Reporting : Demographic Questionnaire

Followup Study for Infant Feeding Practices Study II

Pilot total ( survey instrument) 7-13-11

Reporting : Demographic Questionnaire

OMB: 0910-0696

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Job No.18J7 Page 3

CHILD HEALTH & DIET SURVEY OMB # xxxx-xxxx

The following questions should be answered about your 6-year-old child. Expiration Date: zz/zz/zzzz

The Public Disclosure Burden Statement

can be found in the cover letter

Section A

  1. During the past month, what were your regular childcare arrangements for your 6-year-old? (Please “X” all that apply)

Before After Weekends or

School School Non-School Days

Parent cared for the child

Childcare in my home provided by someone other than a parent

Childcare in someone else’s home

A before- or after-school childcare program at school

Childcare center

Other

  1. What kind of school does your 6-year-old currently attend? (Please “X” all that apply)

Public Home-schooled

Private My 6-year-old does not attend any type of school (Go to Question 7)

  1. What grade is your 6-year-old in?

Preschool or Junior Kindergarten First grade

Kindergarten Second grade

  1. How many days a week is your child in school?

Whole days: 0 days 1 day 2 days 3 days 4 days 5 days

Half days: 0 days 1 day 2 days 3 days 4 days 5 days

  1. During this school year, has a special plan been developed at school to provide your 6-year-old with extra help or support such as a special needs program or an Individualized Education Program (IEP)?

EXPLANATORY NOTE:  Some children have difficulty in school because of a health problem, condition, or disability. These children may receive services from a program called Special Education and have a written intervention plan called an Individualized Education Program (IEP).

Yes No Don’t know

  1. During this school year, has your 6-year-old received any of the following services? (Please “X” all that apply)

Speech or language therapy

Occupational therapy or other type of therapy for help with handwriting or other motor skills

Physical therapy

Special instruction or help in one or more school subjects such as reading or math

Special services because of a problem with vision or hearing

Psychological services or counseling because of a problem with emotions, behavior, or socialization

Behavioral support, such as a behavior management plan
or individual support in the classroom by an assistant

Special support because of a chronic health condition

Other (please specify) ______________________________________________________

None of these

  1. About how many books does your 6-year-old have?

None 10 or more books

1 or 2 books Don’t know

3 to 9 books

  1. How often do you read aloud to your 6-year-old?

Never At least 3 times a week

Several times a year Everyday

Several times a month Don’t know

Once a week

  1. Does your family encourage your 6 year-old to start and keep doing hobbies?

Yes No Don’t know

  1. Does your 6-year-old get special lessons or belong to any organization that encourages activities such as sports, music, art, dance, drama, etc.?

Yes No Don’t know

  1. How often has a family member taken or arranged to take your 6-year-old to any type of musical or theatrical performance within the past year?

Never About once a month

Once or twice About once a week or more often

Several times

  1. Here is a list of items that describe children. For each item, please “X” how true it has been for your 6 year-old during the past six months. He or she …

Not Somewhat Certainly

True True True

  1. ...is considerate of other people's feelings

  2. ...is restless, overactive, cannot stay still for long

  3. ...often complains of headaches, stomach aches or sickness

  4. ...shares toys or treats readily with other children

  5. ...often loses temper

  6. is rather solitary, prefers to play alone

  7. ...is generally well behaved, usually does what adults request

  8. ...has many worries, or often seems worried

  9. ...is helpful if someone is hurt, upset, or feeling ill

  10. ...is constantly fidgeting or squirming

  11. ...has at least one good friend

  12. ...often fights with other children or bullies them

  13. ...is often unhappy, depressed, or tearful

  14. ...is generally liked by other children

  15. ...is easily distracted, concentration wanders

  16. ...: is nervous or clingy in new situations

  17. ...is kind to younger children

  18. ...often lies or cheats

  19. ...is picked on or bullied by other children

  20. ...often offers to help others (parents, teachers, other children)

  21. ...thinks things out before acting

  22. ...steals from home, school or elsewhere

  23. ...gets along better with adults than with other children

  24. ...has many fears, is easily scared

  25. ...has good attention span, sees chores or homework through to the end

Section B

  1. How tall is your 6-year-old now (without shoes)? Please use the enclosed tape measure to measure the height. Have your child back up to a wall with the back of the head, shoulder blades, buttocks, and heels touching the wall. Lay a hard-backed book or other flat item from your child’s head to the wall and level with the floor. Mark the wall under the book and then measure from the floor to the mark. Please tell us the height to the nearest quarter inch.

