAR_INFECTION_AGE) How old was {he/she or YOUR CHILD} when {he/she or YOUR CHILD} first had an ear infection?

|___|___| (EAR_INFECTION_AGE_UNIT)

NUMBER

REFUSED…………………………………………………………. -1

DON’T KNOW…………………………………………………….. -2

MC015 (EAR_INFECTION_AGE_UNIT)

DAYS ……………………………………………………………… 1

WEEKS ……………………………………………………………. 2

MONTHS ………………………………………………………….. 3

REFUSED…………………………………………………………. -1

DON’T KNOW…………………………………………………….. -2

MC017 (GASTRO) Has {C_FNAME or YOUR CHILD} ever had diarrhea or vomiting?

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

MC019 (GASTRO_AGE) How old was {he/she or YOUR CHILD} when {he/she or YOUR CHILD} first had diarrhea or vomiting?

|___|___| (GASTRO_AGE_UNIT)

NUMBER

REFUSED…………………………………………………………. -1

DON’T KNOW…………………………………………………….. -2

MC021 (GASTRO_AGE_UNIT)

DAYS ……………………………………………………………… 1

WEEKS ……………………………………………………………. 2

MONTHS ………………………………………………………….. 3

REFUSED…………………………………………………………. -1

DON’T KNOW…………………………………………………….. -2

MC023 (RESPIRATORY) Has {C_FNAME or YOUR CHILD} ever had wheezing or whistling in the chest?

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

MC025 (RESPIRATORY_AGE) How old was {he/she or YOUR CHILD} when {he/she or YOUR CHILD} first had wheezing or whistling in the chest?

|___|___| (RESPIRATORY_AGE)

NUMBER

REFUSED…………………………………………………………. -1

DON’T KNOW…………………………………………………….. -2

(RESPIRATORY_AGE_UNIT)

DAYS ……………………………………………………………… 1

WEEKS ……………………………………………………………. 2

MONTHS ………………………………………………………….. 3

REFUSED…………………………………………………………. -1

DON’T KNOW…………………………………………………….. -2

MC027 (FEVER) Since {C_FNAME or YOUR CHILD} was born, on how many days has {he/she} had a fever over 101 degrees, not related to receiving immunizations? (IF NEEDED: or 38.3 degrees Celsius?)

|___|___|___|

NUMBER OF DAYS

INTERVIEWER INSTRUCTION: ENTER “0” IF NONE

REFUSED…………………………………………………………. -1

DON’T KNOW…………………………………………………….. -2

MC029 (FAIL_THRIVE) Has a doctor ever told you that {C_FNAME or YOUR CHILD} has failure to thrive, or any other concern about proper growth?

YES	……………………………………………	1
NO	……………………………………………	2
REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

Health Care

HC001 (TIME_STAMP_5) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

The next questions are about where {C_FNAME} goes for health care.

HC004 (R_HCARE). First, what kind of place does {C_FNAME or YOUR CHILD} usually go to when {he/she} needs routine or well-child care, such as a check-up or well-baby shots (immunizations)?

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 WELL-CHILD CARE ANYWHERE	………………………	7	(HCARE_SICK)
REFUSED	………………………	-1	(HCARE_SICK)
DON’T KNOW	………………………	-2	(HCARE_SICK)

HC007 (LAST_VISIT) What was the date of {C_FNAME or YOUR CHILD}’s most recent well-child visit or checkup?

MONTH: |___|___| (VISIT_WT)

M M

DAY: |___|___| (VISIT_WT)

D D

YEAR: |___|___|___|___| (VISIT_WT)

Y Y Y Y

HAS NOT HAD A VISIT	………………………………	-7	(SAME_CARE)
REFUSED	………………………………	-1	(SAME_CARE)
DON’T KNOW	………………………………	-2	(SAME_CARE)

INTERVIEWER INSTRUCTION:

SHOW CALENDAR TO ASSIST IN DATE RECALL.
ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR

HC010 (VISIT_WT) What was {C_FNAME or YOUR CHILD}’s weight at that visit?

|___|___|

Pounds

REFUSED	………………………………	-1
DON’T KNOW	………………………………	-2

PROGRAMMER INSTRUCTIONS: INCLUDE A SOFT EDIT IF WEIGHT < 10 OR > 25 POUNDS

HC013 (SAME_CARE) If {C_FNAME or YOUR CHILD} is sick or if you have concerns about {his/her or YOUR CHILD’S} health, does {he/she or YOUR CHILD} go to the same place as for well-child visits?

