27.1 Survey

OMB #: 0925-0593

Expiration Date: 7/31/ 2013

12-Month Mother Interview, Phase II

Recruitment Strategy Substudy

Event Name(s):

12-Month Mother Interview (EH, PB, HI)

Instrument Name(s) and Versions:

12-Month Mother Interview (EH, PB, HI) – 1.0

Recruitment Groups:

Enhanced Household, Provider-Based, High Intensity

12-Month Mother Interview (EH, PB, HI)

TABLE OF CONTENTS

INTERVIEW INTRODUCTION 1

PARTICIPANT VERIFICATION 3

CHILD DEVELOPMENT AND PARENTING 5

CHILD CARE ARRANGEMENTS 14

HEALTH CARE 17

MEDICAL CONDITIONS 19

HEALTH INSURANCE 22

PRODUCT USE 24

IN-HOME EXPOSURES 25

HEALTH BEHAVIORS 29

NEIGHBORHOOD CHARACTERISTICS 31

TRACING QUESTIONS 35

12-Month Mother Interview (EH, PB, HI)

CAPI

Interview Introduction

(TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IN001 Thank you for agreeing to participate in the National Children’s Study. This interview will take about 30 minutes to complete. Your answers are important to us. There are no right or wrong answers, just those that help us understand your situation. During this interview, we will ask about yourself, your {child/ children}, your health, where you live, and your feelings about being a part of the National Children’s Study. You can skip over any questions or stop the interview at any time. We will keep everything that you tell us confidential.

INTERVIEWER-COMPLETED QUESTIONS

IN004 (MULT_CHILD) IS THERE MORE THAN ONE CHILD OF THIS MOTHER ELIGIBLE FOR THE 12 MONTH VISIT TODAY?

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

IN005 (CHILD_NUM) HOW MANY CHILDREN OF THIS MOTHER ARE ELIGIBLE FOR THE 12 MONTH VISIT TODAY?

|___|___|

NUMBER OF CHILDREN

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

IN011 (CHILD_QNUM) WHICH NUMBER CHILD IS THIS QUESTIONNAIRE FOR?

|___|___|

PROGRAMMER INSTRUCTION: CHILD_QNUM CANNOT BE GREATER THAN CHILD_NUM

IN017 (CHILD_SEX) IS CHILD_QNUM A MALE OR FEMALE?

MALE	…………………………………………………….	1
FEMALE	…………………………………………………….	2

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

Participant Verification

INTERVIEWER INSTRUCTION: IF CHILD_QNUM>1, SAY, “I’d like to ask about your next child.”

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. IF CHILD’S NAME NOT KNOWN, GO TO (C_FNAME)(C_LNAME).

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:

• 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

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

PROGRAMMER INSTRUCTIONS: 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_STAMP2)
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

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 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 9 MONTHS OR GREATER THAN 15 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. You may notice your baby’s personality developing a bit more now that he or she is twelve months old.

CDP003 (CALM) Overall, would you describe your baby as … calm?

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

CDP004 (WORRIED) … Worried?

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

CDP005 (SOCIAL) … Sociable or outgoing?

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

CDP006 (ANGRY) … Angry?

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

CDP007 (SHY) … Shy or quiet?

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

CDP008 (STUBBORN) … Stubborn?

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

CDP009 (HAPPY) … Happy?

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

CDP010 (C_HEALTH) Would you say {C_FNAME or YOUR CHILD}’s health is poor, fair, good, or excellent?

POOR	…………………………………………………..	1
FAIR	…………………………………………………..	2
GOOD	………………………………………………….	3
EXCELLENT	…………………………………………………..	4
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP013 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 your baby…

CDP0116 (EYES_FOLLOW) … Follow you with {his/her} eyes?

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

CDP017 (SMILE) … Smile when you smile at {him/her}?

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

CDP018 (REACH_1) … Try to get a toy that is out of reach?

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

CDP019 (FEED) … Feed {him/herself} a cracker or cereal?

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

CDP020 (WAVE) … Wave goodbye?

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

CDP021 REACH_2) … Reach for toys or food held to {him/her}?

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

CDP022 (GRAB) … Grab an object like a block or rattle from you?

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

CDP023 SWITCH_HANDS) … Move a toy or block from one hand to the other?

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

CDP024 (PICKUP) … Pick up a small object like a Cheerio or raisin?

