Form 8.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/ 2013

Pregnancy Visit 1 Interview, Phase 2e

Pregnancy Visit 1 Interview

Event:	Pregnancy Visit 1
Participant:	Pregnant Woman
Domain:	Questionnaire
Type of Document:	Interview
Allowable Mode:	In Person
Allowable Method:	CAPI
Recruitment Groups:	EH, PB, HI, PBS
Version:	x.x
Release:	MDES 3.0

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Pregnancy Visit 1 Interview

TABLE OF CONTENTS

INTERVIEW INTRODUCTION 1

CURRENT PREGNANCY INFORMATION 2

MEDICAL HISTORY 10

HEALTH INSURANCE 15

HOUSING CHARACTERISTICS 17

PETS 25

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS 26

COMMUTING 33

FAMILY INCOME 36

PREGNANCY CARE LOG INTRODUCTION 38

Pregnancy Visit 1 Interview
CAPI

INTERVIEW INTRODUCTION

(TIME_STAMP_IN_ST) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS:

• IF FIRST PREGNANCY VISIT 1 INTERVIEW, GO TO AGE_ELIG.

• IF SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW, GO TO CPI001.

IN005/(AGE_ELIG).

PARTICIPANT IS AGE-ELIGIBLE 1

PARTICIPANT IS YOUNGER THAN AGE OF MAJORITY 2 (END_AGE)

PARTICIPANT IS OVER AGE 49 3

AGE ELIGIBILITY IS UNKNOWN 4

PROGRAMMER INSTRUCTION:

• BASED ON DOB_CONFIRM OR PERSON_DOB FROM PARTICIPANT CONSENT AND VERIFICATION INSTRUMENT, CALCULATE AGE. USING KNOWN LOCAL AGE OF MAJORITY TO DETERMINE WHETHER PARTICIPANT IS ELIGIBLE (AT LEAST AGE OF MAJORITY AND LESS THAN AGE 50); SET AGE_ELIG AS APPROPRIATE

(TIME_STAMP_IN_ET) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

CURRENT PREGNANCY INFORMATION

(TIME_STAMP_CPI_ST) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

CPI001. We’ll begin by asking some questions about you, your health, and your health history. First, I’ll ask about your current pregnancy.

CPI001A/(PREGNANT). The first questions ask about how your pregnancy is progressing. Are you still pregnant?

YES 1 (DUE_DATE_MM)(DUE_DATE_DD)(DUE_DATE_YY)

NO 2

REFUSED -1 (END_LOSS)

DON’T KNOW -2 (END_LOSS)

CPI001B. I’m so sorry for your loss. I know this can be a difficult time.

INTERVIEWER INSTRUCTIONS:

• USE SOCIAL CUES AND PROFESSIONAL JUDGMENT IN RESPONSE

PROGRAMMER/INTERVIEWER INSTRUCTION:

• IF STUDY CENTER HAS PREGNANCY LOSS INFORMATION TO DISSEMINATE, OFFER TO PARTICIPANT AND GO TO LOSS_INFO.

• OTHERWISE GO TO END_LOSS.

CPI001C/(LOSS_INFO). INTERVIEWER ANSWERED QUESTION: DID PARTICIPANT REQUEST ADDITIONAL INFORMATION ON COPING WITH PREGNANCY LOSS?

YES 1 (eND_LOSS)

NO 2 (eND_LOSS)

CPI002/(DUE_DATE_MM)(DUE_DATE_DD)(DUE_DATE_YY). What is your current due date?

INTERVIEWER INSTRUCTIONS:

• 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

MONTH
|___|___|
M M

IF VALID RESPONSE PROVIDED (KNOW_DATE)

REFUSED -1 (DATE_PERIOD)

DON’T KNOW -2 (DATE_PERIOD)

DATE:

|___|___|

D D

REFUSED -1

DON’T KNOW -2

YEAR:

|___|___|___|___|

Y Y Y Y

REFUSED -1 (DATE_PERIOD)

DON’T KNOW -2 (DATE_PERIOD)

PROGRAMMER INSTRUCTIONS:

• CHECK REPORTED DUE DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:

• IF DATE IS MORE THAN 9 MONTHS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 9 MONTHS FROM TODAY. RE-ENTER DATE.”

• IF DATE IS MORE THAN 1 MONTH BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT OCCURRED MORE THAN A MONTH BEFORE TODAY. RE-ENTER DATE.”

• IF VALID DUE DATE WAS PROVIDED, SET DUE_DATE = YYYY-MM-DD AS REPORTED; GO TO KNOW_DATE

• IF NO VALID DATE IS GIVEN  GO TO DATE_PERIOD.

CPI003/(KNOW_DATE). How did you find out your due date? Did you ...

Figure it out yourself 1

Have an ultrasound to figure it out 2

Have a doctor or other provider tell you without an ultrasound……………………………….. 3

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• GO TO KNEW_DATE.

CPI004/(DATE_PERIOD). What was the first day of your last menstrual period?

INTERVIEWER INSTRUCTIONS:

• ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR

• CODE DAY AS “15” IF PARTICIPANT IS UNSURE/ UNABLE TO ESTIMATE DAY.

• IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE.

