Form 13.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/ 2013

Birth Interview, Phase 2e

Birth Interview

Event:	Birth
Participant:	Mother
Domain:	Questionnaire
Type of Document:	Interview
Recruitment Groups: Allowable Mode: Allowable Method: Version: Release:	EH, PB, HI, PBS In Person, Telephone CAPI, CATI Vx.x MDES 3.0

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Birth Interview

TABLE OF CONTENTS

INTERVIEWER-COMPLETED QUESTIONS 1

BABY CHARACTERISTICS 3

HOUSING CHARACTERISTICS 8

ENVIRONMENTAL EXPOSURES 10

INFANT FEEDING 13

INFANT SLEEP 14

WELL BABY CARE AND IMMUNIZATIONS 16

WORK AND PLANS FOR CHILDCARE 17

INFANT MEDICAL CARE LOG INTRODUCTION 22

MEDICAL HISTORY 23

INTERVIEWER-COMPLETED QUESTIONS 31

Birth Interview

(TIME_STAMP_1) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

INTERVIEWER-COMPLETED QUESTIONS

IC010/(BIRTH_DELIVER). WHERE DID PARTICIPANT DELIVER BABY OR BABIES?

HOSPITAL, 1

BIRTHING CENTER, 2

AT HOME 3

SOME OTHER PLACE -5

PROGRAMMER INSTRUCTIONS:

• IF BIRTH_DELIVER = 1, DISPLAY “hospital” THROUGHOUT THE INSTRUMENT.

• IF BIRTH_DELIVER = 2, DISPLAY “birthing center” THROUGHOUT THE INSTRUMENT.

• IF BIRTH_DELIVER = -5, DISPLAY “other place” THROUGHOUT THE INSTRUMENT.

IC020/(MULTIPLE). WAS THIS A MULTIPLE BIRTH?

YES 1

NO …. 2

IC030/(MULTIPLE_NUM). HOW MANY BABIES WERE DELIVERED?

|___|___|

NUMBER OF BABIES

IC040/(CHILD_DOB). WHAT WAS THE {BABY’S/BABIES’} DATE OF BIRTH?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF MULTIPLE=1, DISPLAY “babies”

• IF MULTIPLE=2, DISPLAY “baby”

• IF BIRTH_DELIVER=3, GO TO BABY_NAME.

IC050/(RELEASE). {HAS BABY}{HAVE BABIES} BEEN RELEASED FROM THE {HOSPITAL/BIRTHING CENTER/OTHER PLACE}?

INTERVIEWER INSTRUCTIONS:

• ASK ONLY IF NEEDED.

• IF MULTIPLE BIRTH AND AT LEAST ONE BABY HAS BEEN RELEASED FROM HOSPITAL, SELECT “1”.

YES 1

NO 2

PROGRAMMER INSTRUCTIONS:

• DISPLAY {HAS BABY} IF MULTIPLE=2

• DISPLAY { HAVE BABIES} IF MULTIPLE=1

BABY CHARACTERISTICS

BC001/(BABY_NAME). During this interview, we would like to refer to your {baby/babies} by name. {Let’s start with your first {twin/triplet/higher order} birth. What name would you like me to use to talk about your {first/next} baby}. {Now let’s talk about your next baby. What name would you like me to use to talk about your next baby?}

NAME PROVIDED 1

NO OFFICIAL NAME SELECTED 3 (BABY_SEX)

REFUSED -1 (BABY_SEX)

DON’T KNOW -2 (BABY_SEX)

PROGRAMMER INSTRUCTIONS:

• LOOP THROUGH QUESTIONS BABY_FNAME THROUGH BABY_RACE UNTIL NUMBER OF LOOPS = MULTIPLE_NUM .

• BASED ON NUMBER OF LOOPS, DISPLAY APPROPRIATE ADJECTIVES (E.G. “FIRST” OR “NEXT”)

• If MULTIPLE = 1 AND MULTIPLE_NUM = 2 AND FIRST LOOP, DISPLAY: “Let’s start with your first twin birth. What name would you like me to use to talk about your first baby?”

• IF MULTIPLE = 1 AND MULTIPLE_NUM = 3 AND FIRST LOOP, DISPLAY: ““Let’s start with your first triplet birth. What name would you like me to use to talk about your first baby?”

• IF MULTIPLE = 1 AND MULTIPLE_NUM ≥ 4 AND FIRST LOOP, DISPLAY: ““Let’s start with your first higher order birth. What name would you like me to use to talk about your first baby?”

• IF MULTIPLE = 1 AND MULTIPLE_NUM = 2 AND SECOND LOOP, DISPLAY: “Now let’s talk about your next baby. What name would you like me to use to talk about your next baby?”

• IF MULTIPLE = 1 AND MULTIPLE_NUM ≥ 3 AND SECOND OR HIGHER LOOP, DISPLAY: “Now let’s talk about your next baby. What name would you like me to use to talk about your next baby?”

• IF MULTIPLE =2, DISPLAY: “What name would you like me to use to talk about your baby?”

INTERVIEWER INSTRUCTION:

ENTER TEXT AND CONFIRM SPELLING

_____________________

FIRST NAME

(BABY_FNAME)

REFUSED -1

DON’T KNOW -2

_____________

MIDDLE NAME

(BABY_MNAME)

REFUSED -1

DON’T KNOW -2

___________________

LAST NAME

(BABY_LNAME)

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF MULTIPLE = 1, DISPLAY “your babies” THROUGHOUT THE INSTRUMENT.

• IF MULTIPLE = 2 AND VALID RESPONSE PROVIDED FOR BABY_FNAME, DISPLAY BABY_FNAME THROUGHOUT THE INSTRUMENT.