YES…………………………………………………………1 NO…………………………………………………………..2 REFUSED………………………………………………...-1 DON’T KNOW……………………………………………-2 NOT APPLICABLE / HAS NOT BEEN SICK……….…-7

HC016 (HCARE_SICK). What kind of place does {C_FNAME or YOUR CHILD} usually go to when {he/she or YOUR CHILD} is sick, doesn’t feel well, or if you have concerns about {his/her or YOUR CHILD’S} health?

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
REFUSED	………………………	-1
DON’T KNOW NOT APPLICABLE / HAS NOT BEEN SICK	………………………	-2 -7

Health Insurance

HI001 (TIME_STAMP_6) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Now I’m going to ask about health insurance. We have asked about this before. Sometimes, it changes, so we are going to ask again.

HI003 (INSURE).. Is {C_FNAME or YOUR CHILD} 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)

Now I’ll read a list of different types of insurance. Please tell me which types {C_FNAME} currently has. Does {C_FNAME} currently have…

INTERVIEWER INSTRUCTIONS: RE-READ INTRODUCTORY STATEMENT AS NEEDED

HI005 (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

HI007 (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

HI009 (INS_TRICARE) TRICARE, VA, or other military health care?

YES	……………………………………………	1
NO	……………………………………………	2
REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

HI011 (INS_IHS) Indian Health Service?

YES	……………………………………………	1
NO	……………………………………………	2
REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

HI013 (INS_MEDICARE) Medicare, for people with certain disabilities?

YES	……………………………………………	1
NO	……………………………………………	2
REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

HI015 (INS_OTH) Any other type of health insurance or health coverage plan?

YES	……………………………………………	1
NO	……………………………………………	2
REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

Child Care Arrangements

CC001 (TIME_STAMP_7) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Next, I’d like to ask you about different types of child care {C_FNAME or YOUR CHILD} may receive from someone other than parents or guardians. This includes regularly scheduled care arrangements with relatives and non-relatives, and day care or early childhood programs, whether or not there is a charge or fee, but not occasional baby-sitting.

CC003 (CHILDCARE) Does {C_FNAME or YOUR CHILD} currently receive any regularly scheduled care from someone other than a parent or guardian, for example from relatives, friends or other non-relatives, or a child care center or program?

YES	……………………………………………	1
NO	……………………………………………	2	(TIME_STAMP_8)
REFUSED	……………………………………………	-1	(TIME_STAMP_8)
DON’T KNOW	……………………………………………	-2	(TIME_STAMP_8)

CC005 (FAMILY_CARE) Does {C_FNAME or YOUR CHILD} receive any care from relatives, for example, from grandparents, brothers or sisters, or any other relatives. This includes all regularly scheduled care arrangements with relatives that happen at least weekly, but does not include occasional baby-sitting.

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

CC007 (FAMILY_CARE_HRS) Approximately how many total hours each week does {C_FNAME or YOUR CHILD} receive care from relatives?

|___|___|

NUMBER OF HOURS PER WEEK

REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

PROGRAMMER INSTRUCTION: INCLUDE SOFT EDIT IF RESPONSE EXCEEDS 50 HOURS PER WEEK

Home Care

CC009 Now I’d like to ask you about any regularly scheduled care {C_FNAME or YOUR CHILD} receives from someone not related to {him/her}, either in your home or someone else’s home. This includes all regularly scheduled care arrangements with non-relatives that happen at least weekly, including home child care providers, regularly scheduled sitter arrangements, or neighbors. This does not include day care centers, early childhood programs, or occasional babysitting.

CC011 (HOMECARE) Does {C_FNAME or YOUR CHILD} receive any regularly scheduled care either in your home or someone else’s home from someone not related to {him/her}?

INTERVIEWER INSTRUCTION: IF NECESSARY READ… “This includes arrangements with non-relatives including home child care providers, regularly scheduled sitter arrangements, or neighbors. This does not include day care centers, early childhood programs, or occasional babysitting.”

