Form 2.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/2013

Pregnancy Screener Interview Instrument (PB), Phase II

Event Name(s):

Pregnancy Screener Instrument (PB)

Instrument Name(s) and Versions:

Pregnancy Screener Instrument (PB) – 2.0

Recruitment Groups:

Provider-Based

Pregnancy Screener Interview Instrument (PB)

TABLE OF CONTENTS

INITIAL CONVERSATION WITH OUTGOING CALLER 1

VERBAL PERMISSION TO SCREENING FOR STUDY ELIGIBILITY 4

ELIGIBILITY QUESTIONS……………………………………………………………………. 4

FAMILIARITY WITH THE NATIONAL CHILDREN’S STUDY 8

PREGNANCY SCREENER 10

DEMOGRAPHIC QUESTIONS 17

TRACING QUESTIONS 23

CLOSING STATEMENTS 29

CONCLUSION 31

FINAL INTERVIEWER-COMPLETED QUESTIONS 32

Pregnancy Screener Interview Instrument (PB)

CATI

INSTRUCTIONS TO INTERVIEWER: Questionnaire and other required text is shown in regular font. Interviewer instructions and text not to be read to respondents is shown in ALL CAPS. Introductory text that may or may not be appropriate for all recruitment schemas is shaded. Variable names are shown in BOLD CAPS.

INITIAL CONVERSATION WITH OUTGOING CALLER

ICO001/(TIME_STAMP_1). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

ICO002/(FEMALE_1). Hello, my name is [DATA COLLECTOR’S NAME ]. I’m calling from the National Children’s Study. I’d like to speak with [NAME OF WOMAN IDENTIFIED BY PROVIDER]. Is she available?

YES 1 (TIME_STAMP_3)

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• PRELOAD NAME OF POTENTIAL PARTICIPANT.

ICO003/(BEST_TTC_1). What would be a good time to reach her?

|___|___| : |___|___|

H H M M

REFUSED -1

DON’T KNOW -2

(BEST_TTC_2)

AM 1

PM 2

REFUSED -1

DON’T KNOW -2

(BEST_TTC_3)

AFTER TIME REPORTED 1

BEFORE TIME REPORTED 2

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• ENTER IN HOUR AND MINUTE VALUES; AND SELECT AM OR PM.

ICO004/(PHONE). Is this a good phone number to reach [NAME]?

PROGRAMMER INSTRUCTION:

• PRELOAD NAME.

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• PRELOAD NAME OF POTENTIAL PARTICIPANT.

ICO005/(R_PHONE_1). Would you please tell me a telephone number where she can be reached?

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

REFUSED -1

DON’T KNOW -2

RESPONDENT HAS NO TELEPHONE/NOT APPLICABLE -7

ICO007. Thank you again for speaking with me today. Please ask her to call us at [LOCAL SC TOLL-FREE NUMBER].

(TIME_STAMP_2). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

INTERVIEWER INSTRUCTION:

• END INTERVIEW.

(TIME_STAMP_3). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

INTERVIEWER INSTRUCTION:

• WHEN SPEAKING TO THE POTENTIAL PARTICIPANT IDENTIFIED BY A PROVIDER.

ICO008. I’m [NAME] from the National Children’s Study. Your healthcare provider has indicated that you may be interested in participating in the National Children’s Study. I’d like to tell you a bit about the Study and see if you are able to take part. I will just need a few minutes of your time.

INTERVIEWER INSTRUCTION:

• IF ADDITIONAL INFORMATION IS NEEDED, SAY:

The information we get from those who take part in the study may help us learn information that will improve our children’s health for years to come.

{NAME OF LOCAL ACADEMIC INSTITUTION AND NAME OF PROVIDER} are part of this important research study aimed at improving the health and well being of children.

PROGRAMMER INSTRUCTION:

• PRELOAD NAME OF LOCAL ACADEMIC INSTITUTION AND NAME OF PROVIDER.

VERBAL PERMISSION TO SCREENING FOR STUDY ELIGIBILITY

VC013. I would like to ask you some questions to determine if you may be able to participate in the Study. Is this alright with you? You can skip over any question I ask or you can stop the interview at any time. The information we collect from you is protected by law and we will keep all of it private.

ELIGIBILITY QUESTIONS

EL001/(R_FNAME)/(R_LNAME). What is your full name?

_____________________ ___________________

FIRST NAME LAST NAME

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTIONS:

• CONFIRM SPELLING.

• IF RESPONDENT REFUSES TO PROVIDE FIRST NAME, ASK FOR INITIALS.

EL003/(PERSON_DOB). What is your date of birth?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• INCLUDE A SOFT EDIT/WARNING IF CALCULATED AGE IS LESS THAN LOCAL AGE OF MAJORITY OR GREATER THAN 49.