• OTHERWISE, IF MULTIPLE = 2 AND VALID RESPONSE NOT PROVIDED FOR BABY_FNAME, DISPLAY “your baby” THROUGHOUT THE INSTRUMENT.

BC007/(BABY_SEX). What is the sex of the baby?

MALE 1

FEMALE 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF BABY_SEX=1, DISPLAY “he” AND “him” THROUGHOUT THE INSTRUMENT.

• IF BABY_SEX=2, DISPLAY “she” AND “her” THROUGHOUT THE INSTRUMENT.

• IF BABY_SEX = -1, OR -2, DISPLAY “the baby” THROUGHOUT THE INSTRUMENT.

BC007A/(BABY_BWT_LB)/(BABY_BWT_OZ). How much did {BABY_FNAME/your baby} weigh when {he/she} was born?

POUNDS: |___|___|

P P

REFUSED -1

DON’T KNOW -2

OUNCES: |___|___|

O O

REFUSED -1

DON’T KNOW -2

BC007B/(ETHNICITY). Do you consider {BABY_FNAME/your baby} to be Hispanic, Latino/a or Spanish origin?

INTERVIEWER INSTRUCTIONS:

• SELECT ALL THAT APPLY.

• PROBE: Anything else?

No, the baby 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

BC007C/(RACE). What race do you consider {BABY_FNAME/your baby} to be? You may select one or more.

INTERVIEWER INSTRUCTIONS:

• IF USING SHOWCARDS, REFER PARENT/CAREGIVER TO APPROPRIATE SHOWCARD.

• OTHERWISE, READ RESPONSE CATEGORIES TO PARENT/CAREGIVER.

• 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 MULTIPLE_NUM < NUMBER OF LOOPS, AND

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

• 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 BABY_NAME.

• IF MULTIPLE_NUM = NUMBER OF LOOPS, AND

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

• 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 LIVE_MOM.

BC007D/(RACE_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• LIMIT FREE TEXT TO 255 CHARACTERS.

• IF MULTIPLE_NUM < NUMBER OF LOOPS, LOOP TO BABY_NAME.

• IF MULTIPLE_NUM = NUMBER OF LOOPS, GO TO LIVE_MOM.

BC008/(LIVE_MOM). {Does {BABY_FNAME/your baby}}/{Do your babies}/{When {BABY_FNAME/your baby} leaves the}/{When your baby leaves the} {hospital/ birthing center/ other place} will {he/she/your baby} live with you?

YES 1 (RECENT_MOVE)

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF MULTIPLE = 2 AND VALID RESPONSE PROVIDED FOR BABY_FNAME AND EITHER RELEASE=1 OR BIRTH_DELIVER = 3, DISPLAY “Does BABY_FNAME”.

• IF MULTIPLE = 2 AND VALID RESPONSE NOT PROVIDED FOR BABY_FNAME = AND EITHER RELEASE=1 OR BIRTH_DELIVER = 3, DISPLAY “Does your baby”.

• IF MULTIPLE = 1 AND EITHER RELEASE=1 OR BIRTH_DELIVER = 3, DISPLAY “Do your babies”.

• IF MULTIPLE = 2 AND RELEASE = 2 AND VALID RESPONSE PROVIDED FOR BABY_FNAME, DISPLAY “When BABY_FNAME leaves the” .

• IF MULTIPLE = 2 AND RELEASE = 2 AND VALID RESPONSE NOT PROVIDED FOR BABY_FNAME, DISPLAY “When your baby leaves the”.

• IF MULTIPLE = 1 AND RELEASE = 2, DISPLAY “your babies leave”.

BC009/(LIVE_OTH). With whom {does {he/she}/{do they}}/{will {he/she/they}} live?

BABY’S FATHER 1

BABY’S GRANDPARENT(S) 2

OTHER FAMILY MEMBER 3

PLACING IN FOSTER CARE 4

PLACING FOR ADOPTION 5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF MULTIPLE = 2 AND BABY_SEX = 1 AND EITHER RELEASE=1 OR BIRTH_DELIVER = 3, DISPLAY “does he”.

• IF MULTIPLE = 2 AND BABY_SEX = 2 AND EITHER RELEASE=1 OR BIRTH_DELIVER = 3, DISPLAY “does she”.

• IF MULTIPLE = 1 AND BABY_SEX = -1, OR -2, OR IF MULTIPLE = 2, AND EITHER RELEASE=1 OR BIRTH_DELIVER = 3, DISPLAY “do they”.

• IF MULTIPLE = 2 AND BABY_SEX = 1 AND RELEASE=2, DISPLAY “will he”.

• IF MULTIPLE = 2 AND BABY_SEX = 2 RELEASE=2, DISPLAY “will she”.

• IF MULTIPLE = 1 AND BABY_SEX = -1, OR -2, OR IF MULTIPLE = 2, AND RELEASE=2, DISPLAY “will they”.

(TIME_STAMP_2). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

HOUSING CHARACTERISTICS

(TIME_STAMP_3) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

HC001/(RECENT_MOVE). Have you moved or changed your housing situation since we contacted you last?

YES 1

NO 2 (HC008)

REFUSED -1 (HC008)

DON’T KNOW -2 (HC008)

HC004/(OWN_HOME). Is your current 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)

HC005/(OWN_HOME_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

HC006/(AGE_HOME). Can you tell us when your home or building was built? Was it between…

INTERVIEWER INSTRUCTION:

• IF USING SHOWCARDS, REFER PARTICIPANT TO APPROPRIATE SHOWCARD. OTHERWISE, READ RESPONSE CATEGORIES TO PARTICIPANT.