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

CC013 (HOMECARE_HRS) Approximately how many total hours each week does {C_FNAME or YOUR CHILD} receive care in a home from non-relatives?

|___|___|

NUMBER OF HOURS PER WEEK

REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

PROGRAMMER INSTRUCTION: INCLUDE SOFT EDIT IF RESPONSE > 50 HOURS PER WEEK

CC015

Now I want to ask you about child care centers {C_FNAME or YOUR CHILD} may attend on a regular basis. Such centers include day care centers, early learning centers, nursery schools, and preschools.

CC017 (DAYCARE) Does {C_FNAME or YOUR CHILD} receive any care in child care centers? (Such centers include day care centers, early learning centers, nursery schools, and preschools.)

YES	……………………………………………	1
NO	……………………………………………	2	(TIME_STAMP_8)
REFUSED	……………………………………………	-1	(TIME_STAMP_8)
DON’T KNOW	……………………………………………	-2	(TIME_STAMP_8)

CC019 (DAYCARE_HRS) Approximately how many total hours each week does {C_FNAME or YOUR CHILD} receive care in child care centers?

|___|___|

NUMBER OF HOURS PER WEEK

REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

PROGRAMMER INSTRUCTION: INCLUDE SOFT EDIT IF RESPONSE EXCEEDS 50 HOURS PER WEEK

Pets

PT001 (TIME_STAMP_8) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTION: THIS SECTION SHOULD ONLY BE ASKED FOR THE FIRST ELIGIBLE CHILD. IF CHILD_QNUM > 1 SKIP TO (TIME_STAMP_17)

Now I’d like to ask about any pets you may have in your home.

PT003 (PETS) Are there any pets that spend any time inside your home?

YES	……………………………………………	1
NO	……………………………………………	2	(TIME_STAMP_9)
REFUSED	……………………………………………	-1	(TIME_STAMP_9)
DON’T KNOW	……………………………………………	-2	(TIME_STAMP_9)

PT005 (PET_TYPE) What kind of pets are these?

INTERVIEWER INSTRUCTION: PROBE FOR MULTIPLE RESPONSES; “Any others?”

INTERVIEWER INSTRUCTION: SELECT ALL THAT APPLY.

DOG	…………….	1
CAT	…………….	2
SMALL MAMMAL (RABBIT, GERBIL, HAMSTER, GUINEA PIG, FERRET, MOUSE)	…………….	3
BIRD	…………….	4
FISH OR REPTILE (TURTLE, SNAKE, LIZARD)	…………….	5
OTHER	…………….	-5	(PET_TYPE_OTH)
REFUSED	…………….	-1
DON’T KNOW	…………….	-2

PT007 (PET_TYPE_OTH) OTHER: SPECIFY

REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

PT009 (PET_MEDS) Are any products ever used on your pets to control fleas, ticks, or mites? This includes flea collars, flea and tick powders, shampoos, or other flea, tick and mite control products. (This does not include pills given to your pet to control for fleas or other insects.)

YES	……………………………………………	1
NO	……………………………………………	2	(TIME_STAMP_9)
REFUSED	……………………………………………	-1	(TIME_STAMP_9)
DON’T KNOW	……………………………………………	-2	(TIME_STAMP_9)

PT011 ( PET_MED_TIME) When were any of these last used on any of your pets?

WITHIN THE LAST MONTH …………………………………………… 1

1-3 MONTHS AGO ……………………………………………………… 2

4-6 MONTHS AGO ……………………………………………………… 3

MORE THAN 6 MONTHS AGO ………………………………………. 4

REFUSED ……………………………………………………………….. -1

DON’T KNOW ………………………………………………………….. -2

In-Home Exposures

IHE001 (TIME_STAMP_9) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IHE020 I would now like to ask about whether you have seen signs of rodents or seen cockroaches in your home in the last 6 months.

IHE046 (RODENT) In the last 6 months, have you seen signs of mice, rats, or other rodents in your home (not including pets)?

YES	……………………………………………	1
NO	……………………………………………	2
REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

IHE047 (ROACH) Since {C_FNAME or YOUR CHILD} was born, have you seen cockroaches in your home?

YES	……………………………………………	1
NO	……………………………………………	2
REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

Maternal Behaviors

MB001 (TIME_STAMP_10) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

The next questions are about your experiences, since {C_FNAME} was born. First, I’d like to ask about some questions about work. People’s work situations sometimes change after having a baby.