• FORMAT PERSON_DOB AS YYYYMMDD.

• IF FULL DOB IS GIVEN CALCULATE AGE AND AGE_RANGE BASED ON RESPONSE; SKIP TO AGE_ELIG.

• IF ONLY MONTH AND YEAR ARE PROVIDED, CALCULATE AGE AND AGE_RANGE AND SKIP TO AGE_ELIG.

INTERVIEWER INSTRUCTION:

• IF UNDER LOCAL AGE OF MAJORITY, NOT ELIGIBLE FOR THE STUDY, EVEN IF PREGNANT; SKIP TO AGE_ELIG.

EL004/(AGE). How old are you?

ENTER AGE AT LAST BIRTHDAY IN YEARS

|___|___| (AGE_ELIG)

AGE

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• INCLUDE A SOFT EDIT/WARNING IF AGE ENTERED IS LESS LOCAL AGE OF MAJORITY OR GREATER THAN 49

• CALCULATE AGE_RANGE BASED ON RESPONSE.

EL005/(AGE_RANGE).

Which range best describes your age? Would you say…

Less than 18 1

18-24 2

25-34 3

35-44 4

45-49 5

50-64 6

65 or older 7

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• DESCRIBE HOW THE ANSWER TO THIS QUESTION DETERMINES HER ELIGIBILITY AND THAT ALL DATA ARE KEPT CONFIDENTIAL AND SECURE.

EL006/(AGE_ELIG).

RESPONDENT IS AGE-ELIGIBLE 1

RESPONDENT IS YOUNGER THAN AGE OF MAJORITY 2

RESPONDENT IS OVER AGE 49 3

AGE ELIGIBILITY IS UNKNOWN -6

PROGRAMMER INSTRUCTIONS: 

• BASED ON REPORTED AGE OF RESPONDENT DETERMINE WHETHER SHE IS CONSIDERED A MINOR BASED ON LOCAL REQUIREMENTS.

• IF RESPONDENT IS DETERMINED TO BE A MINOR, SET PPG_FIRST = 5.

(TIME_STAMP_4). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

EL012/(ADDRESS VARIABLES). What is your address?

ADDRESS 1/(ADDRESS_1).

STREET NUMBER

PRE-DIRECTIONAL

STREET NAME

STREET TYPE

POST DIRECTIONAL

ADDRESS 2/(ADDRESS_2).

UNIT (UNIT)

UNIT TYPE

UNIT NUMBER

CITY (CITY)

STATE (STATE)

ZIP CODE (ZIP)

ZIP+4 (ZIP4)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• IF RESPONDENT REFUSES/DON’T KNOW: DESCRIBE HOW HER ELIGIBILITY IS DETERMINED BY HER RESIDENTIAL ADDRESS AND THAT ALL DATA ARE KEPT CONFIDENTIAL AND SECURE.

PROGRAMMER INSTRUCTIONS:

• IF SUFFICIENT ADDRESS INFORMATION IS PROVIDED GO TO DU_ELIG_CONFIRM AND SET VALUE AS APPROPRIATE.

• IF RESPONDENT REFUSES TO PROVIDE ADDRESS INFORMATION GO TO DU_ELIG_CONFIRM AND SET AS UNKNOWN.

EL014/(DU_ELIG_CONFIRM).

RESPONDENT LIVES IN AN ELIGIBLE DWELLING UNIT 1

RESPONDENT DOES NOT LIVE IN AN ELIGIBLE DWELLING UNIT 2 (TIME_STAMP_10)

SET PPG_FIRST = 6

DWELLING UNIT ELIGIBILITY IS UNKNOWN 3

INTERVIEWER INSTRUCTION:

• THIS QUESTION IS USED TO FLAG ELIGIBILITY.

FAMILIARITY WITH THE NATIONAL CHILDREN’S STUDY

FA001/(TIME_STAMP_5). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

FA002/(KNOW_NCS). Before today, had you heard about the National Children’s Study?

YES 1

NO 2 (ELIG)

REFUSED -1 (ELIG)

DON’T KNOW -2 (ELIG)

FA003/(HOW_KNOW_NCS). How did you hear about the National Children’s Study?

INTERVIEWER INSTRUCTION:

• SELECT ALL THAT APPLY AND PROBE FOR ANY OTHER MEANS.