PROGRAMMER INSTRUCTION:

• IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS. OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE PER BELOW.

2001 TO PRESENT, 1

1981 TO 2000, 2

1961 TO 1980, 3

1941 TO 1960, OR 4

1940 OR BEFORE 5

REFUSED -1

DON’T KNOW -2

HC007/(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

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

ENTER IN NUMERIC VALUE AND SELECT ASSOCIATED UNIT OF TIME

PROGRAMMER INSTRUCTION:

INCLUDE SOFT EDIT IF VALUE > 18 YEARS.

HC008. Now I have a few questions about {C_FNAME/the child}’s primary household.

HC009/(NUM_HH). How many persons are currently living in or staying in this household, not including the child?

|___|___|

NUMBER OF PERSONS

REFUSED -1 (TIME_STAMP_4)

DON’T KNOW -2 (TIME_STAMP_4)

HC010/(MILITARY_HH). Have any household members ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard? Active duty does not include training for the Reserves or National Guard, but does include activation, for example, for the Persian Gulf War.

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LOOP THROUGH FNAME_HH, CHILD_RELAT, CHILD_RELAT_OTH_1 (IF CHILD_RELAT = 7), CHILD_RELAT_OTH_2 (IF CHILD_RELAT = 8), HH_MEM_DOB, ACTIVE_DUTY (IF MILITARY_HH = 1 AND EITHER HH_MEM_AGE ≥ 18 YEARS OR HH_MEM_DOB = -1 OR -2), AND BRANCH_SERV (IF ACTIVE_DUTY = 1, 2 OR 3) UNTIL NUMBER OF LOOPS = NUM_HH.

• THEN GO TO TIME_STAMP_4.

HC011/(FNAME_HH). {What are the names of all the persons living or staying in this household? Start with the name of the person, or one of the persons, who owns or rents this home}/{What is the name of the next person living or staying here?}

INTERVIEWER INSTRUCTION:

• CONFIRM SPELLING.

_________________________________

FIRST NAME

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF FIRST LOOP CYCLE, DISPLAY “What are the names of all the persons…”

• IF SUBSEQUENT LOOP CYCLE, DISPLAY “What is the name of the next person…”

HC012/(CHILD_RELAT). How is {F_NAME} related to the child?

MOTHER 1 (HH_MEM_DOB)

FATHER 2 (HH_MEM_DOB)

GRANDMOTHER 3 (HH_MEM_DOB)

GRANDFATHER 4 (HH_MEM_DOB)

SISTER 5 (HH_MEM_DOB)

BROTHER 6 (HH_MEM_DOB)

OTHER RELATIVE 7

OTHER NON-RELATIVE 8 (CHILD_RELAT_OTH_2)

REFUSED -1 (HH_MEM_DOB)

DON’T KNOW -2 (HH_MEM_DOB)

PROGRAMMER INSTRUCTIONS:

• DISPLAY F_NAME.

HC013/(CHILD_RELAT_OTH_1).

SPECIFY: _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• LIMIT TEXT TO 255 CHARACTERS.

• GO TO HH_MEM_DOB.

HC014/(CHILD_RELAT_OTH_2).

SPECIFY: _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

HC015/(HH_MEM_DOB). What is {F_NAME}’s date of birth?

INTERVIEWER INSTRUCTIONS:

• IF PARENT/CAREGIVER REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS

• 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

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• FORMAT HH_MEM_DOB AS YYYYMMDD.

• DISPLAY F_NAME.

• IF MILITARY_HH = 1 AND,

  • IF VALID RESPONSE PROVIDED FOR HH_MEM_DOB, CALCULATE DERIVED VARIABLE, HH_MEM_AGE, BASED ON HH_MEM_DOB AND DATE OF CURRENT INTERVIEW;

    • IF HH_MEM_AGE > 18 YEARS, GO TO ACTIVE_DUTY.

  • IF VALID RESPONSE NOT PROVIDED FOR HH_MEM_DOB, GO TO ACTIVE_DUTY.

• OTHERWISE, COMPLETE LOOP:

  • IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO FNAME_HH.

  • IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO TIME_STAMP_4.

HC020/(ACTIVE_DUTY). Has {F_NAME} ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard?

INTERVIEWER INSTRUCTION:

• READ AS NECESSARY: [Active duty does not include training for the Reserves or National Guard, but does include activation, for example, for the Persian Gulf War.]

Yes, they are now on active duty, 1

Yes, they were on active duty during the last 6

months, but not now, 2

Yes, they were on active duty in the past, but not

during the last 6 months, 3

No, they are training for Reserves or National

Guard only, or 4

No, they never served in the military? 5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• DISPLAY F_NAME.

• IF ACTIVE_DUTY = 1, 2, OR 3, GO TO BRANCH_SERV.

• OTHERWISE, IF ACTIVE_DUTY = 4, 5, -1, OR -2, COMPLETE LOOP:

  • IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO FNAME_HH.

  • IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO TIME_STAMP_4.

HC025/(BRANCH_SERV). What {is/was} his or her branch of service?

Air Force, 1

Army, 2

Marine Corps, 3

Navy, or 4

Coast Guard? 5

NOT IN U.S. ARMED FORCES -7

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF ACTIVE_DUTY = 1, DISPLAY “is”.

• IF ACTIVE_DUTY = 2 OR 3, DISPLAY “was”.

• IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO FNAME_HH TO BEGIN NEXT LOOP.

• IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO TIME_STAMP_4.

(TIME_STAMP_4). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

ENVIRONMENTAL EXPOSURES

EX001/(RENOVATE). The next few questions ask about any recent additions or renovations to your home.