MONTH:
|___|___|
M M

IF VALID RESPONSE PROVIDED (KNEW_DATE)

REFUSED -1 (HOME_TEST)

DON’T KNOW -2 (HOME_TEST)

DATE:

|___|___|

D D

REFUSED -1 (HOME_TEST)

DON’T KNOW -2

YEAR:

|___|___|___|___|

Y Y Y Y

REFUSED -1 (HOME_TEST)

DON’T KNOW -2 (HOME_TEST)

PROGRAMMER INSTRUCTIONS:

• CHECK REPORTED MENSTRUAL DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:

• IF DATE IS MORE THAN 10 MONTHS BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 10 MONTHS BEFORE TODAY. CONFIRM DATE. IF DATE IS CORRECT, ENTER ‘DON’T KNOW’.”

• IF DATE IS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT HAS NOT OCCURRED YET. RE-ENTER DATE.”

• IF VALID DATE WAS PROVIDED, CALCULATE DUE DATE FROM THE FIRST DATE OF LAST MENSTRUAL PERIOD AND SET DUE_DATE YYYY-MM-DD = DATE_PERIOD + 280 DAYS; GO TO KNEW_DATE.

CPI004A/(KNEW_DATE). DID PARTICIPANT GIVE DATE?

PARTICIPANT GAVE COMPLETE DATE 1

INTERVIEWER ENTERED 15 FOR DAY 2

CPI005/(HOME_TEST). Did you use a home pregnancy test to help find out you were pregnant?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI006/(MULTIPLE_GESTATION). Are you pregnant with a single baby (singleton), twins, or triplets or other multiple births?

SINGLETON 1

TWINS 2

TRIPLETS OR HIGHER 3

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• IF MULTIPLE_GESTATION =2 OR 3, DISPLAY “BABIES” AS APPROPRIATE THROUGHOUT INSTRUMENT.

• OTHERWISE, DISPLAY “BABY.”

CPI008/(BIRTH_PLAN). Where do you plan to deliver your {baby/babies}?

In a hospital, 1

A birthing center, 2

At home, or 3 (PN_VITAMIN)

Some other place? 4

REFUSED -1 (PN_VITAMIN)

DON’T KNOW -2 (PN_VITAMIN)

CPI009/(BIRTH_ADDR). What is the name and address of the place where you are planning to deliver your (baby/babies)?

_____________________________________________________

NAME OF BIRTH HOSPITAL/BIRTHING CENTER (BIRTH_PLACE)

REFUSED -1

DON’T KNOW -2

_____________________________________________________

STREET ADDRESS (B_ADDRESS_1)/(B_ADDRESS_2)

REFUSED -1

DON’T KNOW -2

_____________________________________________________

CITY (B_CITY)

REFUSED -1

DON’T KNOW -2

|___|___|

STATE (B_STATE)

REFUSED -1

DON’T KNOW -2

|___|___|___|___|___|

ZIP CODE (B_ZIPCODE)

REFUSED -1

DON’T KNOW -2

CPI010/(PN_VITAMIN). In the month before you became pregnant, did you regularly take multivitamins, prenatal vitamins, folate, or folic acid?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI012/(PREG_VITAMIN). Since you’ve become pregnant, have you regularly taken multivitamins, prenatal vitamins, folate, or folic acid?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI013/(DATE_VISIT). What was the date of your most recent doctor’s visit or checkup since you’ve become pregnant?

INTERVIEWER INSTRUCTION:

• ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR

MONTH:
|___|___|
M M

HAVE NOT HAD A VISIT -7 (TIME_STAMP_CPI_ET)

REFUSED -1 (TIME_STAMP_ CPI_ET)

DON’T KNOW -2 (TIME_STAMP_ CPI_ET)

DATE:

|___|___|

D D

REFUSED -1

DON’T KNOW -2

YEAR:

|___|___|___|___|

Y Y Y Y

REFUSED -1 (TIME_STAMP_ CPI_ET)

DON’T KNOW -2 (TIME_STAMP_ CPI_ET)

CPI014. {At this visit or at}/{At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?

PROGRAMMER INSTRUCTION:

• IF VALID DATE FOR DATE_VISIT IS PROVIDED, DISPLAY “ At this visit or at”.

• OTHERWISE, DISPLAY “At”.

INTERVIEWER INSTRUCTION:

• FOR ITEMS DIABETES_1, HIGHBP_PREG, URINE, PREECLAMP, EARLY_LABOR, ANEMIA, NAUSEA, KIDNEY, RH_DISEASE, GROUP_B, HERPES, VAGINOSIS, OTH_CONDITION, AND CONDITION_OTH, RE-READ INTRODUCTORY STATEMENT ({At this visit or at}/{At}] any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

CPI014A/(DIABETES_1). Diabetes?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI014B/(HIGHBP_PREG). High blood pressure?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI014C/(URINE). Protein in your urine?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI014D/(PREECLAMP). Preeclampsia or toxemia?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI014E/(EARLY_LABOR). Early or premature labor?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI014F/(ANEMIA). Anemia or low blood count?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI014G/(NAUSEA). Severe nausea or vomiting (hyperemesis)?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI014H/(KIDNEY). Bladder or kidney infection?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI014I/(RH_DISEASE). Rh disease or isoimmunization?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI014J/(GROUP_B). Infection with bacteria called Group B strep?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI014K/(HERPES). Infection with a Herpes virus?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI014L/(VAGINOSIS). Infection of the vagina with bacteria (bacterial vaginosis?)

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI014M/(OTH_CONDITION). Any other serious condition?

YES 1

NO 2 (TIME_STAMP_CPI_ET)

REFUSED -1 (TIME_STAMP_CPI_ET)

DON’T KNOW -2 (TIME_STAMP_CPI_ET)

CPI015/(CONDITION_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

(TIME_STAMP_CPI_ET) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

MEDICAL HISTORY

(TIME_STAMP_MD_ST). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

MD001. This next question is about your health when you are not pregnant.