_____ inches

  1. How much does your 6-year-old weigh now (without shoes)? Please weigh your child on a scale. _____ pounds

  2. How tall was your 6-year-old the last time he or she was measured at a doctor’s visit? ______feet _____ inches

  3. What was the date of the height measurement? Month____ / Day_____ / Year________

  4. How much did your 6-year-old weigh the last time he or she was weighed at a doctor’s visit? _____pounds

  5. What was the date of the weight measurement? Month____ / Day_____ / Year________

  6. Please indicate how you would classify your 6-year-old’s weight at each of the 2 periods listed below:

Very Very

Underweight Underweight Average Overweight Overweight

Now

First year of life

  1. Thinking about your 6-year-old, would you like him or her to weigh:

A lot less A little more

A little less A lot more

About the same

  1. How old was your 6-year-old the first time you took him or her to a dentist?

_____years My 6-year-old has never been to a dentist (Go to Question 12)

  1. During the past 12 months, has your 6-year-old been to a dentist?

Yes No

  1. How many dental cavities (teeth with decay) has your 6-year-old had in his or her lifetime?

None 1 2 3 4 5 6 or more

  1. How often does your 6-year-old usually brush his or her teeth? If someone else brushes your 6-year-old’s teeth, please count this.

Never (Go to Question 14) 2 times a day

A few times a week 3 or more times a day

Once a day

  1. Does your 6-year-old usually brush his or her teeth by himself or herself, or does an older child or adult help?
    (Please “X” all that apply)

My 6-year-old brushes his or her teeth by himself or herself

An older child helps my 6-year-old brush his or her teeth

An adult helps my 6-year-old brush his or her teeth

An adult brushes my 6-year-old’s teeth

  1. During the past 12 months, how many times did you take your 6-year-old to a doctor or other health professional for each of the following reasons?

2 3 4 5 6 or

None Once times times times times more times

Routine well child visit

Sick visit

Follow up visit

Emergency room visit due to illness

  1. During the past 12 months, how many times did your 6-year-old have the following infections?

2 3 4 5 6 or

None Once times times times times more times

Ear infection

Sinus infection

Throat infection, e.g. strep throat

Pneumonia or lung infection

Urinary tract infection

Cold or upper respiratory infection

  1. During this current school year, how many days has your 6-year-old missed school because of illness? Count part of the day as a whole day.

None Three to four weeks

1 to 2 days More than one month

3 to 4 days Most of the year

One to two weeks Does not go to school

  1. Does your 6-year-old have any trouble seeing?

No

Yes, but he or she sees normally when wearing eyeglasses

Yes, and eyeglasses cannot correct his or her vision problem enough for him or her to see normally

  1. During the past month, was your 6-year-old given any herbal or botanical remedies or supplements? (Only count things taken by mouth. Do not count anything applied to the skin on administered in any other way.)

Yes No (Go To Question 21a)

  1. Please list all the kinds of herbal or botanical remedies or supplements your 6-year-old was given in the past month.

________________________________________________________________________________________

  1. Why was your 6-year-old given an herbal or botanical remedy or supplement in the past month? (Please X” All That Apply)

To relieve or reduce symptoms of an illness To reduce stress or anxiety

To reduce congestion To help my 6-year-old sleep

To strengthen or maintain health  Other: specify__________________________ 

21A. Has a doctor or other health professional ever told you that
your 6-year-old has any of the following conditions?