Since our last contact, 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 or wallpapering, carpeting, or refinishing floors.

YES 1

NO 2 (DECORATE)

REFUSED -1 (DECORATE)

DON’T KNOW -2 (DECORATE)

EX002/(RENOVATE_ROOM). Which rooms were renovated?

INTERVIEWER INSTRUCTION:

• SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

BABY’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF RENOVATE_ROOM=ANY COMBINATION OF 1 THROUGH 7, INCLUDING JUST ONE OF THOSE RESPONSES, GO TO DECORATE.

• IF RENOVATE_ROOM=ANY COMBINATION OF 1 THROUGH 7, AND -5, GO TO RENOVATE_ROOM_OTH.

• IF RENOVATE_ROOM= -5, GO TO RENOVATE_ROOM_OTH.

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

EX003/(RENOVATE_ROOM_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

EX004/(DECORATE). Since our last contact, were any smaller projects done in your home, such as painting, wallpapering, refinishing floors, or installing new carpet?

YES 1

NO 2 (SMOKE)

REFUSED -1 (SMOKE)

DON’T KNOW -2 (SMOKE)

EX005/(DECORATE_ROOM). In which rooms were these smaller projects done?

INTERVIEWER INSTRUCTION:

• SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

BABY’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF DECORATE_ROOM=ANY COMBINATION OF 1 THROUGH 7, INCLUDING JUST ONE OF THOSE RESPONSES, GO TO SMOKE.

• IF DECORATE_ROOM=ANY COMBINATION OF 1 THROUGH 7, AND -5, GO TO DECORATE_ROOM_OTH.

• IF RENOVATE_ROOM= -5, GO TO RENOVATE_ROOM_OTH.

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

EX006/(DECORATE_ROOM_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

EX007/(SMOKE). Currently, do you or others in your household smoke cigarettes, cigarillos, cigars, pipes or other tobacco products?

YES 1

NO 2 (TIME_STAMP_5)

REFUSED -1 (TIME_STAMP_5)

DON’T KNOW -2 (TIME_STAMP_5)

EX008/(SMOKE_LOCATE). Do those who smoke usually smoke indoors, outdoors, or both indoors and outdoors?

INDOORS 1

OUTDOORS 2

BOTH 3

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_5). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS:

• IF BIRTH_DELIVER ≠3 AND RELEASE=2 GO TO FED_BABY.

• OTHERWISE, GO TO HOW_FED.

INFANT FEEDING

IF001/(FED_BABY). Have you fed {BABY_FNAME/your baby/your babies} since {his/her/their} birth?

YES 1

NO 2 (PLAN_FEED)

REFUSED -1 (PLAN_FEED)

DON’T KNOW -2 (PLAN_FEED)

IF002/(HOW_FED). How have you fed {BABY_FNAME/your baby/your babies}? Did you breast or bottle feed?

BREAST ONLY 1

BOTTLE ONLY 2

BOTH BREAST AND BOTTLE 3

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF LIVE_MOM = 2, GO TO TIME_STAMP_10.

• OTHERWISE, GO TO PLAN_FEED.

IF003/(PLAN_FEED). {Have you fed/Do you plan to feed} the {baby/babies} breast milk, formula or both?

BREAST MILK 1

FORMULA 2

BOTH BREAST MILK AND FORMULA 3

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF FED_BABY = 2, -1, OR -2, DISPLAY “Do you plan to feed”.

• OTHERWISE, DISPLAY “Have you fed”.

(TIME_STAMP_6). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS:

• IF BIRTH_DELIVER ≠3 AND RELEASE=2, GO TO POS_HOSP.

• OTHERWISE, GO TO POS_HOME.

INFANT SLEEP

IS001/(POS_HOSP). Do the nurses here in the {hospital/birthing center/other place} usually put {{BABY_FNAME}/your baby} to sleep on {his/her/their} {stomach{s}, back{s}, or side{s}?

STOMACH 1

BACK 2

SIDE 3

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF MULTIPLE=1, DISPLAY “their stomachs, backs, or sides”.

• OTHERWISE, DISPLAY “stomach, back, or side”.

IS002/(POS_HOME). In what position do you {usually put {BABY_FNAME}/your baby/your babies}/{plan to put {BABY_FNAME/your baby/your babies} to sleep at home?

STOMACH 1

BACK 2

SIDE 3

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF BIRTH_DELIVER = 3 OR RELEASE= 1, DISPLAY “usually put…”.

• OTHERWISE, DISPLAY “plan to put …”.

IS003/(SLEEP_ROOM). {When you go home from the {hospital/birthing center/other place}, do you plan for}/{Do/Does}{BABY_FNAME/your baby/your babies} {to} sleep…

In {his/her/their} own room, 1

In a room with other children, 2

In your bedroom, or 3

Another location? 4

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF RELEASE = 2, DISPLAY “When you go home from the … do you plan for” and “to”

• IF BIRTH_DELIVER = 3 OR RELEASE=1, AND IF MULTIPLE=1, DISPLAY “Do your babies sleep…”

• OTHERWISE, IF BIRTH_DELIVER = 3 OR RELEASE=1 AND MULTIPLE = 2, DISPLAY “Does … sleep…”

IS004/(BED). {When you go home from the {hospital/birthing center/other place}, do you plan for}/{Do/Does}{BABY_FNAME/your baby/your babies} {to} sleep in …

A bassinette, 1 (TIME_STAMP_7)

A crib, 2 (TIME_STAMP_7)

A co-sleeper, 3 (TIME_STAMP_7)