MB003 (WORK_PREG) Just before you gave birth to {C_FNAME or YOUR CHILD}, were you employed at a job or business?

YES	……………………………………………	1
NO	……………………………………………	2	(TIME_STAMP_11)
REFUSED	……………………………………………	-1	(TIME_STAMP_11)
DON’T KNOW	……………………………………………	-2	(TIME_STAMP_11)

MB005 (WORK_NOW) Have you returned to work, or are you currently on maternity leave from this job? Please look at this card and tell me which category best describes your work situation.

INTERVIEWER INSTRUCTION: DISPLAY SHOW CARD WITH RESPONSE CATEGORIES

RETURNED TO WORK	1
UNPAID LEAVE	2	(TIME_STAMP_11)
PAID LEAVE	3	(TIME_STAMP_11)
LEFT THE POSITION	4	(TIME_STAMP_11)
LOOKING FOR WORK	5	(TIME_STAMP_11)
OTHER	-5	(WORK_NOW_OTH)
REFUSED	-1	(TIME_STAMP_11)
DON’T KNOW	-2	(TIME_STAMP_11)

MB006 (WORK_NOW_OTH) OTHER, SPECIFY

REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

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

|___|___|

HOURS

REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

MB010 (TIME_STAMP_11) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

The next questions ask about smoking in your household.

MB012 (CIG_NOW) Do you currently smoke cigarettes or use any other tobacco product?

YES	………………………………………	1
NO	………………………………………	2
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

MB014 (NUM_SMOKER) How many smokers live in your home now, {including yourself}?

PROGRAMMER INSTRUCTION: ADD bracketed text if R_SMOKE = 1 EDIT: IF R_SMOKE=1, RESPONSE TO NUM_SMOKER MUST BE >/=1.

|___|___|

NUMBER OF SMOKERS

INTERVIEWER INSTRUCTION: ENTER “0” IF NONE

REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

MB016 (SMOKE_INSIDE) Does anyone smoke inside the house?

YES	………………………………………	1
NO	………………………………………	2
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

MB018 (SMOKE_RULES) Which of the following statements describes the rules about smoking inside your home now?

No one is allowed to smoke anywhere inside my home,	………………………	1
Smoking is allowed in some rooms at some times, or	………………………	2
Smoking is permitted anywhere inside my home	………………………	3
REFUSED	………………………	-1
DON’T KNOW	………………………	-2

MB020 (SMOKE_HOURS) On average, about how many hours per day do people smoke in the same room as {C_FNAME or YOUR CHILD}, or near enough that {he/she} can see or smell the smoke? Please consider all the places {C_FNAME or YOUR CHILD} is during the day, including at home, at daycare, or some other place. If {he/she} is not exposed to smoke, answer “0.”

|___|___|

HOURS

REFUSED	……………………………………………	-1
DON’T KNOW	……………………………………………	-2

Financial Security

FS001 (TIME_STAMP_12) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

The next few questions are about whether you feel you have enough money for yourself and the people in your house.

FS017 (PAY_BILLS) How difficult is it for you and your family to pay your bills? Would you say it is…

Very difficult	………………………………………	1
Somewhat difficult	………………………………………	2
Not very difficult	………………………………………	3
Not difficult at all	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

FS021 (WIC) Since {C_FNAME or YOUR CHILD} was born, did you receive benefits from the WIC program, that is, the Women, Infants and Children program?

YES	………………………………………	1
NO	………………………………………	2
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

FS023 (FOOD_STAMP) Since {C_FNAME or YOUR CHILD} was born, did you or any members of your household receive Food Stamps (which includes a food stamp card or voucher, or cash grants from the state for food)?

YES	………………………………………	1
NO	………………………………………	2
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

FS025 (TANF) Since {C_FNAME or YOUR CHILD} was born, have you or any members of your household received TANF or welfare?

YES	………………………………………	1
NO	………………………………………	2
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

Household Composition and Demographics

DM001 (TIME_STAMP_13) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

The next question is about the language spoken to your baby.

DM015 (NONENGLISH_FREQ) How often do you use a language other than English in speaking to your {BABY?} Would you say…

INTERVIEWER INSTRUCTION: PROBE “We just need to know in general?”