ADVANCE LETTER MAILED BY NCS 1

HOUSEHOLD ENUMERATION 2

CONTINUOUS TRACKING OF DU – NEW MEMBER OF EXISTING HOUSEHOLD 3

CONTINUOUS TRACKING OF DU – NEW HOUSEHOLD 4

PRENATAL CARE PROVIDER 5

OTHER HEALTH CARE PROVIDER 6

OTHER NCS RESPONDENT 7

FRIEND 8

NEIGHBOR 9

FAMILY MEMBER 10

CO-WORKER 11

SELF/RESPONDENT REFERRAL 12

SCHOOL 13

WIC OR OTHER SOCIAL AGENCY 14

RELIGIOUS ORGANIZATION 15

COMMUNITY PARTNERS/OUTREACH EVENT 16

MEDIA: PRINT MEDIA 17

MEDIA: TV 18

MEDIA: RADIO 19

SOCIAL NETWORKING MEDIA (E.G., INTERNET, FACEBOOK, MYSPACE, BLOGS, ETC.) 20

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF HOW_KNOW_NCS CODED WITH ANY COMBINATION OF VALUES 1 – 20, THEN GO TO ELIG.

• IF HOW_KNOW_NCS CODED -5, OR ANY COMBINATION OF VALUES 1 – 20 AND -5, GO TO HOW_KNOW_NCS_OTH.

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

FA008/(HOW_KNOW_NCS_OTH).

SPECIFY ___________________________

REFUSED -1

DON’T KNOW -2

FA009/(ELIG). PROGRAMMER INSTRUCTIONS:

• PROGRAM SKIP PATTERNS ACCORDING TO TABLE BELOW:

		DU_ELIG_CONFIRM
			1	2	3
AGE_ELIG			ELIGIBLE DWELLING UNIT	INELIGIBLE DWELLING UNIT	UNKNOWN ELIGIBILITY
	1	AGE-ELIGIBLE	TIME_STAMP_6	TIME_STAMP_6	TIME_STAMP_6
	2	YOUNGER THAN AGE OF MAJORITY	TIME_STAMP_11	TIME_STAMP_11	TIME_STAMP_11
	3	OVER AGE 49	TIME_STAMP_6	TIME_STAMP_6	TIME_STAMP_6
	4	UNKNOWN	CODE AS REFUSAL; TIME_STAMP_12	CODE AS REFUSAL; TIME_STAMP_12	CODE AS REFUSAL; TIME_STAMP_12

PREGNANCY SCREENER

PS001/(TIME_STAMP_6). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

PS002. We are asking women of childbearing age a few questions about pregnancy. Not all women who answer these questions will be able to take part in the National Children’s Study now, but almost every woman who answers these questions will have a chance to take part in some way in the future. We first want to know….

PS004/(PREGNANT). IF ADULT IS KNOWN TO BE PREGNANT, ADD Just to confirm, Are you pregnant now?

YES 1 (ORIG_DUE_DATE)

SET PPG_FIRST = 1

NO, NO ADDITIONAL INFORMATION PROVIDED 2 (PS005)

(IF VOLUNTEERED BY RESPONDENT)

NO, RECENTLY LOST PREGNANCY (MISCARRIAGE/ABORTION) 3 (TIME_STAMP_8);

IF AGE_ELIG = 1; SET PPG_FIRST = 3

IF AGE_ELIG = 3; SET PPG_FIRST = 5

NO, RECENTLY GAVE BIRTH 4 (TIME_STAMP_8);

IF AGE_ELIG = 1; SET PPG_FIRST = 4

IF AGE_ELIG = 3; SET PPG_FIRST = 5

NO, UNABLE TO HAVE CHILDREN (HYSTERECTOMY, TUBAL LIGATION) 5

IF AGE_ELIG = 1; HYSTER

IF AGE_ELIG = 3; SET PPG_FIRST = 5 (TIME_STAMP_8);

REFUSED -1

IF AGE_ELIG = 1; (TIME_STAMP_7)

IF AGE_ELIG = 3; SET PPG_FIRST = 5 (TIME_STAMP_8);

DON’T KNOW -2

IF AGE_ELIG = 1; (TIME_STAMP_7)

IF AGE_ELIG = 3; SET PPG_FIRST = 5 (TIME_STAMP_8);

PS005. IF PREGNANT = NO - NO ADD’L INFO AND AGE_ELIG =1 (TIME_STAMP_7)

IF PREGNANT = NO - NO ADD’L INFO AND AGE_ELIG = 3 (TIME_STAMP_8)

SET PPG_FIRST = 5

INTERVIEWER INSTRUCTION:

• IF NOT PREGNANT AND OVER 49, NOT ELIGIBLE FOR THE STUDY.

PS006/(ORIG_DUE_DATE). Congratulations. When is your baby due?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1

DON’T KNOW -2

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.

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 ORIG_DUE_DATE = YYYYMMDD AS REPORTED ; GO TO PS008 DATE_PERIOD; SET PPG_FIRST = 1.

• IF NO VALID DATE IS GIVEN  GO TO PS008 DATE_PERIOD.

PS008/(DATE_PERIOD). What was the first day of your last menstrual period?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

IF VALID RESPONSE PROVIDED (TIME_STAMP_8)

REFUSED -1

DON’T KNOW -2

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.