An adult bed alone, 4 (TIME_STAMP_7)

An adult bed with you, 5 (TIME_STAMP_7)

An adult bed with another child, or 6 (TIME_STAMP_7)

Something else -5

REFUSED -1 (TIME_STAMP_7)

DON’T KNOW -2 (TIME_STAMP_7)

PROGRAMMER INSTRUCTIONS:

• IF RELEASE = 2, DISPLAY “When you go home from… do you plan for” and “to”

• IF BIRTH_DELIVER = 3 OR RELEASE=1, AND IF MULTIPLE=1, DISPLAY “Do your babies sleep…”

• OTHERWISE, IF BIRTH_DELIVER = 3 OR RELEASE=1 AND MULTIPLE = 2, DISPLAY “Does … sleep…”

IS005/(BED_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

(TIME_STAMP_7). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

WELL BABY CARE AND IMMUNIZATIONS

WB001(HCARE). Where do you plan to take your new {baby/babies} for well-baby checkups?

Hospital clinic 1 (VACCINE)

Health department clinic 2 (VACCINE)

Private doctor's office or Health Maintenance Organization (HMO) 3 (VACCINE)

Some other place …………………………………………… -5

REFUSED -1 (VACCINE)

DON'T KNOW -2 (VACCINE)

WB003/(HCARE_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

WB003/(VACCINE). Do you plan for your new {baby/babies} to have well-baby shots or vaccinations?

YES 1

YES, ON A DELAYED SCHEDULE 2

NO 3

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_8). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

WORK AND PLANS FOR CHILDCARE

WCC001/(EMPLOY2). Are you currently employed?

YES 1

NO 2 (WCC003)

REFUSED -1

DON’T KNOW -2

WCC002/(RETURN_JOB_YET). {Have you returned/Do you plan to return} to your current job?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF BIRTH_DELIVER = 3 OR RELEASE = 1, display “Have you returned”.

• OTHERWISE, display “Do you plan to return”.

• IF BIRTH_DELIVER = 3 OR RELEASE = 1, AND RETURN_JOB_YET = 1, GO TO (RETURN_JOB_DT_MM)(RETURN_JOB_DT_DD)(RETURN_JOB_DT_YY).

• IF RELEASE = 2 AND RETURN_JOB_YET = 1, GO TO (RETURN_JOB)/(RETURN_JOB_UNIT).

• IF RETURN_JOB_YET = 2, -1, OR -2, GO TO WCC003G.

WCC003/(RETURN_JOB_DT_MM)(RETURN_JOB_DT_DD)(RETURN_JOB_DT_YY). When did you return to your job?

MONTH: |___|___|

M M

REFUSED -1 (WCC003G)

DON’T KNOW -2

DAY: |___|___|

D D

REFUSED -1 (WCC003G)

DON’T KNOW -2

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1 (WCC003G)

DON’T KNOW -2

WCC003A/(RETURN_JOB). When do you plan to return to your current job?

|___|___|

NUMBER

DOESN’T PLAN TO RETURN TO WORK -7

REFUSED -1

DON’T KNOW -2

WCC003B/(RETURN_JOB_UNIT)

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

INTERVIEWER INSTRUCTION:

ENTER IN NUMERIC VALUE AND SELECT ASSOCIATED UNIT OF TIME

PROGRAMMER INSTRUCTION:

• INCLUDE SOFT EDIT IF VALUE > 1 YEAR OR >12 MONTHS OR > 52 WEEKS OR >365 DAYS.

• IF EMPLOY2 = 1, AND WORK_NAME PREVIOUSLY SET TO COMPLETE, AND VALID RESPONSE PROVIDED, GO TO WORK_NAME_CONFIRM.

• IF EMPLOY2 = 1, AND WORK_NAME PREVIOUSLY NOT SET TO COMPLETE, GO TO WORK_NAME.

• OTHERWISE, GO TO WCC003.

WCC003C/(WORK_NAME_CONFIRM). Let me confirm the name of the place where you work. I have it as {PARTICIPANT’S WORK PLACE NAME}. Is that correct?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF WORK_NAME_CONFIRM = -2, GO TO WORK_NAME.

• OTHERWISE, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING WORK_NAME.

WCC003D/(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 COLLECTED PREVIOUSLY AND VALID WORK ADDRESS PROVIDED, GO TO WORK ADDRESS VARIABLES CONFIRM.

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

WCC003E/(WORK ADDRESS VARIABLES CONFIRM).

Let me confirm your work address. I have it as {PARTICIPANT’S WORK ADDRESS}.

__________________________________________________

(WORK_ADDRESS_1) ADDRESS 1 - STREET/PO BOX

(WORK_ADDRESS_2) ADDRESS 2

(WORK_UNIT) UNIT

(WORK_CITY) CITY

|___|___| |___|___|___|___|___| |___|___|___|___

STATE ZIP CODE ZIP+4

(WORK_STATE) (WORK_ZIP) (WORK_ZIP4)

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• PRELOAD WORK ADDRESS; ALLOW INTERVIEWER TO MAKE CORRECTIONS.

• IF VALID ADDRESS NOT PROVIDED OR WORK ADDRESS VARIABLES CONFIRM = -1 or -2, GO TO WORK ADDRESS VARIABLES.

• OTHERWISE, GO TO WCC003.

WCC003F/(WORK ADDRESS VARIABLES). ENTER ADDRESS

INTERVIEWER INSTRUCTION:

• PROBE AND ENTER AS MUCH INFORMATION AS PARTICIPANT KNOWS.