MD002/(HEALTH). Would you say your health in general is . . .

Excellent 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF FIRST PREGNANCY VISIT 1 INTERVIEW, GO TO HEIGHT_FT/HT_INCH.

• IF SUBSEQUENT PREGANCY VISIT 1 INTERVIEW, GO TO WEIGHT.

MD103/(HEIGHT_FT)/(HT_INCH). How tall are you without shoes?

|___|

FEET

REFUSED -1

DON’T KNOW -2

|___|___|

INCHES

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• DISPLAY A SOFT EDIT IF HEIGHT_FT > 7 OR < 4

• IF HEIGHT_FT IS PROVIDED, DISPLAY A SOFT EDIT IF HT_INCH > 12.

• IF HEIGHT_FT IS NOT PROVIDED, DISPLAY A SOFT EDIT IF HT_INCH > 84 OR < 48.

MD104/(WEIGHT). What was your weight just before you became pregnant?

|___|___|___|

POUNDS

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• DISPLAY A SOFT EDIT IF WEIGHT < 90 OR > 400.

• FOR MD110:

  • IF FIRST PREGNANCY VISIT 1 INTERVIEW (I.E., NO PREGNANCY VISIT 1 INTERVIEWS SET TO COMPLETE), DISPLAY “IN THE PAST.”

  • IF ONE PREVIOUS PREGNANCY VISIT 1 INTERVIEW SET TO COMPLETE, DISPLAY “SINCE” AND DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW.

  • IF TWO OR MORE PREVIOUS PREGNANCY VISIT 1 INTERVIEWS SET TO COMPLETE, DISPLAY “SINCE” AND DATE OF MOST RECENT PREGNANCY VISIT 1 INTERVIEW.

  • DISPLAY DATE AS MM/DD/YYYY.

MD110. The next questions are about medical conditions or health problems you might have now or may have had {in the past/{since {DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW}}/{since {DATE OF MOST RECENT SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW}}.

PROGRAMMER INSTRUCTIONS:

• FOR ASTHMA, HIGHBP_NOTPREG, DIABETES_NOTPREG, DIABETES_3 AND THYROID_1:

  • IF FIRST PREGNANCY VISIT 1 INTERVIEW (I.E., NO PREGNANCY VISIT 1 INTERVIEWS SET TO COMPLETE), DISPLAY “ever”.

  • IF ONE PREVIOUS PREGNANCY VISIT 1 INTERVIEW SET TO COMPLETE, DISPLAY “since” AND PRELOAD AND DISPLAY DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW.

  • IF TWO OR MORE PREVIOUS PREGNANCY VISIT 1 INTERVIEWS SET TO COMPLETE, DISPLAY “since” AND PRELOAD AND DISPLAY DATE OF MOST RECENT PREGNANCY VISIT 1 INTERVIEW.

  • DISPLAY DATE AS MM/DD/YYYY.

MD111/(ASTHMA). Have you {ever} been told by a doctor or other health care provider that you had asthma {since {DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW}}/{since {DATE OF MOST RECENT SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW}}?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD112/(HIGHBP_NOTPREG). Have you {ever} been told by a doctor or other health care provider that you had

Hypertension or high blood pressure when you’re not pregnant {since {DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW}}/{since {DATE OF MOST RECENT SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW}}?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD113/(DIABETES_NOTPREG). Have you {ever} been told by a doctor or other health care provider that you had

High blood sugar or diabetes when you’re not pregnant {since {DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW}}/{since {DATE OF MOST RECENT SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW}}?

YES 1

NO 2 (THYROID_1)

REFUSED -1 (THYROID_1)

DON’T KNOW -2 (THYROID_1)

MD114/(DIABETES_2). Have you taken any medicine or received other medical treatment for diabetes in the past 12 months?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD115/(DIABETES_3). Have you {ever} taken insulin {since {DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW}}/{since {DATE OF MOST RECENT SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW}}?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD116/(THYROID_1). Have you {ever} been told by a doctor or other health care provider that you had hypothyroidism, that is, an under active thyroid {since {DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW}}/{since {DATE OF MOST RECENT SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW}}?

YES 1

NO 2 (DIFF_HEAR)

REFUSED -1 (DIFF_HEAR)

DON’T KNOW -2 (DIFF_HEAR)

MD117/(THYROID_2). Have you taken any medicine or received other medical treatment for a thyroid problem in the past 12 months?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD120/(DIFF_HEAR). Are you deaf or do you have serious difficulty hearing?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD121/(DIFF_SEE). Are you blind or do you have serious difficulty seeing, even when wearing glasses?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD122/(DIFF_CONCENTRATE). Because of physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD123/(DIFF_WALK). Do you have serious difficulty walking or climbing stairs?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD124/(DIFF_DRESS). Do you have difficulty dressing or bathing?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD125/(DIFF_ERRAND). Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD130. This next question is about where you go for routine health care.

MD131/(HLTH_CARE). What kind of place do you usually go to when you need routine or preventive care, such as a physical examination or check-up?

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 PREVENTIVE CARE ANYWHERE 7

REFUSED -1

DON'T KNOW -2

(TIME_STAMP_MD_ET). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

HEALTH INSURANCE

(TIME_STAMP_HI_ST) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

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

HI001A/(INSURE). Are you currently covered by any kind of health insurance or some other kind of health care plan?