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

CDP025 (HOLD) … Hold two toys or blocks at a time, one in each hand?

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

CDP026 SOUND_1) … Startle or react to a sound?

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

CDP027 (SOUND_2) … Turn towards a sound?

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

CDP028 (SOUND_3) … Turn toward someone when they’re speaking?

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

CDP029 (SPEAK_1) … Make sounds as though {he/she} is trying to speak?

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

CDP030 (SPEAK_2) … Say mama or dada?

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

CDP031 (HEADUP) … Keep head steady when sitting or held up?

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

CDP032 (ROLL_1) … Roll over from stomach to back?

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

CDP033 (ROLL_2) … Roll from back to stomach?

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

CDP034 (SITUP) … Sit up by {him/herself}?

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

CDP035 (STAND) … Stand while holding onto something?

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

CDP036 (STAND_ALONE) … Stand alone, without holding onto something?

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

CDP037 (WALK) … Walk by himself, without holding onto something?

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

CDP038 (SCRIBBLE) … Scribble or draw with a pencil, crayon, or marker?

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

CDP039 (FORK_SPOON) … Try to use a fork or spoon when eating?

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

CDP042 These next questions are about different things you may do as a parent. How often do you feel the following ways or do the following things?

CDP045 (TALK_ABOUT) How often do you talk a lot about {C_FNAME or YOUR CHILD} to friends and family? Would you say…

All of the time,	………………………………………………	1
Some of the time,	………………………………………………	2
Rarely, or	………………………………………………	3
Never?	………………………………………………	4
REFUSED	………………………………………………	-1
DON’T KNOW	………………………………………………	-2

INTERVIEWER INSTRUCTION: USE SHOW CARD WITH CATEGORIES

CDP050 (PICTURES) How often do you carry pictures of {C_FNAME or YOUR CHILD} with you wherever you go?

All of the time,	………………………………………………	1
Some of the time,	………………………………………………	2
Rarely, or	………………………………………………	3
Never?	………………………………………………	4
REFUSED	………………………………………………	-1
DON’T KNOW	………………………………………………	-2

INTERVIEWER INSTRUCTION: USE SHOW CARD WITH CATEGORIES

CDP055 (THINKOF) How often do you find yourself thinking about {C_FNAME or YOUR CHILD}?

All of the time,	………………………………………………	1
Some of the time,	………………………………………………	2
Rarely, or	………………………………………………	3
Never?	………………………………………………	4
REFUSED	………………………………………………	-1
DON’T KNOW	………………………………………………	-2

INTERVIEWER INSTRUCTION: USE SHOW CARD WITH CATEGORIES

CDP057 (HOLD_FUN) How often do you think holding and cuddling {C_FNAME or YOUR CHILD} is fun?

All of the time,	………………………………………………	1
Some of the time,	………………………………………………	2
Rarely, or	………………………………………………	3
Never?	………………………………………………	4
REFUSED	………………………………………………	-1
DON’T KNOW	………………………………………………	-2

INTERVIEWER INSTRUCTION: USE SHOW CARD WITH CATEGORIES

CDP059 (GIVE_FUN) How often do you think it’s more fun to get {C_FNAME or YOUR CHILD} something new than to get yourself something new?

All of the time,	………………………………………………	1
Some of the time,	………………………………………………	2
Rarely, or	………………………………………………	3
Never?	………………………………………………	4
REFUSED	………………………………………………	-1
DON’T KNOW	………………………………………………	-2

INTERVIEWER INSTRUCTION: USE SHOW CARD WITH CATEGORIES

CDP061(READ) Do you read to or look at books with {C_FNAME or YOUR CHILD}?

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

CDP062 (READ_FREQ) How often do you read or look at books with {C_FNAME or YOUR CHILD}?

Every day,	…………………………………………	1
5-6 days a week,	…………………………………………	2
2-4 days a week, or	…………………………………………	3
Once a week or less?	…………………………………………	4
REFUSED	…………………………………………	-1
DON’T KNOW	…………………………………………	-2

CDP066 (WATCH_TV) Does {C_FNAME or YOUR CHILD} watch TV and/or DVDs?

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

CDP 068(TV_FREQ) How often does {C_FNAME or YOUR CHILD} watch TV and/or DVDs?