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 ORIG_DUE_DATE YYYYMMDD = DATE_PERIOD + 280 DAYS; GO TO DE001/TIME_STAMP_8; SET PPG_FIRST = 1.

• IF NO VALID DATE IS GIVEN  GO TO PS009/WEEKS_PREG.

PS009/(WEEKS_PREG). How many weeks pregnant are you now? If you’re not sure, please make your best guess.

|___|___|

NUMBER OF WEEKS

IF VALID RESPONSE PROVIDED (TIME_STAMP_8)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

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

PROGRAMMER INSTRUCTIONS:

• REJECT RESPONSES THAT ARE EITHER < 1 WEEK OR GREATER THAN 43 WEEKS.

• IF VALID RESPONSE WAS PROVIDED, CALCULATE PS006 ORIG_DUE_DATE YYYYMMDD =TODAY’S DATE + (280 DAYS – WEEKS_PREG *7); GO TO DE001/TIME_STAMP_8; SET PPG_FIRST = 1.

• IF NO VALID DATE IS CALCULABLE  GO TO PS010 MONTH_PREG.

PS010/(MONTH_PREG). How many months pregnant are you now? If you’re not sure, please make your best guess.

|___|___|

NUMBER OF MONTHS

IF VALID RESPONSE PROVIDED (TIME_STAMP_8)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

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

PROGRAMMER INSTRUCTIONS:

• REJECT RESPONSES THAT ARE EITHER < 1 MONTH OR GREATER THAN 12 MONTHS.

• IF VALID RESPONSE WAS PROVIDED, CALCULATE DUE DATE AS FROM NUMBER OF MONTHS PREGNANT WHERE ORIG_DUE_DATE. YYYYMMDD=TODAY’S DATE + (280 DAYS –((MONTH_PREG*30) -15)); GO TO DE001/TIME_STAMP_8; SET PPG_FIRST = 1.

• IF NO VALID RESPONSE IS CALCULABLE  GO TO PS011 TRIMESTER.

PS011/(TRIMESTER). Are you currently in your First, Second, or Third trimester?

1^ST TRIMESTER (1-3 MONTHS PREGNANT) 1 (TIME_STAMP_8)

2^ND TRIMESTER (4-6 MONTHS PREGNANT) 2 (TIME_STAMP_8)

3^RD TRIMESTER (7-9 MONTHS PREGNANT) 3 (TIME_STAMP_8)

REFUSED -1 (TIME_STAMP_8)

DON’T KNOW -2 (TIME_STAMP_8)

PROGRAMMER INSTRUCTIONS:

• CALCULATE DUE DATE AS FROM REPORTED TRIMESTER:

• 1ST TRIMESTER: ORIG_DUE_DATE = TODAY’S DATE + (280 DAYS – 46 DAYS).

• 2ND TRIMESTER: ORIG_DUE_DATE = TODAY’S DATE + (280 DAYS – 140 DAYS).

• 3RD TRIMESTER: ORIG_DUE_DATE = TODAY’S DATE + (280 DAYS – 235 DAYS).

• DON’T KNOW/REFUSED: ORIG_DUE_DATE = TODAY’S DATE + (280 DAYS – 140 DAYS).

• SET ORIG_DUE_DATE = YYYYMMDD AS CALCULATED.

• SET PPG_FIRST = 1.

(TIME_STAMP_7). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

PS013/(TRYING). Are you currently trying to become pregnant?

YES 1 (TIME_STAMP_8);

SET PPG_FIRST =2

NO 2

RECENTLY LOST PREGNANCY (MISCARRIAGE OR ABORTION) 3 (TIME_STAMP_8);

SET PPG_FIRST = 3

UNABLE TO HAVE CHILDREN (HYSTERECTOMY, TUBAL LIGATION) 4

REFUSED -1

DON’T KNOW -2

PS014/(HYSTER). Do any of the following apply to you? Have you had your uterus removed, sometimes called a hysterectomy?

YES 1 (TIME_STAMP_8);

SET PPG_FIRST = 5

NO 2

REFUSED -1

DON’T KNOW -2

PS015/(OVARIES). (READ IF NECESSARY: Have you had…) both ovaries removed?

YES 1 (TIME_STAMP_8);

SET PPG_FIRST = 5

NO 2

REFUSED -1

DON’T KNOW -2

PS016/(TUBES_TIED). (READ IF NECESSARY: Have you had…) your tubes tied?

YES 1 (TIME_STAMP_8);

SET PPG_FIRST = 5

NO 2

REFUSED -1

DON’T KNOW -2

PS017/(MENOPAUSE). (READ IF NECESSARY: Have you…) stopped having your period or gone through menopause?