YES 1

NO 2 (TIME_STAMP_HI_ET)

REFUSED -1 (TIME_STAMP_HI_ET)

DON’T KNOW -2 (TIME_STAMP_HI_ET)

HI002. Now I’ll read a list of different types of insurance. Please tell me which types you currently have. Do you currently have…

INTERVIEWER INSTRUCTION:

• FOR ITEMS INS_EMPLOY, INS_MEDICAID, INS_TRICARE, INS_IHS, INS_MEDICARE, AND INS_OTH, RE-READ INTRODUCTORY STATEMENT “Do you currently have…” AS NEEDED.

HI002A/(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

HI002B/(INS_MEDICAID). Medicaid or any government-assistance plan for those with low incomes or a disability?

INTERVIEWER INSTRUCTIONS:

• PROVIDE EXAMPLES OF LOCAL MEDICAID PROGRAMS.

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI002C/(INS_TRICARE). TRICARE, VA, or other military health care?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI002D/(INS_IHS). Indian Health Service?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI002E/(INS_MEDICARE). Medicare, for people with certain disabilities?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI002F/(INS_OTH). Any other type of health insurance or health coverage plan?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_HI_ET) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

HOUSING CHARACTERISTICS

(TIME_STAMP_HC_ST) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

HC001. Now I’d like to find out more about your home and the area in which you live.

PROGRAMMER INSTRUCTIONS:

• IF FIRST PREGNANCY VISIT 1 INTERVIEW:

  • IF OWN_HOME WAS ASKED DURING PREGNANCY SCREENER OR PRE-PREGANCY VISIT, THEN ASK RECENT_MOVE.

  • OTHERWISE, GO TO OWN_HOME.

• IF SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW:

  • GO TO RECENT_MOVE.

HC013/(RECENT_MOVE). Have you moved or changed your housing situation since we contacted you last?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• IF FIRST PREGNANCY VISIT1 INTERVIEW:

  • IF RECENT_MOVE = 1, GO TO OWN_HOME.

  • OTHERWISE, GO TO AGE_HOME.

• IF SUBSEQUENT PREGNANCY VISIT1 INTERVIEW:

  • IF RECENT_MOVE = 1, GO TO OWN_HOME.

  • OTHERWISE, GO TO HC018.

HC014/(OWN_HOME). Is your home…

Owned or being bought by you or someone in
your household 1 (AGE_HOME)

Rented by you or someone in your household, or 2 (AGE_HOME)

Occupied without payment of rent? 3 (AGE_HOME)

SOME OTHER ARRANGEMENT -5

REFUSED -1 (AGE_HOME)

DON’T KNOW -2 (AGE_HOME)

HC015/(OWN_HOME_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS

• IF FIRST PREGNANCY VISIT 1 INTERVIEW:

• THE REST OF THE QUESTIONS IN THIS SECTION ARE ONLY ASKED OF A SUBSET OF PARTICIPANTS, DEPENDING UPON WHETHER A PRE-PREGNANCY QUESTIONNAIRE WAS COMPLETED AND RESPONSES TO RECENT_MOVE ABOVE AND DURING THE PRE-PREGNANCY VISIT

• IF RECENT_MOVE DURING THIS EVENT IS “1 ” GO TO AGE_HOME AND CONTINUE THROUGH REST OF SECTION

• IF RECENT_MOVE DURING THIS EVENT IS ‘2,’ -1,’ OR ‘-2 AND

  • NO PRE-PREGNANCY INFORMATION IS AVAILABLE; GO TO AGE_HOME AND CONTINUE THROUGH REST OF SECTION

  • IF RECENT_MOVE WAS ASKED DURING PRE-PREGNANCY QUESTIONNAIRE AND WAS CODED AS “1”; SKIP REST OF SECTION AND GO TO HC033

  • IF RECENT_MOVE WAS ASKED DURING PRE-PREGNANCY QUESTIONNAIRE AND WAS NOT CODED AS “1”; GO TO (AGE_HOME) AND CONTINUE THROUGH SECTION

• IF SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW:

• IF RECENT_MOVE DURING THIS EVENT IS “1” GO TO AGE_HOME AND CONTINUE THROUGH REST OF SECTION

• IF RECENT_MOVE DURING THIS EVENT IS ‘2,’ -1,’ OR ‘--2’, GO TO HC018.

HC016/(AGE_HOME). Can you tell us, which of these categories do you think best describes when your home or building was built?

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT

2001 TO PRESENT 1

1981 TO 2000 2

1961 TO 1980 3

1941 TO 1960 4

1940 OR BEFORE 5

REFUSED -1

DON’T KNOW -2

HC017/(LENGTH_RESIDE)/(LENGTH_RESIDE_UNIT). How long have you lived in this home?

|___|___|

NUMBER

REFUSED -1

DON’T KNOW -2

WEEKS 1

MONTHS 2

YEARS 3

HC018. Now I’m going to ask about how your home is heated and cooled.

HC019/(MAIN_HEAT). Which of these types of heat sources best describes the main heating fuel source for your home?

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT.

ELECTRIC 1 (HEAT2)

GAS – PROPANE OR LP 2 (HEAT2)

OIL 3 (HEAT2)

WOOD 4 (HEAT2)

KEROSENE OR DIESEL 5 (HEAT2)

COAL OR COKE 6 (HEAT2)

SOLAR ENERGY 7 (HEAT2)

HEAT PUMP 8 (HEAT2)

NO HEATING SOURCE -7 (COOLING)

OTHER -5

REFUSED -1 (COOLING)

DON’T KNOW -2 (COOLING)

HC020/(MAIN_HEAT_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

HC021/(HEAT2). Are there any other types of heat you use regularly during the heating season to heat your home?