Every day,	…………………………………………	1
5-6 days a week,	…………………………………………	2
2-4 days a week, or	…………………………………………	3
Once a week or less?	…………………………………………	4
REFUSED	…………………………………………	-1
DON’T KNOW	…………………………………………	-2

CDP080 (PLAY_FREQ) How often do you play with toys with {C_FNAME or YOUR CHILD}?

Every day,	…………………………………………	1
5-6 days a week,	…………………………………………	2
2-4 days a week, or	…………………………………………	3
Once a week or less?	…………………………………………	4
REFUSED	…………………………………………	-1
DON’T KNOW	…………………………………………	-2

CDP082 (WALKS) How often do you go for walks with {C_FNAME or YOUR CHILD}?

Every day,	…………………………………………	1
5-6 days a week,	…………………………………………	2
2-4 days a week, or	…………………………………………	3
Once a week or less?	…………………………………………	4
REFUSED	…………………………………………	-1
DON’T KNOW	…………………………………………	-2

Child Care Arrangements

(TIME_STAMP_3) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

CC001 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.

CC005 (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_4)
REFUSED	……………………………………………	-1	(TIME_STAMP_4)
DON’T KNOW	……………………………………………	-2	(TIME_STAMP_4)

CC008 (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	(CC014)
REFUSED	……………………………………………	-1	CC014)
DON’T KNOW	……………………………………………	-2	(CC014)

CC011 (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

CC014 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.

CC017 (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	(CC023)
REFUSED	……………………………………………	-1	(CC023)
DON’T KNOW	……………………………………………	-2	(CC023)

CC020 (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 EXCEEDS 50 HOURS PER WEEK

CC023 Now I want to ask you about child care centers {C_FNAME} may attend on a regular basis. Such centers include day care centers, early learning centers, nursery schools, and preschools.

CC026 (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_4)
REFUSED	……………………………………………	-1	(TIME_STAMP_4)
DON’T KNOW	……………………………………………	-2	(TIME_STAMP_4)

CC029 (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

Health Care

(TIME_STAMP_4) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HC001 The next questions are about where {C_FNAME or YOUR CHILD} 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: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

HAS NOT HAD A VISIT		1	(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 < 15 OR > 30 POUNDS

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

YES	………………………………	1	(TIME_STAMP_5)
NO	………………………………	2
HAS NOT BEEN SICK	………………………………	3
REFUSED	………………………………	-1
DON’T KNOW	………………………………	-2

HC016 (HCARE_SICK). What kind of place does {C_FNAME or YOUR CHILD} usually go to when {he/she} is sick, doesn’t feel well, or if you have concerns about {his/her} 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
HAS NOT BEEN SICK	………………………	7
REFUSED	………………………	-1
DON’T KNOW	………………………	-2

Medical Conditions

(TIME_STAMP_5) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

MC001 Now I’d like to ask about some illnesses {C_FNAME or YOUR CHILD} may have had in the last 3 months.

MC004 (EAR_INFECTION) In the past 3 months, has {C_FNAME or YOUR CHILD} had an ear infection?

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

MC007 (GASTRO) In the past 3 months, has {C_FNAME or YOUR CHILD} had diarrhea or vomiting?

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

MC0010 (RESPIRATORY) In the past 3 months, has {C_FNAME or YOUR CHILD} had wheezing or whistling in the chest?

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

MC013 (FEVER) In the past 3 months, on how many days has {C_FNAME or YOUR CHILD} had a fever over 101 degrees, not related to receiving immunizations?

INTERVIEWER INSTRUCTION: IF NECESSARY READ… “or 38.3 degrees Celsius?”

|___|___|

NUMBER OF DAYS

INTERVIEW INSTRUCTION: ENTER “0” IF NONE

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

Now I have some questions about specific conditions or health problems {C_FNAME or YOUR CHILD} may have.

MC016 (BLIND) Has a doctor ever told you that {C_FNAME or YOUR CHILD} is blind?

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

MC017 (EYESIGHT) Has a doctor ever told you that {C_FNAME or YOUR CHILD} has difficulty seeing, including nearsightedness or farsightedness?

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

MC018(DEAF) Has a doctor ever told you that {C_FNAME or YOUR CHILD} has difficulty hearing or deafness? Do not include a temporary loss of hearing due to a cold or congestion.