YES 1 (TIME_STAMP_8);

SET PPG_FIRST = 5

NO 2

REFUSED -1

DON’T KNOW -2

PS018/(MED_UNABLE). Is there any other medical reason why you believe you cannot become pregnant?

YES 1

NO 2 (TIME_STAMP_8);

SET PPG_FIRST = 4

REFUSED -1 (TIME_STAMP_8);

SET PPG_FIRST = 4

DON’T KNOW -2 (TIME_STAMP_8);

SET PPG_FIRST = 4

PS019/(MED_UNABLE_OTH).

SPECIFY ___________________

SET PPG_FIRST = 4

REFUSED -1 SET PPG_FIRST = 4

DON’T KNOW -2 SET PPG_FIRST = 4

DEMOGRAPHIC QUESTIONS

(TIME_STAMP_8). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

PROGRAMMER INSTRUCTION:

• IF PPG_FIRST = 3 ), GO TO DE001. OTHERWISE, GO TO DE002.

DE001. I’m so sorry about your loss. I have some additional questions to ask if that is okay.

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.

DE002/(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

Divorced, 4

Separated 5

Widowed, 6

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• RECORD THE RESPONDENT’S CURRENT MARITAL STATUS.

DE003/(EDUC). What is the highest degree or level of school you have completed?

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.

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 (E.g., BA, BS) 5

Post Graduate Degree (E.g.., Masters Or Doctoral) 6

REFUSED -1

DON’T KNOW -2

DE004/(EMPLOY). Last week were you working full time, part time, going to school, keeping house, or something else?

INTERVIEWER INSTRUCTION:

• PROBE AS NEEDED.

WORKING FULL TIME 1 (ETHNICITY)

WORKING PART TIME 2 (ETHNICITY)

WITH A JOB, BUT NOT AT WORK BECAUSE OF TEMPORARY ILLNESS, VACATION, STRIKE 3 (ETHNICITY)

UNEMPLOYED/LAID OFF/LOOKING FOR WORK 4 (ETHNICITY)

RETIRED 5 (ETHNICITY)

IN SCHOOL 6 (ETHNICITY)

KEEPING HOUSE 7 (ETHNICITY)

OTHER -5

REFUSED -1 (ETHNICITY)

DON’T KNOW -2 (ETHNICITY)

DE004A/(EMPLOY_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

DE005/(ETHNICITY). Do you consider yourself to be Hispanic, or Latina?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DE006/(RACE). What race do you consider yourself to be? You may select one or more.

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.

PROBE: Anything else?

SELECT ALL THAT APPLY.

White, 1

Black or African American, 2

American Indian or Alaska Native, 3

Asian, or 4

Native Hawaiian or Other Pacific Islander 5

Multi-Racial 6

SOME OTHER RACE? -5

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• CODE “OTHER” ONLY IF VOLUNTEERED.

PROGRAMMER INSTRUCTIONS:

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

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

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

DE006A/(RACE_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

DE007/(PERSON_LANG). What is the primary language spoken in your home?

ENGLISH 1 (TIME_STAMP_9)

SPANISH 2 (TIME_STAMP_9)

ARABIC 3 (TIME_STAMP_9)

CHINESE 4 (TIME_STAMP_9)

FRENCH 5 (TIME_STAMP_9)

FRENCH CREOLE 6 (TIME_STAMP_9)

GERMAN 7 (TIME_STAMP_9)

ITALIAN 8 (TIME_STAMP_9)

KOREAN 9 (TIME_STAMP_9)

POLISH 10 (TIME_STAMP_9)

RUSSIAN 11 (TIME_STAMP_9)

TAGALOG 12 (TIME_STAMP_9)

VIETNAMESE 13 (TIME_STAMP_9)

URDU 14 (TIME_STAMP_9)

PUNJABI 15 (TIME_STAMP_9)

BENGALI 16 (TIME_STAMP_9)

FARSI 17 (TIME_STAMP_9)

OTHER -5

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

DE008/(PERSON_LANG_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_9). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

DE009. 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 - 1.

DE010/(HH_MEMBERS). How many household members are supported by your total combined family income?

|___|___|

NUMBER

REFUSED -1 (INCOME)

DON’T KNOW -2 (INCOME)

PROGRAMMER INSTRUCTION:

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

DE010/(NUM_CHILD). How many of those people are children? Please include anyone under 18 years and anyone 18 years of age or older and in high school.

|___|___|

NUMBER

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• INCLUDE HARD EDIT IF RESPONSE > HH_MEMBERS.

• INCLUDE SOFT EDIT IF RESPONSE > 10.

DE011/(INCOME_4CAT). Of these income groups, which category best represents your total combined family income during the last calendar year?

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.