INTERVIEWER INSTRUCTIONS:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT

• PROBE: Do you have any space heaters, or any secondary method for heating your home?

• SELECT ALL THAT APPLY.

ELECTRIC 1

GAS – PROPANE OR LP 2

OIL 3

WOOD 4

KEROSENE OR DIESEL 5

COAL OR COKE 6

SOLAR ENERGY 7

HEAT PUMP 8

NO OTHER HEATING SOURCE 9

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF HEAT2 CODED WITH ANY COMBINATION OF VALUES 1 – 8, THEN GO TO COOLING.

• IF HEAT2 CODED 9, -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO COOLING.

• IF HEAT2 CODED -5, OR ANY COMBINATION OF VALUES 1 – 8 AND -5, GO TO HEAT2_OTH.

HC022/(HEAT2_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

HC023/(COOLING). Does your home have any type of cooling or air conditioning besides fans?

YES 1

NO 2 (HC033)

REFUSED -1 (HC033)

DON’T KNOW -2 (HC033)

HC024/(COOL). Not including fans, which of the following kinds of cooling systems do you regularly use?

INTERVIEWER INSTRUCTION:

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY.

Window or wall air conditioners, 1

Central air conditioning 2

Evaporative cooler (swamp cooler), or 3

Some other cooling system? -5

NO COOLING OR AIR CONDITIONING REGULARLY USED -7

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF COOL CODED WITH ANY COMBINATION OF VALUES 1 – 3, THEN GO TO HC033.

• IF COOL CODED 4, -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO HC033.

• IF COOL CODED -5, OR ANY COMBINATION OF VALUES 1 – 3 AND -5, GO TO COOL_OTH.

HC025/(COOL_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

HC033. Now I’d like to ask about the water in your home.

HC034/(WATER_DRINK). What water source in your home do you use most of the time for drinking?

Tap water, 1 (WATER_COOK)

Filtered tap water, 2 (WATER_COOK)

Bottled water, or 3 (WATER_COOK)

Some other source? -5

REFUSED -1 (WATER_COOK)

DON’T KNOW -2 (WATER_COOK)

HC034A/(WATER_DRINK_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

HC035/(WATER_COOK). What water source in your home is used most of the time for cooking?

Tap water, 1 (HC036)

Filtered tap water, 2 (HC036)

Bottled water, or 3 (HC036)

Some other source? -5

REFUSED -1 (HC036)

DON’T KNOW -2 (HC036)

HC035A/(WATER_COOK_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

HC036. 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.

HC037/(WATER). In the past 12 months, have you seen any water damage inside your home?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HC038/(MOLD). In the past 12 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 (HC041)

REFUSED -1 (HC041)

DON’T KNOW -2 (HC041)

HC039/(ROOM_MOLD). In which rooms have you seen the mold or mildew?

INTERVIEWER INSTRUCTION:

• PROBE: Any other rooms?

• SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

PARTICIPANT’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF ROOM_MOLD CODED WITH ANY COMBINATION OF VALUES 1 – 7, THEN GO TO HC041.

• IF ROOM_MOLD CODED -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, GO TO ROOM_MOLD_OTH.

• IF ROOM_MOLD CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO HC041.

HC040/(ROOM_MOLD OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

HC041. The next few questions ask about any recent additions or renovations to your home.

HC042/(PRENOVATE). Since you became pregnant, 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 (PDECORATE)

REFUSED -1 (PDECORATE)

DON’T KNOW -2 (PDECORATE)

HC043/(PRENOVATE_ROOM). Which rooms were renovated?

INTERVIEWER INSTRUCTION:

• PROBE: Any others?

• SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

PARTICIPANT’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF PRENOVATE_ROOM CODED WITH ANY COMBINATION OF VALUES 1 – 7, THEN GO TO PDECORATE.

• IF PRENOVATE_ROOM CODED -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, GO TO PRENOVATE_ROOM_OTH.

• IF PRENOVATE_ROOM CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO PDECORATE.

HC044/(PRENOVATE_ROOM_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

HC045/(PDECORATE). Since you became pregnant, were any smaller projects done in your home, such as painting, wallpapering, refinishing floors, or installing new carpet?

YES 1

NO 2 (TIME_STAMP_HC_ET)

REFUSED -1 (TIME_STAMP_HC_ET)

DON’T KNOW -2 (TIME_STAMP_HC_ET)

HC046/(PDECORATE_ROOM). In which rooms were these smaller projects done?

INTERVIEWER INSTRUCTION:

• PROBE: Any others?

• SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

PARTICIPANT’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF PDECORATE_ROOM CODED WITH ANY COMBINATION OF VALUES 1 – 7, THEN GO TO TIME_STAMP_HC_ET.

• IF PDECORATE_ROOM CODED -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, GO TO PDECORATE_ROOM_OTH.

• IF PDECORATE_ROOM CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO TIME_STAMP_HC_ET.

HC046A/(PDECORATE_ROOM_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

(TIME_STAMP_HC_ET) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PETS

(TIME_STAMP_PT_ST) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PT001. Now I’d like to ask about any pets you may have in your home.

PT002/(PETS). Are there any pets that spend any time inside your home?

YES 1

NO 2 (TIME_STAMP_PT_ET)

REFUSED -1 (TIME_STAMP_PT_ET)

DON’T KNOW -2 (TIME_STAMP_PT_ET)

PT003/(PET_TYPE). What kind of pets are these?