If yes… If yes…



If you answer “Yes” to the first column (21A), please also answer columns 21B and 21C.


21B. How old was your 6‑year‑old when you were first told he or she had the condition? (write in 0 if less than 1 year)

21C. Does your 6‑year‑old currently have the condition?

  1. Hearing problems Yes No Unsure ______ Years Yes No Unsure

  2. A digestive problem like colitis,
    acid reflux, colic, or Crohn’s Yes
    No Unsure ______ Years Yes No Unsure

  3. Eczema or any kind of skin
    allergy (e.g., contact dermatitis) Yes
    No Unsure ______ Years Yes No Unsure

  4. Hay fever or respiratory allergy
    (to pets, pollens, mold,
    dust mites, etc.) Yes
    No Unsure ______ Years Yes No Unsure

  5. Drug allergy Yes No Unsure ______ Years Yes No Unsure

  6. Diabetes Yes No Unsure ______ Years Yes No Unsure

  7. Attention Deficit Disorder or
    Attention Deficit Hyperactivity
    Disorder, ADD, or ADHD Yes
    No Unsure ______ Years Yes No Unsure

  8. Autism or developmental delay Yes No Unsure ______ Years Yes No Unsure

  9. Depression or anxiety Yes No Unsure ______ Years Yes No Unsure

  10. Celiac disease Yes No Unsure ______ Years Yes No Unsure

  1. Has your 6-year-old ever visited an emergency room or urgent care center because of breathing difficulties?

Yes No Not sure

  1. In the past 12 months, has your 6-year-old used an inhaler or nebulizer?

Yes No (Go To Question 25) Not sure (Go To Question 25)

  1. What are the triggers of your 6-year-old’s breathing difficulties? (Please “X” All That Apply)

Exercise Change of seasons

Drug allergy Cold weather

Infections Humid or hot weather

Inhaled allergens (dust, pet, food, etc) Anger or emotion

Perfume, scented candles, air freshener, etc Other

Tobacco or other smoke Don’t know or not sure

  1. Has a doctor or other health professional ever told you that your 6-year-old has asthma?

Yes No (Go To Question 27) Not sure (Go To Question 27)

  1. Does your 6-year-old take daily medications either year-round or seasonally to manage his or her asthma?

Yes, year-round Yes, seasonally No

  1. Has your 6-year-old ever been taken to a doctor because of a possible food allergy?

Yes No (Go To Question 30)

  1. If your 6-year-old was tested by a doctor for a food allergy, what method was used?
    (Please “X” All That Apply)

Description of symptoms only (no medical testing) Food elimination (withdrawal of the specific food

A skin test to see if symptoms disappeared)

A blood test Food challenge (introduction of a specific food to

An esophageal or intestinal study see if symptoms reappeared)

  1. Has your 6-year-old ever been diagnosed by a doctor as having an allergy to any food?

Yes No

  1. Do you currently avoid any foods or food ingredients for your 6-year-old because of a known or suspected food allergy or intolerance?

Yes No (Go to Section C)

  1. Which foods or food ingredients do you currently avoid for your 6-year-old? (Please “X” All That Apply)

Cow's milk or other dairy products Other seafood (for example clams, mussels, squid)

Soy milk or other soy food Beef, pork, chicken, or other animal meat

Eggs or egg products Wheat or gluten

Peanuts, peanut butter, or peanut oil Non-gluten grain or cereal (for example, oats, buckwheat)

Almonds, pecans, walnuts, or other tree nuts Fruit or fruit juice

Sesame or sesame seed oil Artificial colors or flavors

Mustard, sunflower, or other seeds Sulfites

Fish (for example, salmon, codfish, tuna) None of these

Crustacean shellfish (for example, Other

shrimp, crab, or lobster) (please specify)______________________________

  1. How old was your 6-year-old the first time he or she had an allergic or intolerance reaction to any food?

Less than 1 year 3 to 4 years Not sure

1 to 2 years 5 years or older

  1. Did your 6-year-old have a reaction the first time he or she ate the food?

Yes No Not sure

  1. Did the first reaction to food result in an emergency care visit (urgent care or emergency department)?

Yes No Not sure

  1. Which of the following symptoms has your 6-year-old had because of a reaction to food?
    (Please “X” All That Apply)