Less than $30,000 1 (TIME_STAMP_10)

$30,000 - $49,000 2 (TIME_STAMP_10)

$50,000 - $99,999 3 (TIME_STAMP_10)

$100,000 OR MORE 4 (TIME_STAMP_10)

REFUSED -1 (TIME_STAMP_10)

DON’T KNOW -2 (TIME_STAMP_10)

TRACING QUESTIONS

TR001/(TIME_STAMP_10). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

TR002. These next few questions will help us to contact you again in the future.

TR005/(R_PHONE_1). What is the best phone number to reach you?

ENTER PHONE NUMBER AND CONFIRM.

|___|___|___| - |___|___|___| - |___|___|___|___| (PHONE_TYPE)

RESPONDENT HAS NO TELEPHONE -7

REFUSED -1 (HOME_PHONE)

DON’T KNOW -2 (HOME_PHONE)

TR006/(PHONE_NBR_OTH). IF RESPONDENT DOES NOT HAVE A TELEPHONE NUMBER, ASK WHERE RESPONDENT RECEIVES TELEPHONE CALLS, EVEN IF SHE DOES NOT HAVE HER OWN PHONE. ASK FOR AND RECORD THAT NUMBER

ENTER PHONE NUMBER AND CONFIRM.

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

REFUSED -1 HOME_PHONE)

DON’T KNOW -2 HOME_PHONE)

TR007/(PHONE_TYPE). Is that your home, work, cell, or another phone number?

CONFIRM IF KNOWN.

HOME 1 (CELL_PHONE_1)

WORK 2 (HOME_PHONE)

CELL 3 (HOME_PHONE)

FRIEND/RELATIVE 4 (HOME_PHONE)

OTHER -5

REFUSED -1 (HOME_PHONE)

DON’T KNOW -2 (HOME_PHONE)

TR008/(PHONE_TYPE_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

TR009/(HOME_PHONE). What is your home phone number?

ENTER PHONE NUMBER AND CONFIRM.

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

NO HOME NUMBER -7

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• IF PHONE_TYPE = CELL, THEN GO TO CELL_PHONE_2 AND DO NOT ASK CELL_PHONE_1.

TR105/(CELL_PHONE_1). Do you have a personal cell phone?

YES 1

NO 2 (SAME_ADDR)

REFUSED -1 (SAME_ADDR)

DON’T KNOW -2 (SAME_ADDR)

TR106/(CELL_PHONE_2). May we use your personal cell phone to make future study appointments or for appointment reminders?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

TR107/(CELL_PHONE_3). Do you send and receive text messages on your personal cell phone?

YES 1

NO 2 (CELL_PHONE)

REFUSED -1 (CELL_PHONE)

DON’T KNOW -2 (CELL_PHONE)

TR108/(CELL_PHONE_4). May we send text messages to make future study appointments or for appointment reminders?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

TR109/(CELL_PHONE). What is your personal cell phone number?

PROGRAMMER INSTRUCTION:

• IF PHONE_TYPE = 3, THEN SKIP CELL_PHONE AND GO TO SAME_ADDR.

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

PHONE NUMBER

REFUSED -1

DON’T KNOW -2

TR010/(SAME_ADDR). Is your mailing address the same as your street address?

YES (HAVE_EMAIL)

NO 2

REFUSED -1

DON’T KNOW -2

TR011/(MAILING ADDRESS VARIABLES). What is your mailing address?

INTERVIEWER INSTRUCTION:

• PROMPT AS NECESSARY TO COMPLETE INFORMATION.

_____________________________________________________

(MAIL_ADDRESS_1) ADDRESS 1 - STREET/PO BOX

_____________________________________________________

(MAIL_ADDRESS_2) ADDRESS 2

_____________________________________________________

(MAIL_UNIT) UNIT

____________________________________________________

(MAIL_CITY) CITY

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

STATE ZIP CODE ZIP+4

(MAIL_STATE) (MAIL_ZIP) (MAIL_ZIP4)

REFUSED -1

DON’T KNOW -2

TR012/(HAVE_EMAIL). Do you have an email address?

YES 1

NO 2 (PLAN_MOVE)

REFUSED -1 (PLAN_MOVE)

DON’T KNOW -2 (PLAN_MOVE)

TR013/(EMAIL). What is the best email address to reach you?

PROGRAMMER INSTRUCTION:

• SHOW EXAMPLE OF VALID EMAIL ADDRESS SUCH AS [email protected].

ENTER E-MAIL ADDRESS: ___________________________________

REFUSED -1 (PLAN_MOVE)

DON’T KNOW -2 (PLAN_MOVE)

TR014/(EMAIL_TYPE). Is that your personal e-mail, work e-mail, or a family or shared e-mail address?