INTERVIEWER INSTRUCTION:

• PROBE FOR ANY OTHER RESPONSES

• 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 (PET_TYPE_OTH) -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF PET_TYPE CODED WITH ANY COMBINATION OF VALUES 1 – 5, THEN GO TO TIME_STAMP_PT_ET.

• IF PET_TYPE CODED -5, OR ANY COMBINATION OF VALUES 1 – 5 AND -5, GO TO PET_TYPE_OTH.

• IF PET_TYPE CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO TIME_STAMP_PT_ET.

PT003A/(PET_TYPE_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

(TIME_STAMP_PT_ET) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS

(TIME_STAMP_HCD_ST) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

HCD001. Now, I’d like to ask some questions about your schooling and employment.

HCD002/(EDUC). What is the highest degree or level of school that you have completed?

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT.

LESS THAN A HIGH SCHOOL DIPLOMA OR GED 1

HIGH SCHOOL DIPLOMA OR GED 2

SOME COLLEGE BUT NO DEGREE 3

ASSOCIATE DEGREE 4

BACHELOR’S DEGREE (FOR EXAMPLE, BA, BS) 5

POST GRADUATE DEGREE (FOR EXAMPLE, MASTERS OR DOCTORAL) 6

REFUSED -1

DON’T KNOW -2

HCD003/(WORKING). Are you currently working at any full or part time jobs?

YES 1

NO 2 (HCD005D)

REFUSED -1 (HCD005D)

DON’T KNOW -2 (HCD005D)

HCD004/(HOURS). Approximately how many hours each week are you working?

|___|___|___|

NUMBER OF HOURS

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• DISPLAY A SOFT EDIT IF RESPONSE > 60.

HCD005/(SHIFT_WORK). Do you work a shift that starts after 2 pm?

YES 1

NO 2

SOMETIMES 3

REFUSED -1

DON’T KNOW -2

HCD005B/(WORK_NAME). What is the name of the place where you work?

_____________________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

HCD005C/(WORK ADDRESS VARIABLES). What is the address where you work?

INTERVIEWER INSTRUCTION:

• PROBE AND ENTER AS MUCH INFORMATION AS PARTICIPANT KNOWS.

__________________________________________________

ADDRESS 1 - STREET/PO BOX (WORK_ADDRESS_1)

REFUSED -1

DON’T KNOW -2

ADDRESS 2 (WORK_ADDRESS_2)

REFUSED -1

DON’T KNOW -2

UNIT (WORK_UNIT)

REFUSED -1

DON’T KNOW -2

CITY (WORK_CITY)

REFUSED -1

DON’T KNOW -2

|___|___|

STATE (WORK_STATE)

REFUSED -1

DON’T KNOW -2

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

ZIP CODE ZIP+4 (WORK_ZIP) (WORK_ZIP4)

REFUSED -1

DON’T KNOW -2

HCD005D/(ENGLISH_WELL). How well do you speak English? Would you say…

Very well, 1

Well, 2

Not well, or 3

Not at all? 4

REFUSED -1

DON’T KNOW -2

HCD005E. These next questions are about the language that will be spoken to your {baby/babies}.

PROGRAMMER INSTRUCTIONS:

• IF MULTIPLE_GESTATION = 1, -1, OR -2, DISPLAY “baby”.

• OTHERWISE, IF MULTIPLE_GESTATION = 2 OR 3, DISPLAY “babies”.

HCD006/(HH_NONENGLISH). Do you speak a language other than English at home?

YES 1

NO 2 (MARISTAT)

REFUSED -1 (MARISTAT)

DON’T KNOW -2 (MARISTAT)

HCD007/(OTHER_LANG). What is this language?

Spanish 1 (MARISTAT)

Other -5

REFUSED -1 (MARISTAT)

DON’T KNOW -2 (MARISTAT)

HCD008/(OTHER_LANG_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

HCD010/(HH_PRIMARY_LANG). What is the primary language spoken in your home?

ENGLISH 1 (MARISTAT)

SPANISH 2 (MARISTAT)

ARABIC 3 (MARISTAT)

CHINESE 4 (MARISTAT)

FRENCH 5 (MARISTAT)

FRENCH CREOLE 6 (MARISTAT)

GERMAN 7 (MARISTAT)

ITALIAN 8 (MARISTAT)

KOREAN 9 (MARISTAT)

POLISH 10 (MARISTAT)

RUSSIAN 11 (MARISTAT)

TAGALOG 12 (MARISTAT)

VIETNAMESE 13 (MARISTAT)

URDU 14 (MARISTAT)

PUNJABI 15 (MARISTAT)

BENGALI 16 (MARISTAT)

FARSI 17 (MARISTAT)

SIGN LANGUAGE 18 (MARISTAT)

CANNOT CHOOSE 19 (MARISTAT)

OTHER -5

REFUSED -1 (MARISTAT)

DON’T KNOW -2 (MARISTAT)

HCD013/(HH_PRIMARY_LANG_OTH).

OTHER SPECIFY ____________________________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

HCD015/(MARISTAT). I’d like to ask about your marital status. Are you:

Married, 1

Not married but living together with a partner, 2

Never been married, 3 (TIME_STAMP_HCD_ET)

Divorced, 4 (TIME_STAMP_ HCD_ET)

Separated, or 5 (TIME_STAMP_ HCD_ET)

Widowed? 6 (TIME_STAMP_ HCD_ET)

REFUSED -1 (TIME_STAMP_HCD_ET)

DON’T KNOW -2 (TIME_STAMP_ HCD_ET)

INTERVIEWER INSTRUCTION:

• PROBE OR CURRENT MARITAL STATUS

HCD016/(SP_EDUC). What is the highest degree or level of school that your spouse or partner has completed?