Congestion or runny nose Vomiting or spitting up

Asthma, wheezing, or trouble breathing Abdominal pain, gassiness, or diarrhea

Irritability or behavior changes Constipation

Swollen eyes or lips Unexplained weight loss or gain

Hives, welts, or flushed and itchy skin Blood in stool

Eczema or persistent skin rash Loss of consciousness or shock

Esophagitis or severe acid reflux None of these

  1. Has your 6-year-old ever been prescribed an Epi-pen or epinephrine autoinjector for management of his or her food allergy?

Yes No

  1. Have you stopped taking your 6-year-old to restaurants, social gatherings, or parties for fear of accidental reactions?

Yes, always Yes, sometimes No

Section C

  1. In a typical week, how many days do you or another adult in your household do any physical activities with your 6-year-old, including things like active games, sports, walks, biking, ice skating, swimming, or other physical activities? Please include only activities where both the adult and your 6-year-old are active.

0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

  1. In a typical week, how many days is your 6-year-old physically active for a total of at least 60 minutes per day? Add up all the time your 6-year-old spends in any kind of physical activity that makes him or her sweat or breathe hard (for example, playing tag, running, biking, jumping rope, swimming). If your child is active during recess, please include recess time.

0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

  1. Compared with other children of the same age and sex, is your 6-year-old:

A lot more physically active than most A little less physically active than most

A little more physically active than most A lot less physically active than most

Average – same as most Don’t know or not sure

  1. On average, about how many hours per day does your 6-year-old play video games and watch TV programs or videos? (Do not Count School Or Homework Time.)

Weekdays: _______hours -AND- ______minutes -OR- None

Weekends: _______hours -AND- ______minutes -OR - None

  1. Over the past month, how many hours did your 6-year-old usually sleep each night on weekdays? _____ hours

  2. Over the past month, how often has it been difficult to wake up your 6-year-old in the mornings on week days?

Less than once a week 1-2 times per week 3-5 times per week


Less Than Once 1-2 Times 3-5 Times 6-7 Times

A Week Per Week Per Week Per Week

  1. Over the past month, how often has your 6-year-old
    slept about the same number of hours each night?

  2. Over the past month, how often has your 6-year old had trouble
    falling asleep after going to bed?

  3. Over the past month, how often has your 6-year-old
    woken up during the night?

Section D

  1. Do you own a pet or does your 6-year-old regularly spend time indoors where a pet lives (such as at day care or in the school classroom)? (Please “X” All That Apply)

No Yes, one or more hamsters, gerbils, or similar pets

Yes, one or more dogs Yes, one or more birds

Yes, one or more cats Yes, other pet

  1. In the last 12 months, how often have the following products been used in your home?

Less than About A Few

Not Once 1-3 times once times Every

at all a month a month a week a week day

Air fresheners including spray, stick, aerosol, or plug-in

Scented candles (burned) or scented oil (burned)

Pesticides (ant or flying insect killer, flea control, other)

  1. How many times a day does your 6-year-old usually eat? Please count all meals and snacks. ____

  2. How many days a week does your 6-year-old usually eat breakfast? (Please “X” Only One Box)

0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

  1. How many days a week does your 6-year-old usually eat dinner at home with you or another adult in your household?

0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

  1. How many days a week does your 6-year-old usually eat dinner from a fast food restaurant like McDonald’s, Taco Bell, Pizza Hut, etc., including take-out?

0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

  1. During the school week, how many days a week does your 6-year-old usually eat lunch at school from each of the following places?