Never	………………………………………	1
Sometimes	………………………………………	2
Often	`	3
Very often	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

DM017 (TIME_STAMP_14) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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 data you provide is confidential.

DM019 (INCOME) Of these income groups, which category best represents {your/the total combined family} income during [CURRENT YEAR – 1]?

Remember, a family is a group of two or more people who live together and who are related by birth, marriage, or adoption.

INTERVIEWER INSTRUCTION: DISPLAY SHOW CARDS WITH RESPONSE CATEGORIES

Less than $4,999 1 (FAM_SUPPORT)

$5,000-$9,999 2 (FAM_SUPPORT)

$10,000-$19,999 3 (FAM_SUPPORT)

$20,000-$29,999 4 (FAM_SUPPORT)

$30,000-$39,999 5 (FAM_SUPPORT)

$40,000-$49,999 6 (FAM_SUPPORT)

$50,000-$74,999 7 (FAM_SUPPORT)

$75,000-$99,999 8 (FAM_SUPPORT)

$100,000-$199,000 9 (FAM_SUPPORT)

$200,000 or more 10 (FAM_SUPPORT)

REFUSED -1 (INCOME2)

DON’T KNOW -2 (INCOME2)

DM021(INCOME2). Thinking about all {your/your family’s} sources of income, was your total family income in {LAST CALENDAR YEAR} before taxes:

PROBE: Please note, a family is a group of two or more people who live together and who are related by birth, marriage, or adoption.

$20,000 or more 1

Less than $20,000 2

REFUSED -1(TIME_STAMP_15)

DON'T KNOW -2(TIME_STAMP_15)

DM023 (FAM_SUPPORT) Are there any other family members, not living in this household, who are also supported by this income?

YES	………………………………………	1
NO	………………………………………	2	(TIME_STAMP_15)
REFUSED	………………………………………	-1	(TIME_STAMP_15)
DON’T KNOW	………………………………………	-2	(TIME_STAMP_15)

DM025 (FAM_SUPPORT_NUM) How many other family members, not living in this household, are supported by this income?

|___|___|

NUMBER

REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

Thank you for answering these questions.

Tracing Questions

TQ001 (TIME_STAMP_15) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

The next set of questions asks about different ways we might be able to keep in touch with you. Please remember that all the information you provide is confidential and will not be provided to anyone outside the National Children’s Study.

TQ003 (COMM_EMAIL). When we last spoke, we asked questions about communicating with you through your personal email. Has your email address or your preferences regarding use of your personal email changed since then?

YES	………………………………………	1
NO	………………………………………	2	(COMM_CELL)
DON’T REMEMBER	………………………………………	3
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TQ005 (HAVE_EMAIL). Do you have an email address?

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

TQ007 (EMAIL_2). May we use your personal email address to make future study appointments or send appointment reminders?

YES	………………………………………	1
NO	………………………………………	2
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TQ009 (EMAIL_3). May we use your personal email address for questionnaires (like this one) that you can answer over the Internet?

YES	………………………………………	1
NO	………………………………………	2
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TQ011 (EMAIL). What is the best email address to reach you?

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

ENTER E-MAIL ADDRESS: ___________________________________

REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TQ013 (COMM_CELL). When we last spoke, we asked questions about communicating with you through your personal cell phone number. Has your cell phone number or your preferences regarding use of your personal cell phone number changed since then?

YES	………………………………………	1
NO	………………………………………	2	(TIME_STAMP_16)
DON’T REMEMBER	………………………………………	3
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TQ015 (CELL_PHONE_1). Do you have a personal cell phone?

YES	………………………………………	1
NO	………………………………………	2	(TIME_STAMP_16)
REFUSED	………………………………………	-1	(TIME_STAMP_16)
DON’T KNOW	………………………………………	-2	(TIME_STAMP_16)

TQ017 (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

TQ019 (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)

TQ021 (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

TQ023 (CELL_PHONE). What is your personal cell phone number?

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

PHONE NUMBER

RESPONDENT HAS NO CELL PHONE	……………………………	-7
REFUSED	……………………………	-1
DON’T KNOW	……………………………	-2

TQ025 (TIME_STAMP_16) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TQ027 (COMM_CONTACT). Sometimes if people move or change their telephone number, we have difficulty reaching them. At our last visit, we asked for contact information for two friends or relatives not living with you who would know where you could be reached in case we have trouble contacting you. Has that information changed since our last visit?

