Form 21.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/ 2013

9-Month Interview, Phase 2e

9-Month Interview

Event:	9-Month
Respondent:	Parent/Caregiver
Participant: Domain:	Child Questionnaire
Type of Document:	Interview
Allowable Mode:	In Person, Telephone, Mail, Web
Allowable Method:	CAPI/CATI
Recruitment Groups:	EH, PB, HI, LI, PBS
Version:	X.X
Release:	MDES 3.0

This page intentionally left blank.

9-Month Interview

TABLE OF CONTENTS

INTERVIEWER COMPLETED QUESTIONS 1

CHILD DEVELOPMENT AND PARENTING 3

HEALTH CARE 6

9-Month Interview

INTERVIEWER COMPLETED QUESTIONS

(TIME_STAMP_1) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS:

• PRELOAD PARTICIPANT ID (P_ID) FOR CHILD AND RESPONDENT ID (R_P_ID) FOR PARENT/CAREGIVER.

• PRELOAD FIRST NAME OF CHILD OR CHILDREN AND DISPLAY APPROPRIATE NAME IN “C_FNAME” THROUGHOUT THE INSTRUMENT.

• USE “the child” IN APPROPRIATE FIELDS THROUGHOUT THE INSTRUMENT IF CHILD’S NAME IS REFUSED OR DON’T KNOW.

IC001/(MULT_CHILD). IS THERE MORE THAN ONE CHILD IN THIS HOUSEHOLD ELIGIBLE FOR THE 9-MONTH INTERVIEW TODAY?

YES 1

NO 2 (CHILD_SEX)

IC006/(CHILD_NUM). HOW MANY CHILDREN IN THIS HOUSEHOLD ARE ELIGIBLE FOR THE 9-MONTH INTERVIEW TODAY?

|___|___|

NUMBER OF CHILDREN

PROGRAMMER INSTRUCTIONS:

• IF CHILD_NUM=>1, GO TO CHILD_QNUM AND LOOP THROUGH QUESTIONAIRE FROM CHILD_QNUM THROUGH TIME_STAMP_4, THEN GO TO END.

IC011/(CHILD_QNUM). WHICH NUMBER CHILD IS THIS QUESTIONNAIRE FOR?

|___|___|

NUMBER

PROGRAMMER INSTRUCTION:

• CHILD_QNUM CANNOT BE GREATER THAN CHILD_NUM.

IC017/(CHILD_SEX). IS {C_FNAME} A MALE OR A FEMALE?

MALE 1

FEMALE 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF CHILD_SEX = 1, DISPLAY “his” AND “he” IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

• IF CHILD_SEX = 2, DISPLAY “her” AND “she” IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

IC018/(RESP_REL). WHAT IS THE RELATIONSHIP OF PARENT/CAREGIVER TO CHILD?

MOTHER 1 (TIME_STAMP_2)

FATHER 2 (TIME_STAMP_2)

OTHER 3

IC019/(RESP_REL_OTH).

SPECIFY____________________________________

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

Child Development and Parenting

(TIME_STAMP_2) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

CDP001. First, I will read you a list of things {C_FNAME/the child} may already do or may start doing when {he/she} gets older. Does {C_FNAME/the child}:

CDP011/(EYES_FOLLOW). Follow you with {his/her} eyes?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP012/(SMILE). Smile when you smile at {him/her}?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP013/(REACH_1). Try to get a toy that is out of reach?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP014/(FEED). Feed {himself/herself} a cracker or cereal?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP015/(WAVE). Wave goodbye?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP016/(GRAB). Grab an object like a block or rattle from you?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP017/(SWITCH_HANDS). Move a toy or block from one hand to the other?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP018/(PICKUP). Pick up a small object like a Cheerio or raisin?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP019/(HOLD). Hold two toys or blocks at a time, one in each hand?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP021/(SOUND_3). Turn toward someone when they’re speaking?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP022/(SPEAK_1). Make sounds as though {he/she} is trying to speak?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP023/(SPEAK_2). Say mama or dada?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP024/(HEADUP). Keep head steady when sitting or held up?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP026/(ROLL_2). Roll from back to stomach?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP034/(SITUP). Sit up by {himself/herself}?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP035/(STAND). Stand while holding onto something?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP036/(STAND_ALONE). Stand alone, without holding onto something?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP037/(WALK). Walk by {himself/herself}, without holding onto something?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP038/(SCRIBBLE). Scribble or draw with a pencil, crayon, or marker?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP039/(FORK_SPOON). Try to use a fork or spoon when eating?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

Health Care

(TIME_STAMP_3) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

HL001. The next questions are about {C_FNAME/the child}’s health care.