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

MC019 (BIRTH_DEFECT) Has a doctor ever told you that {C_FNAME or YOUR CHILD} has any congenital anomaly or birth defect such as a cleft lip or palate, heart defect, or spina bifida?

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

(MC020 DEFECT_TYPE) What type of congenital anomaly or birth defect have you been told {C_FNAME or YOUR CHILD} has?

SPECIFY _____________________________

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

MC021 (GENETIC) Has a doctor ever told you that {C_FNAME or YOUR CHILD} has Down Syndrome, Turner Syndrome, or other inherited or genetic condition?

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

MC022 (GENETIC_TYPE) What type of condition have you been told {C_FNAME or YOUR CHILD} has?

SPECIFY _____________________________

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

MC023 (FAIL_THRIVE) Has a doctor ever told you that {C_FNAME or YOUR CHILD} has failure to thrive, or concern about proper growth?

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

HEALTH INSURANCE

(TIME_STAMP_6) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HI001 Now I’m going to switch to another subject and ask about health insurance.

HI004 (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)

HI007 Now I’ll read a list of different types of insurance. Please tell me which types {C_FNAME or YOUR CHILD} currently has. Does {C_FNAME} currently have…

INTERVIEWER INSTRUCTIONS: RE-READ INTRODUCTORY STATEMENT AS NEEDED

HI010 (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

HI011 (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

HI012 (INS_TRICARE) TRICARE, VA, or other military health care?

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

HI013 (INS_IHS) Indian Health Service?

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

HI014(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

Product Use

(TIME_STAMP_7) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PU001 The next questions ask about lice exposure and treatment.

PU008 (LICE_1) In the past 6 months, have you treated {C_FNAME or YOUR CHILD} or other people in your home for lice or scabies?

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

PU010 (LICE_2) Who did you treat, was it {C_FNAME or YOUR CHILD}, someone else, or both?

C_FNAME or YOUR CHILD}	……………………………	1
SOMEONE ELSE	……………………………	2	(LICE_OTH_1)
BOTH {C_FNAME or YOUR CHILD} AND SOMEONE ELSE	……………………………	3	(LICE_OTH_2)
REFUSED	……………………………	-1
DON’T KNOW	……………………………	-2

PU013 (LICE_OTH_1) OTHER: SPECIFY _______________________________

PU014 (LICE_OTH_2) OTHER: SPECIFY _______________________________

PU015 (LICE_OTH_3) OTHER: SPECIFY _______________________________

INTERVIEWER INSTRUCTION: SELECT ALL THAT APPLY; PROBE: “Anyone else?”

In-Home Exposures

(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, THEN GO TO (HB012(SMOKE_HOURS)

IHE001 Do you use any methods to “allergy-proof” your home? Please answer “yes” or “no” to each method I describe.

IHE004 (TANNIC_ACID) Tannic acid or other mite control chemicals?

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

IHE006 (COVERS ) Impermeable mattress and or pillow covers on your child’s bed or crib?

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

IHE008 (VACUUM) Use a special vacuum such as a HEPA vacuum?

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

IHE010 (REMOVAL) Intentionally removed rugs or upholstered furniture?

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

IHE012 (METHOD) Any other methods?

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

IHE013 (METHOD_OTH) SPECIFY: ____________________________

IHE016 (AIR_FILTER) Does your furnace or air conditioning system use a special HEPA (High Efficiency Particulate Air) or other type of allergy filter to filter the air?

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

IHE018 (OPEN_WINDOW) Thinking about the past 7 days, approximately how many hours a day did you keep the windows or doors open in your home (for ventilation or to let air in)? Was it…

Less than 1 hour per day,	……………………………………	1
1-3 hours per day,	……………………………………	2
4-12 hours per day,	……………………………………	3
More than 12 hours per day, or	……………………………………	4
Not at all?	……………………………………	5
REFUSED	……………………………………	-1
DON’T KNOW	……………………………………	-2

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) In the last 6 months, have you seen cockroaches in your home?

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

IHE050 Water damage is a common problem that occurs inside of many homes. Water damage includes water stains on the ceiling or walls, rotting wood, and flaking sheetrock or plaster. This damage may be from broken pipes, a leaky roof, or floods.

IHE052 (WATER) In the last 6 months, have you seen any water damage inside your home?

