Form 9.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/ 2013

Pregnancy Visit 2 Interview, Phase 2e

ASSUME PREGNANCY VISIT 1 WAS

ADMINISTERED UNLESS NOTED

Pregnancy Visit 2 Interview

Event:	Pregnancy Visit 2
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 2 Interview

TABLE OF CONTENTS

INTERVIEW INTRODUCTION 1

CURRENT PREGNANCY INFORMATION 2

HOUSING CHARACTERISTICS 12

EMPLOYMENT 20

SOCIAL SUPPORT 24

HEALTH INSURANCE 26

CLOSING SCRIPTS 28

Pregnancy Visit 2 Interview

CAPI

(TIME_STAMP_IN_ST) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS:

• IF FIRST PREGNANCY VISIT 2 INTERVIEW, GO TO AGE_ELIG.

• IF SUBSEQUENT PREGNANCY VISIT 2 INTERVIEW, GO TO CPI001.

IN004/(AGE_ELIG).

PARTICIPANT IS AGE-ELIGIBLE 1

PARTICIPANT IS OVER AGE 49 2

PROGRAMMER INSTRUCTION:

• BASED ON DOB_CONFIRM OR PERSON_DOB FROM THE PARTICIPANT CONSENT AND VERIFICATION INSTRUMENT, CALCULATE AGE. USING KNOWN LOCAL AGE OF MAJORITY DETERMINE IF SHE 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

PROGRAMMER INSTRUCTIONS:

• IF MULTIPLE_GESTATION = 2 OR 3 IN PREGNANCY VISIT 1 INTERVIEW, DISPLAY “babies” AS APPROPRIATE THROUGHOUT INSTRUMENT

• ELSE, IF MULTIPLE_GESTATION = 1, -1, OR -2 IN PREGNANCY VISIT 1 INTERVIEW, USE “baby”.

CPI001. First, I’d like to update some information about your current pregnancy.

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

YES 1

NO 2

REFUSED -1 (END_LOSS)

DON’T KNOW -2 (END_LOSS)

PROGRAMMER INSTRUCTIONS:

• IF PREGNANT = 1, GO TO DUE_DATE.

• IF PREGNANT = 2, GO TO CPI001B.

• OTHERWISE, GO TO END.

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). 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

REFUSED -1 (BPLAN_CHANGE)

DON’T KNOW -2

DATE:

|___|___|

D D

REFUSED -1 (BPLAN_CHANGE)

DON’T KNOW -2

YEAR:

|___|___|___|___|

Y Y Y Y

REFUSED -1 (BPLAN_CHANGE)

DON’T KNOW -2 (BPLAN_CHANGE)

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 = YYYYMMDD AS REPORTED; GO TO DATE_KNOWN.

CPI004A/(DATE_KNOWN). DID PARTICIPANT GIVE DATE?

PARTICIPANT GAVE COMPLETE DATE 1

PARTICIPANT GAVE PARTIAL DATE 2

CPI007/(BPLAN_CHANGE). Has the place where you plan to deliver your {baby/babies} changed since we last spoke with you?

YES 1

NO 2

REFUSED -1 (USE_PR_LOG)

DON’T KNOW -2

CPI008/(BIRTH_PLAN). {So we make sure we have the correct information,} Where do you plan to deliver your {baby/babies}?

PROGRAMMER INSTRUCTION:

• IF BPLAN_CHANGE = 2, BEGIN WITH BRACKETED PHRASE

In a hospital, 1

A birthing center, 2

At home, or 3 (USE_PR_LOG)

Some other place? 4

REFUSED -1 (USE_PR_LOG)

DON’T KNOW -2 (USE_PR_LOG)

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/(USE_PR_LOG). Are you using the Pregnancy Health Care Log? This is the booklet that you or your health care provider (doctor, midwife, nurse, etc.) uses to record information about your medical visits.