HL002/(R_HCARE). First, what kind of place does {C_FNAME/the child} usually go to when {he/she} needs routine or well-child care, such as a check-up or well-baby shots (immunizations)?

Clinic or health center ……………………… 1 (C_HEALTH)

Doctor's office or Health Maintenance Organization (HMO) …… 2 (C_HEALTH)

Hospital emergency room ……………………… 3 (C_HEALTH)

Hospital outpatient department ……………………… 4 (C_HEALTH)

Some other place ……………………… -5

DOESN'T GO TO ONE PLACE MOST OFTEN 6 (C_HEALTH)

DOESN'T GET WELL-CHILD CARE ANYWHERE 7 (C_HEALTH)

REFUSED ……………………… -1 (C_HEALTH)

DON’T KNOW ……………………… -2 (C_HEALTH)

HL002A/(R_HCARE_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

HL003/(C_HEALTH). Would you say {C_FNAME/the child}’s health in general is poor, fair, good, or excellent?

POOR 1

FAIR 2

GOOD 3

EXCELLENT 4

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF RESP_REL = 1, GO TO USE_IC_LOG.

• OTHERWISE, GO TO HL011.

HL004/(USE_IC_LOG). First, are you using the Infant and Child Health Care Log? This is the booklet that you or your health care provider (pediatrician or family medicine doctor, specialist (like a surgeon, heart, allergy, or skin doctor), nurse practitioner, physician assistant, nurse, social worker/counselor, etc.) uses to record information about the child’s medical visits.

YES 1 (NUM_PROV_IC_LOG)

NO 2

REFUSED -1 (HL011)

DON’T KNOW -2 (HL011)

HL005/(REASON_NO_IC_LOG). Is that because

Your child hasn’t had a medical visit since our last interview, 1 (HL011)

You’ve misplaced the log 2 (HL006)

You’ve forgotten to bring it to the child’s medical visits 3 (HL007)

The log was too much trouble to complete, or 4 (HL007)

The log was too difficult to understand? 5 (HL011)

OTHER (SPECIFY): -5

REFUSED -1 (HL011)

DON’T KNOW -2 (HL011)

HL005A/(REASON_NO_IC_LOG_OTH).

OTHER: SPECIFY _______________________________ (HL011)

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

HL006. We’ll get another Infant and Child Health Care Log in the mail to you today. (HL011)

HL007. 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 the child’s medical visits. (HL011)

HL008/(NUM_PROV_IC_LOG). How many health care providers has the child seen since using this Infant and Child Health Care Log?

|___|___|

NUMBER OF PROVIDERS

REFUSED -1

DON’T KNOW -2

HL009/(NUM_PROV_REC). Of those providers that the child has 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

HL011. I am now going to ask some questions about the child’s visits to a doctor or other health care provider (pediatrician or family medicine doctor, specialist (like a surgeon, heart, allergy, or skin doctor). It would be helpful if you referred to {the Infant and Child 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:

• DISPLAY TEXT IN BRACKETS IF USE_IC_LOG = 1.

HL012/(LAST_VISIT_MM)(LAST_VISIT_DD)(LAST_VISIT_YY). What was the date of {C_FNAME/the child}’s most recent well-child visit or checkup?

MONTH:

|___|___|

M M

HAS NOT HAD A VISIT -7 (SAME_CARE)

REFUSED -1 (SAME_CARE)

DON’T KNOW -2

DAY:

|___|___|

D D

REFUSED -1 (SAME_CARE)

DON’T KNOW -2

YEAR:

|___|___|___|___|

Y Y Y Y

REFUSED -1 (SAME_CARE)

DON’T KNOW -2 (SAME_CARE)

INTERVIEWER INSTRUCTIONS:

• SHOW CALENDAR TO ASSIST IN DATE RECALL.

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

HL013/(VISIT_WT). What was {C_FNAME/the child}’s weight at that visit?

|___|___|

POUNDS

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• INCLUDE A SOFT EDIT IF WEIGHT < 13 OR > 26 POUNDS.

• IF USE_IC_LOG = 1, GO TO HL014.

• OTHERWISE, GO TO SAME_CARE

HL014. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Infant and Child Health Care Log.

HL015/(SAME_CARE). If {C_FNAME/the child} is sick or if you have concerns about {his/her} health, does {he/she} go to the same place as for well-child visits?

YES 1 (HOSPITAL)

NO 2

HAS NOT BEEN SICK -7 (TIME_STAMP_4)

REFUSED -1

DON’T KNOW -2

HL016/(HCARE_SICK). What kind of place does {C_FNAME/the child} usually go to when {he/she} is sick, doesn’t feel well, or if you have concerns about {his/her} health?