(WORK_ADDRESS1) ADDRESS 1 - STREET/PO BOX

(WORK_ADDRESS2) ADDRESS 2

(WORK_UNIT) UNIT

(WORK_CITY) CITY

|___|___| |___|___|___|___|___| |___|___|___|___

STATE ZIP CODE ZIP+4

(WORK_STATE) (WORK_ZIP) (WORK_ZIP4)

WCC003. Next I would like to ask you a few questions about your plans for childcare.

WCC004/(CHILDCARE). Will {BABY_FNAME/your baby/your babies} receive regularly scheduled care from someone other than you or the {baby’s/babies’} father?

YES 1

NO 2 (TIME_STAMP_9)

REFUSED -1

DON’T KNOW -2

WCC005/(CCARE_TYPE). Please describe the type of setting in which most of the childcare will occur.

PARTICIPANT’S HOME 1 (CCARE_WHO)

OTHER PRIVATE HOME 2 (CCARE_WHO)

CHILD CARE CENTER 3 (CCARE_WHO)

OTHER -5

REFUSED -1 (CCARE_WHO)

DON’T KNOW -2 (CCARE_WHO)

WCC006/(CCARE_TYPE_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

LIMIT TEXT TO 255 CHARACTERS.

WCC007/(CCARE_WHO). Which best describes the person who will be caring for {BABY_FNAME/your baby/your babies}?

INTERVIEWER INSTRUCTION:

• IF USING SHOWCARDS, REFER PARTICIPANT TO APPROPRIATE SHOWCARD. OTHERWISE, READ RESPONSE CATEGORIES TO PARTICIPANT.

PROGRAMMER INSTRUCTION:

• IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS. OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE PER BELOW.

YOUR MOTHER 1 (TIME_STAMP_9)

YOUR FATHER 2 (TIME_STAMP_9)

YOUR MOTHER IN-LAW 3 (TIME_STAMP_9)

YOUR FATHER IN-LAW 4 (TIME_STAMP_9)

GUARDIAN 5 (TIME_STAMP_9)

OTHER RELATIVE 6

FRIEND 7 (TIME_STAMP_9)

NANNY 8 (TIME_STAMP_9)

PROFESSIONAL IN HOME DAYCARE 9 (TIME_STAMP_9)

PROFESSIONAL CENTER BASED DAYCARE 10 (TIME_STAMP_9)

OTHER - 5 (CCARE_WHO_OTH)

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

WCC008/(REL_CARE_OTH).

SPECIFY ________________________ (TIME_STAMP_9)

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

WCC009/(CCARE_WHO_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

(TIME_STAMP_9) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

INFANT MEDICAL CARE LOG INTRODUCTION

ICL001. In order to help keep track of your {child’s/children’s} doctor visits or other health care provider visits, we are providing you with an Infant and Child Health Care Log {for each child}. At each Study visit or telephone interview, we will ask you about any health care visits your {child/children} had since the last Study visit or telephone interview. {This log/these logs} will help you remember that information.

The Infant and Child Health Care Log is very similar to the Pregnancy Health Care Log, and will be used the same way. The only difference is the addition of the Immunization/Vaccination/Shot Log which is where all of your {child’s/children’s} vaccination information will need to be written down.

It will be very helpful if you use the log to write down information whenever your {child receives /children receive} health care, so that you will be able to remember it accurately during NCS Study visits or telephone interviews.

INTERVIEWER INSTRUCTIONS:

• DISTRIBUTE INFANT AND CHILD HEALTH CARE LOG WHERE NUMBER OF INFANT AND CHILD HEALTH CARE LOGS = MULTIPLE_NUM.

• EXPLAIN INFANT AND CHILD HEALTH CARE LOG.

PROGRAMMER INSTRUCTIONS:

• IF MULTIPLE_CHILD = 1, THEN DISPLAY “children’s”, “for each child”, children”, “these logs”, AND “children receive” AS APPROPRIATE.

• IF MULTIPLE_CHILD =2, THEN DISPLAY “child’s”, “child”, “this log”, and “child receives” AS APPROPRIATE.

(TIME_STAMP_10) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

MEDICAL HISTORY

PROGRAMMER INSTRUCTIONS:

• IF LOW INTENSITY INTERVIEW – NON AND PREGNANT SET TO COMPLETE FOR CURRENT PREGNANCY, GO TO MD009.

• OTHERWISE, GO TO MD001.

MD001. Now, I will ask about your recent medical history.

MD002/(USE_PR_LOG). Have you used the Pregnancy Health Care Log since {DATE OF PV2 VISIT}/{DATE OF PV1 VISIT}? 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_PR_LOG)

NO 2

REFUSED -1 (NUM_PROV_PR_LOG)

DON’T KNOW -2 (NUM_PROV_PR_LOG)

PROGRAMMER INSTRUCTIONS:

• IF PV2 VISIT FOR CURRENT PREGNANCY SET TO COMPLETE, PRELOAD DATE OF PV2 VISIT.

• IF PV1 VISIT FOR CURRENT PREGNANCY SET TO COMPLETE, BUT PV2 VISIT NOT SET TO COMPLETE, PRELOAD DATE OF PV1 VISIT.

MD003/(REASON_NO_PR_LOG). Is that because…

You haven’t had a medical visit since our last interview, 1 (MD009)

You’ve misplaced the log, 2 (NUM_PROV_PR_LOG)

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

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

The log was too difficult to understand 5 (NUM_PROV_PR_LOG)

OTHER: -5

REFUSED -1 (MD006)

DON’T KNOW -2 (MD006)

MD003A/(REASON_NO_PR_LOG_OTH). OTHER: SPECIFY

_____________________________________ (MD006)

PROGRAMMER instruction:

• Limit free text to 255 characters.