YES 1 (NUM_PROV_LOG)

NO 2

REFUSED -1 (CPI017)

DON’T KNOW -2 (CPI017)

CPI011/(REASON_NO_PR_LOG). Is that because…

You haven’t had a medical visit since our last interview, 1 (CPI017)

You’ve misplaced the log, 2 (CPI013)

You’ve forgotten to bring it to your medical visits 3 (CPI014)

The log was too much trouble to complete, or 4 (CPI014)

The log was too difficult to understand 5 (CPI017)

OTHER: -5

REFUSED -1 (CPI014)

DON’T KNOW -2 (CPI014)

CPI012/(REASON_NO_PR_LOG_OTH).

SPECIFY:_____________________________________ (CPI017)

REFUSED -1 (CPI017)

DON’T KNOW -2 (CPI017)

PROGRAMMER instruction:

• Limit free text to 255 characters.

CPI013. We’ll get another Pregnancy Health Care Log in the mail to you today. (CPI017)

CPI014. This information is very important to the study. Please keep the log in a safe place and bring the log with you to all of your medical visits. (CPI017)

CPI015/(NUM_PROV_PR_LOG). How many health care providers have you seen since using this Pregnancy Health Care Log?

|___|___|

NUMBER OF PROVIDERS

REFUSED -1

DON’T KNOW -2

CPI016/(NUM_PROV_REC). Of those providers that you have seen, how many providers have you recorded their contact information such as address or phone number?

|___|___|

NUMBER OF CONTACTS

REFUSED -1

DON’T KNOW -2

CPI017. I am now going to ask some questions about visits to a doctor or other health care provider (doctor, midwife, nurse, etc.). You may want to refer to {the Pregnancy Health Care Log that you received as part of this study or to} any other personal record or calendar that you keep that would help you to remember the dates of these visits. If you have this information available, please go and get it now.

PROGRAMMER INSTRUCTION:

• DISPLAY TEXT IN BRACKETS IN CPI017 IF USE_PR_LOG=1.

CPI018/(DATE_VISIT). What was the date of your most recent doctor’s visit or checkup since you’ve become pregnant?

INTERVIEWER INSTRUCTION:

• SHOW CALENDAR TO ASSIST IN DATE RECALL.

• 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)

PROGRAMMER INSTRUCTION:

• IF VALID RESPONSE PROVIDED, AND USE_PR_LOG=1, GO TO CPI019.

• IF VALID RESPONSE PROVIDED AND USE_PR_LOG≠ 1 OR IF DATE_VISIT = -2, GO TO CPI020.

• OTHERWISE IF DATE_VISIT = -7 OR -1, GO TO TIME_STAMP_CPI_ET.

CPI019. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Pregnancy Health Care Log.

CPI020. {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?

INTERVIEWER INSTRUCTIONS:

• 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

PROGRAMMER INSTRUCTIONS:

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

• OTHERWISE DISPLAY ‘”At”.

CPI020A/(DIABETES_1). Diabetes?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020B/(HIGHBP_PREG). High blood pressure?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020C/(URINE). Protein in your urine?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020D/(PREECLAMP). Preeclampsia or toxemia?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020E/(EARLY_LABOR). Early or premature labor?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020F/(ANEMIA). Anemia or low blood count?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020G/(NAUSEA). Severe nausea or vomiting (hyperemesis)?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020H/(KIDNEY). Bladder or kidney infection?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020I/(RH_DISEASE). Rh disease or isoimmunization?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020J/(GROUP_B). Infection with a bacteria called Group B strep?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020K/(HERPES). Infection with a Herpes virus?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020L/(VAGINOSIS). Infection of the vagina with bacteria (Bacterial vaginosis?)

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020M/(OTH_CONDITION). Any other serious condition?

YES 1

NO 2 (HOSPITAL)

REFUSED -1 (HOSPITAL)

DON’T KNOW -2 (HOSPITAL)

CPI020N/(CONDITION_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER instruction:

• Limit free text to 255 characters

CPI021/(HOSPITAL). Since you’ve been pregnant, have you spent at least one night in the hospital?