Food brought from home ____

A complete school lunch from the school cafeteria ____

Individual items from the school cafeteria ____

Salad bar in the school cafeteria ____

Fast food from the school cafeteria (such as McDonalds, Taco Bell, or KFC) ____

Food from a school vending machine, school canteen, or school store ____

Does not go to school

  1. During the past month, what type of fat did you most often use to cook with at home? (Please “X” Only One Box)

Butter Olive oil

Margarine Other vegetable oil

Crisco Lard or other animal fat

Corn oil Cooking spray (specify type of oil)______

Canola oil Didn’t use fat in cooking

  1. During the past month, what kind of milk did your 6-year-old usually drink? (Please “X” Only One Box)

Plain Cow’s Milk: Other Milk:

Whole or regular milk Sweetened cow’s milk

2% fat or reduced-fat (chocolate, vanilla, fruit flavored, etc.)

1%, ½%, or low-fat Soy milk

Fat-free, skim, or nonfat Other kind of milk

Didn’t drink milk

  1. During the past month, what type of rice did your 6-year-old eat? (Please “X” Only One Box)

Only white rice Mostly brown rice

Only brown rice About half and half

Mostly white rice Didn’t eat rice

  1. During the past month, what type of pasta did your 6-year-old eat? (Please “X” Only One Box)

Only white pasta Mostly whole wheat pasta

Only whole wheat pasta About half and half

Mostly white pasta Didn’t eat pasta

  1. During the past month, what type of bread did your 6-year-old eat? (Please “X” Only One Box)

Only white bread Mostly whole wheat bread

Only whole wheat bread About half and half

Mostly white bread Didn’t eat bread

  1. During the past month, how often did your 6-year-old eat or drink each food listed below?

Think about all the meals and snacks your 6-year-old had at home, school, restaurants, play dates, and anywhere else. Please include food eaten on weekdays and over the weekend.

If your 6-year-old ate the food once a day or more, write the number per day in the first column. If your 6-year-old ate the food less than once a day, write the number per week in the second column. If your 6-year-old ate the food less than once a week, write the number per month in the third column. If your 6-year-old did not eat the food at all during the past month, check the box in the fourth column. (Fill In Only One Column For Each Item)

Per Per Per Did

Day Week Month not eat

  1. Hot or cold cereals ____ ____ ____

  2. Milk: all types to drink or on cereal ____ ____ ____

  3. Cheese: all types (include cheese as a snack, on a sandwich,
    and in foods such as lasagna, quesadillas, or casseroles).
    Do not count cheese on pizza ____ ____ ____

  4. Ice cream or other frozen dairy desserts, such as frozen yogurt
    and sherbet. Don’t include sugar free kinds ____ ____ ____

  5. Other dairy products, such as pudding or yogurt.
    Don’t include sugar free or plain kinds ____ ____ ____

  6. Sugar free frozen dairy desserts or sugar free pudding, plain or
    sugar free yogurt, or other sugar free dairy products ____ ____ ____

  7. Regular soda or pop that contains sugar. Don’t include
    diet soda or diet pop ____ ____ ____

  8. Water: include tap, bottled, and unflavored sparkling water ____ ____ ____

  9. 100% pure fruit juice or 100% pure vegetable juice ____ ____ ____

  10. Sweetened drinks: Kool-aid, lemonade, sweet tea, Hi-C,
    cranberry cocktail, Gatorade, etc. ____ ____ ____

  11. Fruits: fresh, frozen, or canned. Don’t include juice ____ ____ ____

  12. Green leafy or lettuce salad, with or without other vegetables ____ ____ ____

  13. Fried potatoes including French fries, home fries and hash browns ____ ____ ____

  14. Other kinds of potatoes such as baked, boiled, mashed,
    sweet potatoes and potato salad ____ ____ ____

  15. Refried beans, baked beans, beans in soup, pork and beans,
    or any other cooked dried beans. Don’t include green beans ____ ____ ____

  16. Other vegetables: fresh, frozen, or canned (other than lettuce
    salads, potatoes, or cooked dried beans) ____ ____ ____