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

IHE053 (MOLD) In the last 6 months, have you seen any mold or mildew on walls or other surfaces, other than the shower or bathtub, inside your home?

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

IHE054 (ROOM_MOLD) In which rooms have you seen the mold or mildew?

PROBE: Any other rooms?

KITCHEN	……………………………	1
LIVING ROOM	……………………………	2
HALL/LANDING	……………………………	3
{C_FNAME}’s BEDROOM	……………………………	4
OTHER BEDROOM	……………………………	5
BATHROOM/TOILET	……………………………	6
BASEMENT	……………………………	7
OTHER	……………………………	-5	(ROOM_MOLD_OTH)
REFUSED	……………………………	-1
DON’T KNOW	……………………………	-2

INTERVIEWER INSTRUCTION: SELECT ALL THAT APPLY.

IHE055 (ROOM_MOLD_OTH) SPECIFY _____________________________

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

(TIME_STAMP_9) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

The next few questions ask about any recent additions or renovations to your home.

IHE056 (RENOVATE) In the last 6 months, 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, wallpapering, carpeting or re-finishing floors.

YES	………………………………………	1
NO	………………………………………	2	(TIME_STAMP_10)
REFUSED	………………………………………	-1	(TIME_STAMP_10)
DON’T KNOW	………………………………………	-2	(TIME_STAMP_10)

IHE057(RENOVATE_ROOM) Which rooms were renovated?

PROBE: Any others?

SELECT ALL THAT APPLY.

KITCHEN	……………………………	1
LIVING ROOM	……………………………	2
HALL/LANDING	……………………………	3
{C_FNAME}’sBEDROOM	……………………………	4
OTHER BEDROOM	……………………………	5
BATHROOM/TOILET	……………………………	6
BASEMENT	……………………………	7
OTHER	……………………………	-5	(RENOVATE_ROOM_OTH)
REFUSED	……………………………	-1
DON’T KNOW	……………………………	-2

IHE058 (RENOVATE_ROOM_OTH) SPECIFY _____________________________

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

PROGRAMMER INSTRUCTION: IF CHILD_NUM = 1, GO TO (TIME_STAMP_10)

Health Behaviors

(TIME_STAMP_10) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HB004 (CIG_NOW) Do you currently smoke cigarettes or use any other tobacco product?

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

HB006 (NUM_SMOKER) How many smokers live in your home now, {including yourself}?

PROGRAMMER INSTRUCTION: ADD bracketed text if CIG_NOW = 1

|___|___|

NUMBER OF SMOKERS

INTERVIEW INSTRUCTION: ENTER “0” IF NONE

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

HB010 (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

HB012 (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, enter “0.”

|___|___|

HOURS

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

INTERVIEWER INSTRUCTON: IF (CHILD_QNUM) > 1, GO TO (CHILD_QNUM) AND LOOP THROUGH QUESTIONNIARE THROUGH HB012 (SMOKE_HOURS) FOR EACH CHILD UNTIL (CHILD_NUM = CHILD_QNUM). THEN GO TO (END)

HB014 (DRINK) Do you drink any type of alcoholic beverage?

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

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

5 or more times a week 1

2-4 times a week 2

Once a week 3

1-3 times a month 4

Less than once a month 5

Never 6

REFUSED -1 (TIME_STAMP_11)

DON’T KNOW -2 (TIME_STAMP_11)

HB016 (DRINK_NOW_5) 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
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

Neighborhood Characteristics

(TIME_STAMP_11) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

NC001 Now I’d like to ask a few questions about your neighborhood.

NC004 (NEIGH_DEFN) When you are talking to someone about your neighborhood, what do you mean? Is it…

The block or street you live on,	………………………………………	1
Several blocks or streets in each direction,	………………………………………	2
The area within a 15 minute walk from your house, or	………………………………………	3
An area larger than a 15 minute walk from your house?	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC006 (NEIGH_FAM) How many of your relatives or in-laws live in your neighborhood?  Would you say…

None	………………………………………	1
A few	………………………………………	2
Many	………………………………………	3
Most	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC008 (NEIGH_FRIEND) How many of your friends live in your neighborhood?  Would you say…

None	………………………………………	1
A few	………………………………………	2
Many	………………………………………	3
Most	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC010 (NEIGHBORS) About how many adults do you recognize or know by sight in this neighborhood? Would you say you recognize …

None	………………………………………	1
A few	………………………………………	2
Many	………………………………………	3
Most	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC012 (NEIGH_NUM_TALK) In the past 30 days, that is since [INSERT DATE 30 DAYS AGO], how many of your neighbors have you talked with for 10 minutes of more? Would you say…

None	………………………………………	1
1 or 2	………………………………………	2
3 to 5	………………………………………	3
6 or more	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC014 (NEIGH_HELP) About how often do you and people in your neighborhood do favors for each other? By favors, we mean such things as watching each other’s children, helping with shopping, lending garden or house tools.