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT.

LESS THAN A HIGH SCHOOL DIPLOMA OR GED 1

HIGH SCHOOL DIPLOMA OR GED 2

SOME COLLEGE BUT NO DEGREE 3

ASSOCIATE DEGREE 4

BACHELOR’S DEGREE (FOR EXAMPLE, BA, BS) 5

POST GRADUATE DEGREE (FOR EXAMPLE,MASTERS OR DOCTORAL) 6

REFUSED -1

DON’T KNOW -2

HCD017/(SP_ETHNICITY). Does your spouse or partner consider himself [OR HERSELF, IF VOLUNTEERED] to be Hispanic, Latino/a or Spanish origin?

INTERVIEWER INSTRUCTIONS:

• SELECT ALL THAT APPLY.

• PROBE: Anything else?

No, my spouse is not of Hispanic, Latino/a, or Spanish origin 1

Yes, Mexican, Mexican American, Chicano/a 2

Yes, Puerto Rican 3

Yes, Cuban 4

Yes, Another Hispanic, Latino/a, or Spanish origin 5

REFUSED -1

DON’T KNOW -2

HCD018/(SP_RACE). What race does your spouse (or partner) consider himself [OR HERSELF, IF VOLUNTEERED] to be? You may select one or more.

INTERVIEWER INSTRUCTIONS:

• IF USING SHOWCARDS, REFER PARTICIPANT TO APPROPRIATE SHOWCARD.

• OTHERWISE, READ RESPONSE CATEGORIES TO PARTICIPANT.

• PROBE FOR ANY OTHER RESPONSES

• ONLY USE “SOME OTHER RACE” IF VOLUNTEERED.

• SELECT ALL THAT APPLY.

WHITE, 1

BLACK OR AFRICAN AMERICAN, 2

AMERICAN INDIAN OR ALASKA NATIVE, 3

ASIAN INDIAN 4

CHINESE 5

FILIPINO 6

JAPANESE 7

KOREAN 8

VIETNAMESE 9

OTHER ASIAN 10

NATIVE HAWAIIAN 11

GUAMANIAN OR CHAMORRO 12

OTHER PACIFIC ISLANDER 13

SAMOAN 14

SOME OTHER RACE -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF RACE = ANY COMBINATION OF 1 THROUGH 15, GO TO ETHNICITY.

• IF RACE = ANY COMBINATION OF 1 THROUGH 15 AND -5, GO TO SP_RACE_OTH.

• IF RACE = -5, GO TO SP_RACE_OTH.

• IF RACE = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO ETHNICITY.

HCD018A/(SP_RACE_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

HCD018B/(ETHNICITY). Do you consider yourself to be Hispanic, Latino/a or Spanish origin?

INTERVIEWER INSTRUCTIONS:

• SELECT ALL THAT APPLY.

• PROBE: Anything else?

No, not of Hispanic, Latino/a, or Spanish origin 1

Yes, Mexican, Mexican American, Chicano/a 2

Yes, Puerto Rican 3

Yes, Cuban 4

Yes, Another Hispanic, Latino/a, or Spanish origin 5

REFUSED -1

DON’T KNOW -2

HCD018C/(RACE). What race do you consider yourself to be? You may select one or more.

INTERVIEWER INSTRUCTIONS:

• IF USING SHOWCARDS, REFER PARTICIPANT TO APPROPRIATE SHOWCARD.

• OTHERWISE, READ RESPONSE CATEGORIES TO PARTICIPANT.

• SELECT ALL THAT APPLY.

• CODE “SOME OTHER RACE” ONLY IF VOLUNTEERED.

• PROBE: Anything else?

WHITE, 1

BLACK OR AFRICAN AMERICAN, 2

AMERICAN INDIAN OR ALASKA NATIVE, 3

ASIAN INDIAN 4

CHINESE 5

FILIPINO 6

JAPANESE 7

KOREAN 8

VIETNAMESE 9

OTHER ASIAN 10

NATIVE HAWAIIAN 11

GUAMANIAN OR CHAMORRO 12

OTHER PACIFIC ISLANDER 13

SAMOAN 14

SOME OTHER RACE -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF RACE = ANY COMBINATION OF 1 THROUGH 15, GO TO PARTICIPANT_SEX.

• IF RACE = ANY COMBINATION OF 1 THROUGH 15 AND -5, GO TO RACE_OTH.

• IF RACE = -5, GO TO RACE_OTH.

• IF RACE = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PARTICIPANT_SEX.

HCD018D/(RACE_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

HCD019/(PARTICIPANT_SEX). WHAT IS THE SEX OF THE MOTHER?

MALE 1

FEMALE 2

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• DO NOT ADMINISTER PARTICIPANT_SEX TO THE MOTHER.

(TIME_STAMP_HCD_ET) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

COMMUTING

(TIME_STAMP_CO_ST) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

CO001. Next, I’ll be asking about commuting and how you travel from place to place.

CO002/(COMMUTE). Think of the longest regular commute that you take, to work, school, or other places. By regular commute, I mean some place that you travel to at least 3 days a week. Since you became pregnant, how do you normally get to your destination?

INTERVIEWER INSTRUCTION:

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY

CAR 1

BUS 2

TRAIN, SUBWAY, RAIL, OR LIGHT RAIL 3

WALK, BIKE (NON-MOTORIZED) 4

DOES NOT HAVE A REGULAR COMMUTE -7

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF COMMUTE = ANY COMBINATION OF 1 THROUGH 4, GO TO COMMUTE_TIME.