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

TQ029 (CONTACT_1). Could I have the name of a friend or relative not currently living with you who should know where you could be reached in case we have trouble contacting you?

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

TQ031 (CONTACT_FNAME_1)/(CONTACT_LNAME_1). What is this person’s name?

______________ __________________

FIRST NAME LAST NAME

REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

INTERVIEWER INSTRUCTION:

IF RESPONDENT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS
CONFIRM SPELLING OF FIRST AND LAST NAMES.

TQ033 (CONTACT_RELATE_1).What is his/her relationship to you?

MOTHER/FATHER	………………………	1
BROTHER/SISTER	………………………	2
AUNT/UNCLE	………………………	3
GRANDPARENT	………………………	4
NEIGHBOR	………………………	5
FRIEND	………………………	6
OTHER	………………………	-5	(CONTACT_RELATE1 _OTH)
REFUSED	………………………	-1
DON’T KNOW	………………………	-2

TQ034 (CONTACT_RELATE1_OTH) SPECIFY _____________________________

REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TQ036 (CONTACT_ADDR_1). What is his/her address?

INTERVIEWER INSTRUCTIONS: PROMPT AS NECESSARY TO COMPLETE INFORMATION

____________________________________________________

STREET (C_ADDR1_1)/(C_ADDR_2_1)/(C_UNIT_1)

___________________________________

CITY (C_CITY_1)

|___|___| |___|___|___|___|___| + |___|___|___|___|

STATE ZIP CODE

(C_STATE_1) (C_ZIPCODE_1) (C_ZIP4_1)

REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TQ038 (CONTACT_PHONE_1) What is his/her telephone number?

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

PHONE NUMBER

CONTACT HAS NO PHONE	……………………………	-7
REFUSED	……………………………	-1
DON’T KNOW	……………………………	-2

INTERVIEWER INSTRUCTION: IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

TQ040 (CONTACT_2) Now I’d like to collect information on a second contact who does not currently live with you. What is this person’s name?

(CONTACT_FNAME_2)/(CONTACT_LNAME_2). What is this person’s name?

______________ __________________

FIRST NAME LAST NAME

REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TQ042 INTERVIEWER INSTRUCTION:

IF RESPONDENT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS
CONFIRM SPELLING OF FIRST AND LAST NAMES.

TQ044 (CONTACT_RELATE_2).What is his/her relationship to you?

MOTHER/FATHER	………………………	1
BROTHER/SISTER	………………………	2
AUNT/UNCLE	………………………	3
GRANDPARENT	………………………	4
NEIGHBOR	………………………	5
FRIEND	………………………	6
OTHER	………………………	-5	(CONTACT_RELATE2 _OTH)
REFUSED	………………………	-1
DON’T KNOW	………………………	-2

TQ045 (CONTACT_RELATE2_OTH) SPECIFY _____________________________

REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TQ047 (CONTACT_ADDR_2). What is his/her address?

INTERVIEWER INSTRUCTIONS: PROMPT AS NECESSARY TO COMPLETE INFORMATION

____________________________________________________

STREET (C_ADDR1_2)/(C_ADDR_2_2)/(C_UNIT_2)

____________________________________________________

CITY (C_CITY_2)

|___|___| |___|___|___|___|___| + |___|___|___|___|

STATE ZIP CODE

(C_STATE_2) (C_ZIPCODE_2) (C_ZIP4_2)

REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TQ049 (CONTACT_PHONE_2) What is his/her telephone number?

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

PHONE NUMBER

CONTACT HAS NO PHONE	……………………………	-7
REFUSED	……………………………	-1
DON’T KNOW	……………………………	-2

INTERVIEWER INSTRUCTION: IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

TQ051 (TIME_STAMP_17) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

(END). Thank you for participating in the National Children’s Study and for taking the time to complete this survey. This concludes the interview portion of our visit.

INTERVIEWER INSTRUCTION: EXPLAIN SAQs and RETURN PROCESS.

6-Month Mother Interview (EH, PB, HI) Version 1.1 0

File Type	application/msword
File Title	12 Month Visit: Introduction
File Modified	2011-02-11
File Created	2011-02-11