  17. Rice ____ ____ ____

  18. Pasta ____ ____ ____

  19. Pizza: frozen pizza, fast food pizza, homemade pizza,
    or other pizza ____ ____ ____

  20. Tomato sauces: Mexican-type salsa made with tomato,
    with spaghetti or noodles or mixed into foods such as lasagna ____ ____ ____

  21. Processed meat: bacon, ham, lunch meats, hot dogs, etc ____ ____ ____

  22. Meat (not processed): chicken, turkey, pork, beef, or lamb ____ ____ ____

  23. Fish or shellfish ____ ____ ____

  24. Peanut butter or peanuts. ____ ____ ____

  25. Bread: toast, rolls, bagels, cornbread, tortillas, in sandwiches,
    pancakes, waffles, etc ____ ____ ____

  26. Sweet foods: candy, cookies, cake, doughnuts, muffins,
    pop-tarts, etc. Don’t count frozen or sugar free desserts ____ ____ ____

  27. Popcorn ____ ____ ____

  28. Snacks such as potato chips, corn chips, pretzels, and crackers ____ ____ ____

  1. Please “X” one response for each question which best corresponds to your answer:

Never Rarely Sometimes Often Always

  1. How often are there fruits or vegetables to snack
    on in your home, such as apples, raisins, carrots,
    celery, bananas, or melon?

  2. How often do you encourage your 6-year-old
    to eat all of the food on his or her plate?

  3. How often does your 6-year-old eat all
    of the food on his or her plate?

  1. Please “X” one response for each question which best corresponds to your answer for your 6-year-old child:

Slightly Neither Disagree Slightly

Disagree Disagree Nor Agree Agree Agree

  1. I make sure that my child does not eat too
    many sweets or junk foods

  2. If I did not guide or regulate my child’s eating,
    he or she would eat too much of his or her
    favorite foods

  3. I am especially careful to make sure my child
    eats enough

  4. My child will lose appetite for dinner if he or she
    has had a snack just before

  5. My child is always asking for food

  6. If allowed to, my child would eat too much

  7. My child looks forward to mealtimes

  8. My child enjoys a wide variety of foods

Section E

  1. As best you know, which of the following health conditions do you yourself or your 6-year-old’s other relatives have? (Please “X” All That Apply)

Your 6-Year-Olds Relatives None

You, Brother Grand-Parent, of These

Mother Father or Sister Aunt, or Uncle Relatives

  1. Type 1 diabetes

  2. Adult onset diabetes (Type II)

  3. Asthma

  4. Eczema or any kind of skin allergy
    (e.g., contact dermatitis)

  5. Food allergy

  6. Hay fever or respiratory allergy (to pets, pollens,
    mold, dust mites, etc)

  7. Overweight or obese

  8. Attention Deficit Disorder or Attention Deficit
    Hyperactivity Disorder, ADD, or ADHD

  9. Bipolar disorder

  10. Depression other than bipolar disorder

  11. Anxiety disorder such as generalized
    anxiety disorder

  12. Breast cancer

  1. How much do you weigh? ____ pounds

  2. How tall are you? ____ feet ____ inches

  3. What is your age? ____ years

  4. How often do you yourself do vigorous activities for at least 10 minutes that cause heavy sweating or large increases in breathing or heart rate?

____times per day -OR- ____times per week -OR- ___times per month -OR- Less than once a month….

  1. How much time do you usually spend doing these vigorous activities in one session?

____minutes per session -OR- ____hours per session -OR- None….

  1. How often do you do light or moderate activities for at least 10 minutes that cause only light sweating or slight to moderate increase in breathing or heart rate?

