Postpartum Survey - 2, 6, 9 months

_{ATTACHMENT 3F}

_{Postpartum Survey- 2, 6, & 9 months}

Form Approved:

OMB No. 0923-xxxx

Exp. Date xx/xx/20xx

_{Participant Number:}

SURVEY at 2, 6, & 9 Months

INTERVIEWERS: PLEASE PRINT CLEARLY] Date of Interview:

_{Interviewer Name:}

_{Location of Interview:}

Is there any change in your contact information since we last spoke to you?

 Yes  No  Don’t Know

UPDATED CONTACT INFORMATION Mailing Address

_{Telephone Number – Home Cell Message}

Has the person who is providing care for your baby changed since we last spoke to you?

 Yes

 No

 Don’t know

 Refused

If yes, may we contact them to do baby’s growth and development questionnaires if you are unavailable? If you don’t mind if we contact them please provide their name and contact information below:

_Name

_{Phone number}

Public reporting burden of 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX).

_{Participant Number:}

_{Version 1}

CURRENT BREASTFEEDING PRACTICES

1. Are you currently breastfeeding your baby?

 No, [ skip to 3.]  Refused

_{ Yes If yes,1a. Number of times breastfeed baby per day}

2. Do you currently feed your baby exclusively (ONLY) with breast milk?

 No  Refused

 Yes [stop here]

USE AND PREPARATION OF INFANT FORMULA

3. Do you use baby formula to feed your baby?

 No, [ skip to 5.]  Refused

 Yes If yes, specify below:

3a. Brand of baby formula

_{3b. Number of times per day}

4. Do you use water to mix or prepare baby formula?

 No  Refused

 Yes If yes, specify type of water below:

4a. Type of water used to prepare baby formula

 Unfiltered tap water

 Filtered tap water

 Bottled water

_{ Other → 4b. Specify}

CESSATION OF BREASTFEEDING

5. Have you completely stopped breastfeeding?

 No  Refused

 Yes If Yes, 5a. How old was your baby when you completely stopped breastfeeding?

months weeks

INTRODUCTION OF FOODS

6. Has your baby ever been fed milk (other than breast milk or formula), like cow’s milk, whole milk, soy milk, or Lactaid milk? This includes drinking milk or putting milk in cereal. This does not include using milk in recipes.

 No  Refused

_{ Yes →6a. If yes,What type of other milk?}

7. Has your baby ever been fed cereal, including baby cereal, on a daily basis?

 No  Refused

 Yes → 7a. If yes, on a daily basis since he/she was months weeks old

8. Has your baby ever been fed pureed food on a daily basis? This includes commercial or homemade baby food.

 No  Refused

_{ Yes → 8a. If yes, on a daily basis since he/she was months weeks old}

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_{Participant Number:}

_{Version 1}

9. Has your baby ever been fed solid foods?

 No  Refused

_{ Yes → If yes, on a daily basis since he/she was months weeks old}

_{10. Do you participate in the WIC program?}

FOOD SOURCES

 No  Refused

 Yes → 10a. If yes, which foods do you obtain for your baby using WIC coupons?

HOME QUESTIONS AND OBSERVATIONS

Questions 11 through 20 should be asked of Mom or care giver. 21 through 29 are observations and should be recorded by the interviewer.

11. About how often does your child have a chance to get out of the house?

 Not at all

 About once a month or less

 A few times a month

 About once a week

 4 or more times a week

 Every day

12. About how many children’s books does your child have?

 None

 1 or 2 books

 3 to 9 books

 10 or more books

13. How often do you get a chance to read stories to your child?

 Never

 Several times a year

 Several times a month

 Once a week

 About 3 times a week

 Every day

14. About how often do you take your child to the grocery store?

 Twice a week or more

 Once a week

 Once a month

 Hardly ever

15. About how many, if any, cuddly, soft, or role-playing toys (like a doll) does your child have? (May be shared with sister or brother.)

_{NUMBER OF TOYS}

3

_{Participant Number:}

_{Version 1}

16. About how many, if any, push or pull toys does your child have? (May be shared with sister or brother.)

NUMBER OF TOYS

17. Some parents spend time teaching their children new skills while other parents believe that children learn best on their own. Which of the following best describes your attitude?

 “Parents should always spend time teaching their children.”

 “Parents should usually spend time teaching their children.”

 “Parents should usually allow their children learn on their own.”

 “Parents should always allow their children learn on their own.”

18. How often does your child eat a meal with both mother and father (step-father or father-figure)?

 More than once a day

 Once a day

 Several times a week

 About once a week

 About once a month

 Never

 No father, step-father, or father-figure

19. Children seem to demand attention while their parents are busy, doing housework, for example. How often do you talk to your child while you are working?

 Always talk to child when I’m working

 Often talk to child when I’m working

 Sometimes talk to child when I’m working

 Rarely talk to child when I’m working

 Never talk to child when I’m working

20. Sometimes kids mind pretty well and sometimes they don’t. About how many times, if any, have you had to spank your child in the past week?

NUMBER OF TIMES

 Did not spank last week

OBSERVATIONS

21. Mom / care giver spontaneously vocalized to/conversed with child at least twice.

 Yes  No

22. Mom / care giver responded verbally to child.

 Yes  No

23. Mom / care giver showed physical attention to child.

 Yes  No

24. Mom / care giver did not spank child.

 Yes  No

25. Mom / care giver did not interfere/restrict child more than 3 times.

_{ Yes  No}

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_{Participant Number:}

_{Version 1}

26. Mom / care giver provided appropriate toys/activities to child.

 Yes  No

27. Mom / care giver kept child in view.

 Yes  No

28. Play environment is safe (home or building).

 Yes  No

PERCEIVED STRESS SCALE

The following questions ask about Mom’s feelings and thought during the last month.

29. In the last month, how often have you felt that you were unable to control the important things in your life?

 Never

 Almost never

 Sometimes

 Fairly often

 Very often

 No answer

30. In the last month, how often have felt confident about your ability to handle your personal problems?

 Never

 Almost never

 Sometimes

 Fairly often

 Very often

 No answer

31. In the last month, how often have you felt that things were going your way?

 Never

 Almost never

 Sometimes

 Fairly often

 Very often

 No answer

32. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

 Never

 Almost never

 Sometimes

 Fairly often

 Very often

_{ No answer}

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