YES 1

NO 2 (TIME_STAMP_CPI_ET)

REFUSED -1 (TIME_STAMP_CPI_ET)

DON’T KNOW -2 (TIME_STAMP_CPI_ET)

CPI022/(ADMIN_DATE_MM)(ADMIN_DATE_DD)(ADMIN_DATE_YY). What was the admission date of your most recent hospital stay?

MONTH:

|___|___|

M M

HAVE NOT BEEN HOSPITALIZED
OVERNIGHT/NOT APPLICABLE -7 (TIME_STAMP_CPI_ET)
REFUSED -1 (TIME_STAMP_CPI_ET)

DON’T KNOW -2

DAY:

|___|___|

D D

REFUSED -1 (TIME_STAMP_CPI_ET)

DON’T KNOW -2

YEAR:

|___|___|___|___|

Y Y Y Y

REFUSED -1 (TIME_STAMP_CPI_ET)

DON’T KNOW -2 (TIME_STAMP_CPI_ET)

CPI023/(HOSP_NIGHTS). How many nights did you stay in the hospital during this hospital stay?

INTERVIEWER INSTRUCTION:

• CONFIRM RESPONSE

|___|___|___|

NUMBER OF NIGHTS

REFUSED -1

DON’T KNOW -2

CPI024/(DIAGNOSE). Did a doctor or other health care provider give you a diagnosis during this hospital stay?

YES 1

NO 2 (TIME_STAMP_CPI_ET)

REFUSED -1 (TIME_STAMP_CPI_ET)

DON’T KNOW -2 (TIME_STAMP_CPI_ET)

CPI025/(DIAGNOSE_2). What was the diagnosis?

INTERVIEWER INSTRUCTION:

• PROBE FOR MULTIPLE RESPONSES.

• SELECT ALL THAT APPLY.

DEHYDRATION 1

PRETERM LABOR 2

HYPEREMESIS 3

PREECLAMPSIA 4

RUPTURE OF MEMBRANES 5

KIDNEY DISORDER 6

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF DIAGNOSE_2 CODED WITH ANY COMBINATION OF VALUES 1 – 6, THEN GO TO CPI027.

• IF DIAGNOSE_2 CODED -5, OR ANY COMBINATION OF VALUES 1 – 6 AND -5, GO TO DIAGNOSIS_OTH.

• IF DIAGNOSE_2 CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO CPI027.

CPI026/(DIAGNOSIS_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• Limit free text to 255 characters.

• IF USE_PR_LOG=1, GO TO CPI027.

• OTHERWISE, GO TO TIME_STAMP_CPI_ET.

CPI027. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Pregnancy Health Care Log.

(TIME_STAMP_CPI_ET) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

HOUSING CHARACTERISTICS

(TIME_STAMP_HD_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.

HC001A/(RECENT_MOVE). Have you moved or changed your housing situation since we last spoke with you?

YES 1

NO 2 (HC006)

REFUSED -1 (HC006)

DON’T KNOW -2

HC002/(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)

HC002A/(OWN_HOME_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER instruction:

• Limit free text to 255 characters

HC004/(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

HC005/(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

HC006. Now I’m going to ask about how your home is heated and cooled.

HC007/(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 9 (COOLING)

OTHER -5

REFUSED -1 (COOLING)

DON’T KNOW -2 (COOLING)

HC007A/(MAIN_HEAT _OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER instruction:

• Limit free text to 255 characters

HC008/(HEAT2). Are there any other types of heat you use regularly during the heating season to heat your home?

INTERVIEWER INSTRUCTION:

• 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, 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.

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

HC008A/(HEAT2_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER instruction:

• Limit free text to 255 characters

HC011/(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)

HC012/(COOL). Not including fans, which of the following kinds of cooling systems do you regularly use?

INERVIEWER INSTRUCTION:

• SELECT ALL THAT APPLY.