PERSONAL 1 (PLAN_MOVE)

WORK 2 (PLAN_MOVE)

FAMILY/SHARED 3

REFUSED -1 (PLAN_MOVE)

DON’T KNOW -2 (PLAN_MOVE)

TR015/(EMAIL_SHARE).

PROGRAMMER INSTRUCTION:

• IF RESPONDENT REPORTED A SHARED EMAIL ADDRESS IN EMAIL_TYPE, SET EMAIL_SHARE AS APPROPRIATE THEN GO TO PLAN_MOVE.

YES 1

NO 2

TR016/(PLAN_MOVE). Do you plan on moving from your present address in the next few months?

YES 1

NO 2 (TIME_STAMP_11)

REFUSED -1 (TIME_STAMP_11)

DON’T KNOW -2 (TIME_STAMP_11)

TR017/(WHERE_MOVE). Do you know where you will be moving?

YES 1

NO 1 (WHEN_MOVE)

REFUSED -1 (WHEN_MOVE)

DON’T KNOW -2 (WHEN_MOVE)

TR018/(MOVE_INFO). What is the address of your new home?

ADDRESS KNOWN 1

OUT OF THE COUNTRY 2 (WHEN_MOVE)

PO BOX ADDRESS ONLY 3

REFUSED -1 (WHEN_MOVE)

DON’T KNOW -2 (WHEN_MOVE)

TR019/(NEW ADDRESS VARIABLES). ENTER ADDRESS

INTERVIEWER INSTRUCITON:

• PROBE AND ENTER AS MUCH INFORMATION AS R KNOWS.

_____________________________________________________

(NEW_ADDRESS_1) ADDRESS 1 - STREET/PO BOX

_____________________________________________________

(NEW_ADDRESS_2) ADDRESS 2

_____________________________________________________

(NEW_UNIT) UNIT

____________________________________________________

(NEW_CITY) CITY

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

STATE ZIP CODE ZIP+4

(NEW_STATE) (NEW_ZIP) (NEW_ZIP4)

REFUSED -1

DON’T KNOW -2

TR020/(WHEN_MOVE). Do you know when you will be moving?

YES 1

NO 2 (TIME_STAMP_11)

REFUSED -1 (TIME_STAMP_11)

DON’T KNOW -2 (TIME_STAMP_11)

TR021/(DATE_MOVE). When will you move?

MONTH: |___|___|

M M

YEAR: |___|___|___|___|

Y Y Y Y

PROGRAMMER INSTRUCTION:

• FORMAT DATE_MOVE AS YYYYMM.

REFUSED -1

DON’T KNOW -2

CLOSING STATEMENTS

(TIME_STAMP_10). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

PROGRAMMER INSTRUCTION:

• IF DU_ELIG_CONFIRM = 3 UNKNOWN AND NEW INFORMATION IS RECORDED IN MAILING ADDRESS VARIABLES OR NEW ADDRESS VARIABLES UPDATE DU_ELIG_CONFIRM TO REFLECT THIS INFORMATION.

CS001/(PPG_FIRST).

• PROGRAMMER INSTRUCTION:

• DISPLAY APPROPRIATE PPG_FIRST ASSIGNMENT FOR RESPONDENT AS PREVIOUSLY SET; THEN GO TO TIME_STAMP_11.

PREGNANT AND ELIGIBLE 1

HIGH PROBABILITY –TRYING TO CONCEIVE 2 (CS004)

HIGH PROBABILITY – RECENT PREGNANCY LOSS 3 (CS005)

OTHER PROBABILITY – NOT PREGNANT AND NOT TRYING 4 (CS006)

UNABLE TO CONCEIVE, AGE-INELIGIBLE 5 (CS007)

INELIGIBLE DWELLING UNIT 6 (CS008)

CS003. Thank you for taking the time to answer these questions. You are able to be part of this important study. I would like to tell you more about it and give you all the information you need to decide if you would like to be part of the study.

CS004. Thank you for taking the time to answer these questions. You are able to be part of this important study because you are currently trying to become pregnant. I would like to tell you more about it and give you all the information you need to decide if you would like to be part of the study. (PARTNER_TRYING).

CS005. [I’m so sorry to hear that you’ve lost your baby. I know this can be a hard time.] 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. (PARTNER_TRYING)

CS006. 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. (TIME_STAMP_11)

CS007. Thank you for taking the time to answer these questions. Based on what you’ve told me, we will not ask you to take part in the study. Because your address is in the study area, we may be back in touch at a later time to update your household information. (TIME_STAMP_11)

CS008. Thank you for taking the time to answer these questions. Based on what you’ve told me, we will not ask you to take part in the study. Thank you for your time. (TIME_STAMP_11)

CS009/(BIO_FATHER_HOME). Does the biological father live with you?