• IF COMMUTE = ANY COMBINATION OF 1 THROUGH 4, AND -5, GO TO COMMUTE_OTH.

• IF COMMUTE = -5, GO TO COMMUTE_OTH.

• IF COMMUTE = -7, -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO LOCAL_TRAV.

CO002A/(COMMUTE_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

CO003/(COMMUTE_TIME). About how many minutes is this commute, one way? Be sure to include any routine side trips you make on the way, such as stops at day care or school. {Include only the time spent driving or sitting inside the car, bus, train, subway, rail or light rail.}

|___|___|___|

NUMBER OF MINUTES

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF COMMUTE = ANY COMBINATION OF 1 THROUGH 3, DISPLAY BRACKETED TEXT. OTHERWISE, DO NOT DISPLAY BRACKETED TEXT.

• DISPLAY SOFT EDIT IF RESPONSE > 60.

CO004/(LOCAL_TRAV). Since you became pregnant, how do you normally get to other places, for example, shopping, doctor, visiting friends, or church?

INTERVIEWER INSTRUCTION

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY.

CAR 1

BUS 2

TRAIN, SUBWAY, RAIL, OR LIGHT RAIL 3

WALK, BIKE (NON-MOTORIZED) 4

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF LOCAL_TRAV = ANY COMBINATION OF 1 THROUGH 4, GO TO CO005.

• IF LOCAL_TRAV = ANY COMBINATION OF 1 THROUGH 4, AND -5, GO TO LOCAL_TRAV_OTH.

• IF LOCAL_TRAV = -5, GO TO LOCAL_TRAV_OTH.

• IF LOCAL_TRAV = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO CO005.

CO004A/(LOCAL_TRAV_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

CO005. Next, I’d like to find out about how often you pump gasoline.

CO006/(PUMP_GAS). Since you became pregnant, about how often have you pumped or poured gasoline into a car, truck, motorcycle, other motor vehicle, lawnmower, or other engine:

Every day, 1

4-6 times per week, 2

2-3 times per week, 3

Once a week, 4

One to three times a month, 5

Less than once a month, or 6

Never? 7

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_CO_ET) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

FAMILY INCOME

(TIME_STAMP_FI_ST) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

FI001. Now I’m going to ask a few questions about your income. 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 information you provide is confidential.

Please think about your total combined family income during {CURRENT YEAR – 1} for all members of the family.

PROGRAMMER INSTRUCTION:

• PRELOAD CURRENT YEAR MINUS 1.

FI010/(HH_MEMBERS). How many household members are supported by your total combined family income?

|___|___|

NUMBER

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• RESPONSE MUST BE > 0; DISPLAY A SOFT EDIT IF RESPONSE IS > 15

• IF HH_MEMBERS = 1, -1, or -2, GO TO INCOME.

• OTHERWISE, IF HH_MEMBERS > 1, GO TO NUM_CHILD.

FI011/(NUM_CHILD). How many of those people are children? Please include anyone under 18 years or anyone older than 18 years and in high school

|___|___|

NUMBER

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• DISPLAY HARD EDIT IF RESPONSE > HH_MEMBERS.

• DISPLAY SOFT EDIT IF RESPONSE > 10.

FI012/(INCOME). Of these income groups, which category best represents your combined family income during the last calendar year?

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT.

LESS THAN $4,999 1

$5,000-$9,999 2

$10,000-$19,999 3

$20,000-$29,999 4

$30,000-$39,999 5

$40,000-$49,999 6

$50,000-$74,999 7

$75,000-$99,999 8

$100,000-$199,999 9

$200,000 OR MORE 10

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_FI_ET) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PREGNANCY CARE LOG INTRODUCTION

(TIME_STAMP_PCL_ST) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PCL001. In order to help you keep track of your doctor visits or other health care provider visits during your pregnancy, we are giving you a Pregnancy Health Care Log. {You may be familiar with this log and have used one in the past.} At each Study visit or telephone interview, we will ask you about any health care visits you had since the last Study visit or telephone interview. This log will help you remember that information. The Pregnancy Health Care Log has a Health Care Provider Log section for writing down information about your health care providers; address and phone numbers, and there is also a Health Care Visits and Overnight Hospital Stays section for keeping track of information about your health care visits and any diagnoses, procedures, or treatments.

It will be very helpful if you use the log to write down information any time that you receive health care, so that you will be able to remember it accurately during your NCS Study visits or telephone interviews.

INTERVIEWER INSTRUCTIONS:

• EXPLAIN PREGNANCY HEALTH CARE LOG.

• THEN EXPLAIN SAQ AND RETURN PROCESS

PROGRAMMER INSTRUCTION:

• IF SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW (I.E., AT LEAST ONE PREVIOUS PREGNANCY VISIT 1 INTERVIEW SET TO COMPLETE), DISPLAY BRACKETED TEXT.

END_LOSS. Because your address is in the study area, we may be back in touch at a later time to update your household information. Thank you for taking the time to answer these questions.

INTERVIEWER INSTRUCTIONS:

• DO NOT OFFER SAQS.

• END INTERVIEW.

END_AGE. Thank you for taking the time to answer these questions. {We will contact you again in about three months to ask a few quick questions and update your household information.}

INTERVIEWER INSTRUCTIONS:

• DO NOT OFFER SAQS.

• END INTERVIEW.

(TIME_STAMP_PCL_ET) 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.