Window or wall air conditioners, 1

Central air conditioning, 2

Evaporative cooler (swamp cooler), or 3

NO COOLING OR AIR CONDITIONING REGULARLY USED 4

Some other cooling system -5

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, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO HC033.

• IF HEAT2 CODED -5, OR ANY COMBINATION OF VALUES 1 – 3 AND -5, GO TO COOL_OTH.

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

HC012A/(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). Since we last spoke with you, have you seen any water damage inside your home?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HC038/(MOLD). Since we last spoke with you, 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/(PRENOVATE2). Since we last spoke with you, 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 refinishing floors.

YES 1

NO 2 (PDECORATE2)

REFUSED -1 (PDECORATE2)

DON’T KNOW -2 (PDECORATE2)

HC043/(PRENOVATE2_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 PRENOVATE2_ROOM CODED WITH ANY COMBINATION OF VALUES 1 – 7, THEN GO TO PDECORATE2.

• IF PRENOVATE2_ROOM CODED -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, GO TO PRENOVATE2_ROOM_OTH.

• IF PRENOVATE2_ROOM CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO PDECORATE2.

HC044/(PRENOVATE2_ROOM_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER instruction:

• Limit free text to 255 characters

HC045/(PDECORATE2). Since we last spoke with you, 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/(PDECORATE2_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 PDECORATE2_ROOM CODED WITH ANY COMBINATION OF VALUES 1 – 7, THEN GO TO TIME_STAMP_HC_ET.

• IF PDECORATE2_ROOM CODED -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, GO TO PDECORATE2_ROOM_OTH.

• IF PDECORATE2_ROOM CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO TIME_STAMP_HC_ET.

HC046A/(PDECORATE2_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

EMPLOYMENT

(TIME_STAMP_EM_ST) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

EM001. Now, I’d like to ask some questions about your current employment status.

EM001A. The next questions may be similar to those asked the last time we spoke, but we are asking them again because sometimes the answers change.

EM002/(WORKING). Are you currently working at any full or part time jobs?

YES 1

NO 2 (TIME_STAMP_EM_ET)

REFUSED -1 (TIME_STAMP_EM_ET)

DON’T KNOW -2 (TIME_STAMP_EM_ET)

EM002A/(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.

EM002B/(SHIFT_WORK). Do you work a shift that starts after 2 pm?

YES 1

NO 2

SOMETIMES 3

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF WORKING= 1, AND WORK_NAME PREVIOUSLY COLLECTED AND VALID RESPONSE PROVIDED, GO TO WORK_NAME_CONFIRM.

• IF WORKING = 1, AND WORK_NAME NOT PREVIOUSLY COLLECTED OR VALID RESPONSE NOT PROVIDED, GO TO WORK_NAME.

EM002C/(WORK_NAME_CONFIRM). Let me confirm the name of the place where you work. I have it as {PARTICIPANT’S WORK PLACE NAME}. Is this correct?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTUCTIONS:

• PRELOAD WORK PLACE NAME FROM WORK_NAME IN PREGNANCY VISIT 1.

• IF WORK_NAME_CONFIRM =1 OR -1, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING WORK_NAME.

• OTHERWISE, IF WORK_NAME_CONFIRM = 2 OR -2, GO TO WORK_NAME.

EM002D/(WORK_NAME). What is the name of the place where you work?

______________________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTUCTIONS:

• LIMIT TEXT TO 255 CHARACTERS.

• IF WORK ADDRESS VARIABLES NOT COLLECTED PREVIOUSLY OR VALID WORK ADDRESS NOT PROVIDED, GO TO WORK ADDRESS VARIABLES.

• IF WORK ADDRESS VARIABLES COLLECTED PREVIOUSLY AND VALID WORK ADDRESS PROVIDED, GO TO WORK ADDRESS VARIABLES CONFIRM.

• OTHERWISE, GO TO TIME_STAMP_EM_ET.

EM002E/(WORK ADDRESS VARIABLES). ENTER ADDRESS

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

PROGRAMMER INSTRUCTION:

• GO TO TIME_STAMP_EM_ET.