YES 1 (FATHER_AVAIL)

NO 2 (BIOFATHER_RAISE)

REFUSED -1 (BIOFATHER_RAISE)

DON’T KNOW -2 (BIOFATHER_RAISE)

CS010/(PARTNER_TRYING). Since you say you are currently trying to become pregnant, do you have a {husband/partner} with whom you are trying to become a parent?

PROGRAMMER INSTRUCTION:

• IF MARISTAT = 1, DISPLAY “husband.”

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CS010B/(BIOFATHER_RAISE). {If you become pregnant, will/Will} the biological father be living close by and participating in the care and raising of this child?

PROGRAMMER INSTRUCTION:

• IF PARTNER_TRYING ≠‘YES’, INCLUDE “If you become pregnant, will” in question text

• OTHERWISE DISPLAY “Will.”

Yes 1 (FATHER_AVAIL)

No 2

REFUSED -1

DON’T KNOW -2

CS010C/(SOCFATHER_RAISE). {If you become pregnant, do/Do} you have a partner or significant other who will be participating in the care and raising of this child?

PROGRAMMER INSTRUCTIONS:

• IF PARTNER_TRYING ≠ ‘YES’, INCLUDE “If you become pregnant, do” in question text

• OTHERWISE DISPLAY “Do.”

Yes 1

No 2 (TIME_STAMP_11)

REFUSED -1 (TIME_STAMP_11)

DON’T KNOW -2 (TIME_STAMP_11)

CS011/(FATHER_AVAIL). We would like to invite your {husband/partner/significant other} to participate in the next interview. Will {he/your husband/your partner/your significant other} be available and willing to talk to us when we return to further discuss the National Children’s Study with you?

Yes 1 (TIME_STAMP_11)

No 2 (TIME_STAMP_11)

Refused -1 (TIME_STAMP_11)

Don’t Know -2 (TIME_STAMP_11)

PROGRAMMER INSTRUCTION:

• IF MARISTAT = 1, DISPLAY “husband.”

CONCLUSION

(TIME_STAMP_12). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

(OTHER_FEMALE). Are there any other women in your household who are age [LOCAL AGE OF MAJORITY] 49 or pregnant?”

PROGRAMMER INSTRUCTION:

• PRELOAD LOCAL AGE OF MAJORITY.

YES 1 (FEMALE_1)

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• IF OTHER_FEMALE = YES; LOOP BACK TO FEMALE_1 AND ATTEMPT TO COMPLETE ANOTHER PREGNANCY SCREENER WITH OTHER HOUSEHOLD MEMBER. REPEAT FOR EACH ELIGIBLE FEMALE.

(FEMALE_END_1). Thank you again for your time.

FINAL INTERVIEWER-COMPLETED QUESTIONS

(TIME_STAMP_13). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

IC002/(ENGLISH). WAS THIS DATA COLLECTION SESSION CONDUCTED IN ENGLISH?

YES 1 (INTERPRET)

NO 2

IC003/(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

IC004/(CONTACT_LANG_OTH).

SPECIFY _____________________________

IC005/(INTERPRET). WAS AN INTERPRETER USED?

YES 1

NO 2 (TIME_STAMP_14)

IC006/(CONTACT_INTERPRET). WHAT TYPE OF INTERPRETER WAS USED?

BILINGUAL INTERVIEWER 1 (TIME_STAMP_14)

IN-PERSON PROFESSIONAL INTERPRETER 2 (TIME_STAMP_14)

IN-PERSON FAMILY MEMBER INTERPRETER 3 (TIME_STAMP_14)

LANGUAGE-LINE INTERPRETER 4 (TIME_STAMP_14)

VIDEO INTERPRETER 5 (TIME_STAMP_14)

SIGN LANGUAGE INTERPRETER 6 (TIME_STAMP_14)

OTHER -5

FI007/(CONTACT_INTERPRET_OTH).

SPECIFY _____________________________

(TIME_STAMP_14). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

PROGRAMMER INSTRUCTION:

• IF DU_ELIG_CONFIRM = 3 UNKNOWN AND NEW INFORMATION IS RECORDED IN MAILING ADDRESS VARIABLES OR NEW ADDRESS VARIABLES UPDATE DU_ELIG_CONFIRM TO REFLECT THIS INFORMATION.

PROGRAMMER INSTRUCTION:

• ATTEMPT TO ENROLL WOMEN WHO ARE PREGNANT OR TRYING TO BECOME PREGNANT, AND MEET AGE AND RESIDENCE ELIGIBILITY REQUIREMENTS.

IF PPG_FIRST = 1 AND AGE_ELIG = 1 OR 3 AND DU_ELIG_CONFIRM = 1

OR

IF PPG_FIRST = 2 AND AGE_ELIG = 1 AND DU_ELIG_CONFIRM = 1

 GO TO WOMEN’S INFORMED PERMISSION

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.