MD004/(NUM_PROV_PR_LOG). How many health care providers did you see {between {DATE OF PV2 VISIT} and {CHILD_DOB}}/{between {DATE OF PV1 VISIT} and {CHILD_DOB}}

|___|___|

NUMBER OF PROVIDERS

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF PV2 VISIT FOR CURRENT PREGNANCY SET TO COMPLETE, PRELOAD DATE OF PV2 VISIT AND DISPLAY FIRST BRACKETED PHRASE USING CHILD_DOB COLLECTED EARLIER IN INSTRUMENT.

• IF PV1 VISIT FOR CURRENT PREGNANCY SET TO COMPLETE, BUT PV2 VISIT NOT SET TO COMPLETE, PRELOAD DATE OF PV1 VISIT AND DISPLAY SECOND BRACKETED PHRASE USING CHILD_DOB COLLECTED EARLIER IN INSTRUMENT.

MD005/(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

MD006. 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} personal records or a 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:

• IF USE_PR_LOG=1, DISPLAY BRACKETED TEXT.

MD007/(DATE_VISIT). What was the date of your last doctor’s visit or checkup {between {DATE OF PV2 VISIT} and {CHILD_DOB}}/{between {DATE OF PV1 VISIT} and {CHILD_DOB}}/{before {CHILD_DOB}}?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

HAVE NOT HAD A VISIT -7 (MD009)

REFUSED -1 (MD009)

DON’T KNOW -2 (MD009)

INTERVIEWER INSTRUCTION:

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

PROGRAMMER INSTRUCTIONS:

• IF PV2 VISIT FOR CURRENT PREGNANCY SET TO COMPLETE, PRELOAD DATE OF PV2 VISIT AND DISPLAY FIRST BRACKETED PHRASE USING CHILD_DOB COLLECTED EARLIER IN INSTRUMENT.

• IF PV1 VISIT FOR CURRENT PREGNANCY SET TO COMPLETE, BUT PV2 VISIT NOT SET TO COMPLETE, PRELOAD DATE OF PV1 VISIT AND DISPLAY SECOND BRACKETED PHRASE USING CHILD_DOB COLLECTED EARLIER IN INSTRUMENT.

• OTHERWISE, IF NEITHER PV1 NOR PV2 VISIT SET TO COMPLETE FOR CURRENT PREGNANCY, DISPLAY THIRD BRACKETED PHRASE USING CHILD_ DOB COLLECTED EARLIER IN INSTRUMENT.

PROGRAMMER INSTRUCTION:

• IF USE_PR_LOG=1, GO TO MD008.

• OTHERWISE, GO TO MD009.

MD008. 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.

MD009. {At this visit or at anytime between {DATE OF PV2 VISIT} and {CHILD_DOB}}/{At this visit or at anytime between {DATE OF PV1 VISIT} and {CHILD_DOB}}/{At anytime during your pregnancy} did the doctor or other health care provider tell you that you have any of the following conditions?

PROGRAMMER INSTRUCTIONS:

• IF VALID DATE FOR DATE_VISIT IS PROVIDED AND PV2 VISIT FOR CURRENT PREGNANCY SET TO COMPLETE, PRELOAD DATE OF PV2 VISIT AND DISPLAY FIRST BRACKETED PHRASE USING CHILD_DOB COLLECTED EARLIER IN INSTRUMENT.

• IF VALID DATE FOR DATE_VISIT IS PROVIDED AND PV1 VISIT FOR CURRENT PREGNANCY SET TO COMPLETE, BUT PV2 VISIT NOT SET TO COMPLETE SET TO COMPLETE, PRELOAD DATE OF PV1 VISIT AND DISPLAY SECOND BRACKETED PHRASE USING CHILD_DOB COLLECTED EARLIER IN INSTRUMENT.

• OTHERWISE, IF DATE_VISIT = -1, -2, OR -7, DISPLAY THIRD BRACKETED PHRASE.

INTERVIEWER INSTRUCTIONS:

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at anytime between {DATE OF PV2 VISIT} and {CHILD_DOB}}/{At this visit or at anytime between {DATE OF PV1 VISIT} and {CHILD_DOB}}/{At anytime during your pregnancy} did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED FOR EACH CONDITION.

MD010A/(DIABETES_1). Diabetes?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD010B/(HIGHBP_PREG). High blood pressure?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD010C/(URINE). Protein in your urine?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD010D/(PREECLAMP). Preeclampsia or toxemia?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD010E/(EARLY_LABOR). Early or premature labor?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD010F/(ANEMIA). Anemia or low blood count?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD010G/(NAUSEA). Severe nausea or vomiting (hyperemesis)?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD010H/(KIDNEY). Bladder or kidney Infection?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD010I/(RH_DISEASE). Rh disease or isoimmunization?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD010J/(GROUP_B). Infection with a bacteria called Group B strep?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD010K/(HERPES). Infection with a Herpes virus?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD010L/(VAGINOSIS). Infection of the vagina with bacteria (Bacterial vaginosis?)

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD010M/(OTH_CONDITION). Any other serious condition?

YES 1

NO 2 (M_HOSPITAL)

REFUSED -1 (M_HOSPITAL)

DON’T KNOW -2 (M_HOSPITAL)

MD010N/(CONDITION_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER instruction:

• Limit free text to 255 characters

MD011/(M_HOSPITAL). {Between {DATE OF PV2 VISIT} and {CHILD_DOB}}/{Between {DATE OF PV1 VISIT} and {CHILD_DOB}}/{Since {CHILD_DOB}}, did you spend at least one night in the hospital?