EM002F/(WORK_ADDRESS_VARIABLES_CONFIRM). Let me confirm your work address. I have it as {PARTICIPANT’S WORK ADDRESS}.

__________________________________________________

ADDRESS 1 - STREET/PO BOX (CWORK_ADDRESS_1)

REFUSED -1

DON’T KNOW -2

ADDRESS 2 (CWORK_ADDRESS_2)

REFUSED -1

DON’T KNOW -2

UNIT (CWORK_UNIT)

REFUSED -1

DON’T KNOW -2

CITY (CWORK_CITY)

REFUSED -1

DON’T KNOW -2

|___|___|

STATE (CWORK_STATE)

REFUSED -1

DON’T KNOW -2

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

ZIP CODE ZIP+4 (CWORK_ZIP) (CWORK_ZIP4)

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• PRELOAD WORK ADDRESS; ALLOW INTERVIEWER TO MAKE CORRECTIONS.

(TIME_STAMP_EM_ET) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

SOCIAL SUPPORT

(TIME_STAMP_SS_ST) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

SS001. The following questions ask about your feelings and thoughts during the last month. For the following questions, please refer to the card and choose the answer that best describes your life now.

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT.

SS001A/(LISTEN). Is there someone available to you whom you can count on to listen to you when you need to talk?

NONE OF THE TIME 1

A LITTLE OF THE TIME 2

SOME OF THE TIME 3

MOST OF THE TIME 4

ALL OF THE TIME 5

REFUSED -1

DON'T KNOW -2

SS002/(ADVICE). Is there someone available to give you good advice about a problem?

NONE OF THE TIME 1

A LITTLE OF THE TIME 2

SOME OF THE TIME 3

MOST OF THE TIME 4

ALL OF THE TIME 5

REFUSED -1

DON'T KNOW -2

SS003/(AFFECTION). Is there someone available to you who shows you love and affection?

NONE OF THE TIME 1

A LITTLE OF THE TIME 2

SOME OF THE TIME 3

MOST OF THE TIME 4

ALL OF THE TIME 5

REFUSED -1

DON'T KNOW -2

SS004/(DAILY_HELP). Is there someone available to help you with daily chores?

NONE OF THE TIME 1

A LITTLE OF THE TIME 2

SOME OF THE TIME 3

MOST OF THE TIME 4

ALL OF THE TIME 5

REFUSED -1

DON'T KNOW -2

SS005/(EMOT_SUPPORT). Can you count on anyone to provide you with emotional support (talking over problems or helping you make a difficult decision)?

NONE OF THE TIME 1

A LITTLE OF THE TIME 2

SOME OF THE TIME 3

MOST OF THE TIME 4

ALL OF THE TIME 5

REFUSED -1

DON'T KNOW -2

SS006/(AMT_SUPPORT). Do you have as much contact as you would like with someone you feel close to, someone in whom you can trust and confide?

NONE OF THE TIME 1

A LITTLE OF THE TIME 2

SOME OF THE TIME 3

MOST OF THE TIME 4

ALL OF THE TIME 5

REFUSED -1

DON'T KNOW -2

(TIME_STAMP_SS_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 the subject and ask about health insurance. The next questions are similar to those asked the last time we contacted you, but we are asking them again because sometimes the answers change.

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.

INTERVIEWER INSTRUCTIONS:

• 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

hi003/(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

HI004/(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

HI005/(INS_TRICARE). TRICARE, VA, or other military health care?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI006/(INS_IHS). Indian Health Service?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI007/(INS_MEDICARE). Medicare, for people with certain disabilities?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI008/(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

CLOSING SCRIPTS

(TIME_STAMP_CS_ST) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

INTERVIEWER INSTRUCTIONS:

• EXPLAIN SAQS AND RETURN PROCESS

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:

• OFFER SAQ.

• END INTERVIEW.

(TIME_STAMP_CS_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.