____times per day -OR- ____times per week -OR- ___times per month Less than once a month

  1. How much time do you usually spend doing these light or moderate activities in one session?

____minutes per session -OR- ____hours per session None

  1. For each of the following statements, please “X” the box that best describes how often you felt or behaved this way during the past week

Rarely Some or Occasionally

or None of a Little of or a Moderate Most or All

the Time (Less the Time Amount of the of the Time

than 1 day) (1-2 days) Time (3-4 days) (5-7 days)

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

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

  3. I felt depressed

  4. I felt that everything I did was an effort

  5. I felt hopeful about the future

  6. I felt fearful

  7. My sleep was restless

  8. I was happy

  9. I felt lonely

  10. I could not get “going”

  1. On average, how many cigarettes do you currently smoke per day? (Write in 0 if you do not smoke)

_____ cigarettes per day

  1. How many people not including yourself smoke inside your home most days? (Include family members, friends, and anyone else.)

0 1 2 3 4 or more

  1. Since the birth of your 6-year-old, have you had any pregnancies that ended in a miscarriage, abortion, or stillbirth?

If so, how many? ____ (Write in 0 if none)

  1. Are you pregnant now?

Yes No

  1. How many children have you had after your 6-year-old?

____children No other children after my 6-year-old (Go To Question 16)

  1. Please answer all columns for each child born after your 6-year-old.

How old was this child

when you completely Did this child ever

Sex Date of birth stopped breastfeeding him or her? participate in WIC?

Boy Girl Month___ / Year___ Breastfed ___ Weeks -OR- ___Months Yes No

Never breastfed

Still breastfed

Boy Girl Month___ / Year___ Breastfed ___ Weeks -OR- ___Months Yes No

Never breastfed

Still breastfed

Boy Girl Month___ / Year___ Breastfed ___ Weeks -OR- ___Months Yes No

Never breastfed

Still breastfed

  1. How old was your 6-year-old when the following happened?

  1. I stopped breastfeeding and pumping milk for him or her

___Weeks -OR- ___Months Never breastfed or pumped milk

  1. He or she stopped being fed breast milk, including pumped breast milk

___Weeks -OR- ___Months Never fed breast milk

  1. He or she stopped drinking from a bottle (include breast milk, formula, juice, water,
    and anything else)

___Weeks -OR- ___Months Never drank from a bottle

  1. When you were pregnant with your 6-year-old, did you have gestational diabetes?

Yes No Not sure

  1. Have you worked at a paid job or a business since your 6-year-old was born?

Yes (Go To Question 20) No

  1. For which of the following reasons have you not worked as a paid employee since your 6-year-old was born?
    (Please X” All That Apply)

I wanted to remain at home to raise child/children I had medical complications related to pregnancy

I could not make suitable child care arrangements Other

I could not find a suitable job

(If You Answered Question 19, Go To Question 23)

  1. How old was your 6-year-old when you first returned to work?

____Weeks -OR- ____Months -OR- ___Years

  1. Upon returning to work, did you return to a job with the employer you last worked for while pregnant with your 6-year-old?

Yes (Go To Question 23) No

  1. Why did you not return to your former employer?

Employer did not make a job available I moved out of the area

Employer was no longer in business Other

I chose not to return to this employer

  1. Are you currently working for pay?

Yes No (Go To Question 26)

  1. During the past month, on average how many hours a week were you working?

1-9 hours per week 30-34 hours per week

10-19 hours per week 35-40 hours per week

20-29 hours per week More than 40 hours per week

  1. About how much of your family’s income comes from the money you earn from work?

Less than half About half More than half

  1. Does your 6-year-old have any type of health insurance, or is your 6-year-old covered by any kind of private or governmental health or hospitalization plans or health maintenance organization (HMO) plans?

Yes private health insurance or plan or private HMO

Yes, government plan (Medicaid, State Children’s Health
Insurance Plan (SCHIP), other)

No

  1. During the last 12 months, did you or anyone in your household receive SNAP (Supplemental Nutrition Assistance Program) or Food Stamp benefits?

Yes No


thank you for your help


File Typeapplication/msword
File TitleSupporting Statement for OMB Review
AuthorFDA
Last Modified ByDPresley
File Modified2011-07-14
File Created2011-07-14

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