YES 1

NO 2 (END)

REFUSED -1 (END)

DON’T KNOW -2 (END)

PROGRAMMER INSTRUCTIONS:

• IF PV2 VISIT FOR CURRENT PREGNANCY SET TO COMPLETE, PRELOAD DATE OF PV2 VISIT AND DISPLAY FIRST BRACKETED PHRASE USING CHILD_DOB COLLECTED EARLIER IN INSTRUMENT.

• IF PV1 VISIT FOR CURRENT PREGNANCY SET TO COMPLETE, BUT PV2 VISIT NOT SET TO COMPLETE SET TO COMPLETE, PRELOAD DATE OF PV1 VISIT AND DISPLAY SECOND BRACKETED PHRASE USING CHILD_DOB COLLECTED EARLIER IN INSTRUMENT.

• OTHERWISE, IF NEITHER PV1 NOR PV2 VISIT SET TO COMPLETE FOR CURRENT PREGNANCY, DISPLAY THIRD BRACKETED PHRASE USING CHILD_ DOB COLLECTED EARLIER IN INSTRUMENT.

MD012/(ADMIN_DATE). What was the admission date of your last hospital stay {between {DATE OF PV2 VISIT} and {CHILD_DOB}}/{between {DATE OF PV1 VISIT} and {CHILD_DOB}}/{since {CHILD_DOB}}?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF PV2 VISIT FOR CURRENT PREGNANCY SET TO COMPLETE, PRELOAD DATE OF PV2 VISIT AND DISPLAY FIRST BRACKETED PHRASE USING CHILD_DOB COLLECTED EARLIER IN INSTRUMENT.

• IF PV1 VISIT FOR CURRENT PREGNANCY SET TO COMPLETE, BUT PV2 VISIT NOT SET TO COMPLETE SET TO COMPLETE, PRELOAD DATE OF PV1 VISIT AND DISPLAY SECOND BRACKETED PHRASE USING CHILD_DOB COLLECTED EARLIER IN INSTRUMENT.

• OTHERWISE, IF NEITHER PV1 NOR PV2 VISIT SET TO COMPLETE FOR CURRENT PREGNANCY, DISPLAY THIRD BRACKETED PHRASE USING CHILD_ DOB COLLECTED EARLIER IN INSTRUMENT.

INTERVIEWER INSTRUCTION:

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

MD013/(HOSP_NIGHTS). How many nights did you stay in the hospital during this hospital stay?

|___|___|___|

NUMBER OF NIGHTS

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• CONFIRM RESPONSE.

MD014/(DIAGNOSE). Did a doctor or other health care provider give you a diagnosis during this hospital stay?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD015/(DIAGNOSE_2). What was the diagnosis?

INTERVIEWER INSTRUCTIONS:

• 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 MD016.

• 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 MD016.

MD015A/(DIAGNOSIS_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• Limit free text to 255 characters

• IF USE_PR_LOG =1 AND M_HOSPITAL = 1, GO TO MD016.

• OTHERWISE, GO TO TIME_STAMP_11.

MD016. 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.

END. Thank you for participating in the National Children’s Study and for taking the time to complete this survey. This concludes the interview portion of our visit.

(TIME_STAMP_11) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

INTERVIEWER-COMPLETED QUESTIONS

IC002/(PARTICIPANT). WAS THE INTERVIEW COMPLETED WITH THE BIRTH MOTHER OR A PROXY?

BIRTH MOTHER 1

PROXY 2

IC003/(CONTACT_TYPE). IN WHAT MODE WAS THE QUESTIONNAIRE ADMINISTERED?

IN-PERSON 1

TELEPHONE 2

MAIL 3

WEB 4

IC004/(ENGLISH). WAS THIS DATA COLLECTION SESSION CONDUCTED IN ENGLISH?

YES 1 (INTERPRET)

NO 2

IC005/(CONTACT_LANG). WHAT OTHER LANGUAGE WAS USED TO CONDUCT THIS SESSION?

SPANISH 1 (INTERPRET)

ARABIC 2 (INTERPRET)

CHINESE 3 (INTERPRET)

FRENCH 4 (INTERPRET)

FRENCH CREOLE 5 (INTERPRET)

GERMAN 6 (INTERPRET)

ITALIAN 7 (INTERPRET)

KOREAN 8 (INTERPRET)

POLISH 9 (INTERPRET)

RUSSIAN 10 (INTERPRET)

TAGALOG 11 (INTERPRET)

VIETNAMESE 12 (INTERPRET)

URDU 13 (INTERPRET)

PUNJABI 14 (INTERPRET)

BENGALI 15 (INTERPRET)

FARSI 16 (INTERPRET)

OTHER -5

IC006/(CONTACT_LANG_OTH).

SPECIFY ________________________

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

IC007/(INTERPRET). WAS AN INTERPRETER USED?

YES 1

NO 2 (TIME_STAMP_12)

IC008/(CONTACT_INTERPRET). WHAT TYPE OF INTERPRETER WAS USED?

BILINGUAL INTERVIEWER 1 (TIME_STAMP_12)

IN-PERSON PROFESSIONAL INTERPRETER 2 (TIME_STAMP_12)

IN-PERSON FAMILY MEMBER INTERPRETER 3 (TIME_STAMP_12)

LANGUAGE-LINE INTERPRETER 4 (TIME_STAMP_12)

VIDEO INTERPRETER 5 (TIME_STAMP_12)

SIGN LANGUAGE INTERPRETER 6 (TIME_STAMP_12)

OTHER -5

IC009/(CONTACT_ INTERPRET_OTH).

SPECIFY ________________________

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

(TIME_STAMP_12) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 10 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.