Often	………………………………………	1
Sometimes	………………………………………	2
Rarely	………………………………………	3
Never	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC016 (NEIGH_TALK) How often do you and other people in your neighborhood visit in each other’s homes or speak with each other on the street?

Often	………………………………………	1
Sometimes	………………………………………	2
Rarely	………………………………………	3
Never	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC018 (NEIGH_WATCH_1) If children were skipping school and hanging out, how likely is it that your neighbors would do something about it? Would you say it is

Very Likely,	………………………………………	1
Likely,	………………………………………	2
Unlikely, or	………………………………………	3
Very Unlikely	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC020 (NEIGH_WATCH_2) If children were showing disrespect to an adult, how likely is it that your neighbors would do something about it? Would you say it is…

Very Likely,	………………………………………	1
Likely,	………………………………………	2
Unlikely, or	………………………………………	3
Very Unlikely	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC022 Please tell me if you agree or disagree with the following statements.

NC024(NEIGH_CLOSE) This is a close-knit neighborhood. Would you say you….

Strongly agree,	………………………………………	1
Agree,	………………………………………	2
Disagree, or	………………………………………	3
Strongly disagree	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC026 (NEIGH_TRUST) People in this neighborhood can be trusted. Would you say you…

Strongly agree,	………………………………………	1
Agree,	………………………………………	2
Disagree, or	………………………………………	3
Strongly disagree	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC028 (NEIGH_SAFE_1) I feel safe walking in my neighborhood, day or night.

Strongly agree,	………………………………………	1
Agree,	………………………………………	2
Disagree, or	………………………………………	3
Strongly disagree	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC030 (NEIGH_SAFE_2) Violence is not a problem in my neighborhood.

Strongly agree,	………………………………………	1
Agree,	………………………………………	2
Disagree, or	………………………………………	3
Strongly disagree	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC032 (NEIGH_SAFE_3) My neighborhood is safe from crime.

Strongly agree,	………………………………………	1
Agree,	………………………………………	2
Disagree, or	………………………………………	3
Strongly disagree	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TRACING QUESTIONS

(TIME_STAMP_13) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TQ001 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.

TQ004 (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	………………………………………
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TQ006 (HAVE_EMAIL). Do you have an email address?

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

TQ008 (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

TQ 010(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

TQ012(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

TQ014 (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_14)
DON’T REMEMBER	………………………………………
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TQ016 (CELL_PHONE_1). Do you have a personal cell phone?

YES	………………………………………	1
NO	………………………………………	2	(TIME_STAMP_14)
REFUSED	………………………………………	-1	(TIME_STAMP_14)
DON’T KNOW	………………………………………	-2	(TIME_STAMP_14)

TQ018 (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

TQ020 (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)

TQ022 (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

TQ 024CELL_PHONE). What is your personal cell phone number?

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

PHONE NUMBER

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

(TIME_STAMP_14) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TQ026 (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

TQ028 (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)

(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.

TQ030 (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

TQ032 (CONTACT_RELATE1_OTH) SPECIFY _____________________________

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

TQ034 (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

(CONTACT_PHONE_1) What is his/her telephone number?

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

PHONE NUMBER

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

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

TQ 036(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

INTERVIEWER INSTRUCTION:

• IF RESPONDENT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

TQ038 (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

(CONTACT_RELATE2_OTH) SPECIFY _____________________________

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

TQ040 (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

TQ042 (CONTACT_PHONE_2) What is his/her telephone number?

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

PHONE NUMBER

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

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

INTERVIEW INSTRUCTION: IF (CHILD_QNUM) > 1, GO TO (CHILD_QNUM) AND LOOP THROUGH QUESTIONS FOR NEXT ELIGIBLE CHILD

(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

(TIME_STAMP_15) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.