Clinic or health center 1 (HOSPITAL)

Doctor's office or Health Maintenance Organization (HMO) 2 (HOSPITAL)

Hospital emergency room 3 (HOSPITAL)

Hospital outpatient department 4 (HOSPITAL)

Some other place -5

DOESN'T GO TO ONE PLACE MOST OFTEN 6 (HOSPITAL)

HAS NOT BEEN SICK -7 (TIME_STAMP_4)

REFUSED -1 (HOSPITAL)

DON’T KNOW -2 (HOSPITAL)

HL017/( HCARE_SICK_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

HL018/(HOSPITAL). Since {DATE OF LAST INTERVIEW}, has {C_FNAME/the child} spent at least one night in the hospital?

YES 1

NO 2 (TIME_STAMP_4)

REFUSED -1 (TIME_STAMP_4)

DON’T KNOW -2 (TIME_STAMP_4)

PROGRAMMER INSTRUCTIONS:

• IF 6-MONTH INTERVIEW SET TO COMPLETE, PRELOAD 6-MONTH INTERVIEW DATE FOR DATE OF LAST INTERVIEW.

• IF 6-MONTH INTERVIEW NOT SET TO COMPLETE, PRELOAD DATE OF MOST RECENT CHILD INTERVIEW FOR DATE OF LAST INTERVIEW.

HL019/(HOSPITAL_TIMES). How many times since {DATE OF LAST INTERVIEW} has {C_FNAME/the child} spent at least one night in the hospital?

|___|___|

TIMES

REFUSED -1 (TIME_STAMP_4)

DON’T KNOW -2 (TIME_STAMP_4)

PROGRAMMER INSTRUCTIONS:

• IF 6-MONTH INTERVIEW SET TO COMPLETE, PRELOAD 6-MONTH INTERVIEW DATE FOR DATE OF LAST INTERVIEW.

• IF 6-MONTH INTERVIEW NOT SET TO COMPLETE, PRELOAD DATE OF MOST RECENT CHILD INTERVIEW FOR DATE OF LAST INTERVIEW.

• LOOP THROUGH ADMIN_DATE_MM, ADMIN_DATE_DD, ADMIN_DATE_YY, HOSP_NIGHTS, DIAGNOSE, DIAGNOSE_OTH (IF DIAGNOSE = 1), AND HL024 (IF USE_IC_LOG=1) FOR EACH HOSPITAL ADMISSION.

• TOTAL NUMBER OF LOOPS SHOULD EQUAL VALUE ENTERED IN HOSPITAL.

• AFTER COMPLETING FINAL LOOP, GO TO TIME_STAMP_4.

HL020/(ADMIN_DATE_MM)(ADMIN_DATE_DD)(ADMIN_DATE_YY). What was the admission date of {C_FNAME/the child}’s {most recent/next most recent} hospital stay?

MONTH:

|___|___|

M M

REFUSED -1

DON’T KNOW -2

DAY:

|___|___|

D D

REFUSED -1

DON’T KNOW -2

YEAR:

|___|___|___|___|

Y Y Y Y

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF FIRST LOOP, DISPLAY “most recent”.

• OTHERWISE, DISPLAY “next most recent”.

INTERVIEWER INSTRUCTIONS:

• SHOW CALENDAR TO ASSIST IN DATE RECALL.

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

HL021/(HOSP_NIGHTS). How many nights did {C_FNAME/the child} stay in the hospital during this hospital stay?

|___|___|___|

NUMBER OF NIGHTS

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• CONFIRM RESPONSE

HL022/(DIAGNOSE). Did a doctor or other health care provider give you a diagnosis for {C_FNAME/the child} during this hospital stay?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF DIAGNOSE = 1, GO TO DIAGNOSE_OTH.

• IF DIAGNOSE = 2, -1, OR -2, AND USE_IC_LOG =1, GO TO HL023.

• OTHERWISE, GO TO TIME_STAMP_4.

HL023/(DIAGNOSE_OTH). What was the diagnosis?

INTERVIEWER INSTRUCTIONS:

• ENTER ALL DIAGNOSES IN FIELD SEPARATED BY COMMAS OR AN “AND”.

• PROBE: “Anything else?”

________________________________

DIAGNOSES

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

• IF USE_IC_LOG = 1, GO TO HL024.

• OTHERWISE, GO TO TIME_STAMP_4.

HL024. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Infant and Child Health Care Log.

(TIME_STAMP_4) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

END. Thank you for your time and for being a part of this important research study. This is the end of our interview.

(TIME_STAMP_5) 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.