Form 9.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/2013

Pre-Pregnancy Interview Instrument, Phase II

Event Name(s):

Pre-Pregnancy Instrument (EH, PB, HI)

Instrument Name(s) and Versions:

Pre-Pregnancy Instrument (EH, PB, HI) – 1.1

Recruitment Groups:

Enhanced Household, Provider-Based, and High Intensity

Pre-Pregnancy Interview Instrument (EH, PB, HI)

TABLE OF CONTENTS

INTERVIEW INTRODUCTION 1

MEDICAL HISTORY 3

HEALTH INSURANCE 6

HOUSING CHARACTERISTICS 7

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS 16

FAMILY INCOME 19

TRACING QUESTIONS 20

Pre-Pregnancy Interview Instrument (EH, PB, HI)

CAPI

INTERVIEW INTRODUCTION

(TIME_STAMP_1). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IN001. Thank you for agreeing to participate in the National Children’s Study. This interview will take about 20 minutes to complete. Your answers are important to us. There are no right or wrong answers, just those that help us understand your situation. During this interview, we will ask about yourself, your health, where you live, and your feelings about being a part of the National Children’s Study. You can skip over any questions or stop the interview at any time. We will keep everything that you tell us confidential.

First, we’d like to make sure we have your correct name and birth date.

IN002/(NAME_CONFIRM). Is your name [INSERT PARTICIPANT NAME]?

YES 1 (DOB_CONFIRM)

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• INSERT NAME OF PARTICIPANT IF KNOWN].

IN002A/(R_FNAME) (R_LNAME). What is your full name?

_____________________ _____________________

FIRST NAME LAST NAME

(R_FNAME) (R_LNAME)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTIONS:

• IF PARTICIPANT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS, ASK FOR INITIALS OR SOME OTHER NAME SHE WOULD LIKE TO BE CALLED

• CONFIRM SPELLING OF FIRST NAME IF NOT PREVIOUSLY COLLECTED AND OF LAST NAME FOR ALL PARTICIPANTS.

IN003/(DOB_CONFIRM). Is your birth date [INSERT PARTICIPANT’S DATE OF BIRTH AS MM/DD/YYYY]?

YES 1 (AGE_ELIG)

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• PRELOAD PARTICIPANT’S DOB IF KNOWN

• IF RESPONSE = 1, SET PERSON_DOB TO KNOWN VALUE

INTERVIEWER INSTRUCTIONS:

• IF PARTICIPANT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB IS REQUIRED TO DETERMINE ELIGIBILITY

IN003A/(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

INTERVIEWER INSTRUCTION:

• IF PARTICIPANT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB IS REQUIRED TO DETERMINE ELIGIBILITY

• 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 INSTRUCTION:

• INCLUDE A SOFT EDIT/WARNING IF CALCULATED AGE IS LESS THAN LOCAL AGE OF MAJORITY OR GREATER THAN 50

• FORMAT PERSON_DOB AS YYYYMMDD

IN004/(AGE_ELIG).

PROGRAMMER INSTRUCTION: 

• BASED ON DOB_CONFIRM OR PERSON_DOB CALCULATE AGEUSING 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.

PARTICIPANT IS AGE-ELIGIBLE 1 (TIME_STAMP_2)

PARTICIPANT IS YOUNGER THAN
AGE OF MAJORITY 2 (TIME_STAMP_12)

PARTICIPANT IS OVER AGE 49 3 (TIME_STAMP_12)

AGE ELIGIBILITY IS UNKNOWN 4 (TIME_STAMP_2)

• IF VALUE IS “REFUSED” OR “DON’T KNOW” FLAG CASE FOR SUPERVISOR REVIEW AT SC TO CONFIRM AGE ELIGIBILITY POST-INTERVIEW.

MEDICAL HISTORY

(TIME_STAMP_2). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

MD001. Next, I have some general questions about your health and health care.

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

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

REFUSED -1

DON’T KNOW -2

MD003/(EVER_PREG). Have you ever been pregnant? Please include live births, miscarriages, stillbirths, ectopic pregnancies, and pregnancy terminations.

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD004. The next questions are about medical conditions or health problems you might have now or may have had in the past.

MD005/(ASTHMA). Have you ever been told by a doctor or other health care provider that you had asthma?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD006/(HIGHBP). (Have you ever been told by a doctor or other health care provider that you had)…

Hypertension or high blood pressure {when you’re not pregnant}?

INTERVIEWER INSTRUCTION:

• RE-READ INTRODUCTORY STATEMENT AS NEEDED

PROGRAMMER INSTRUCTION:

• IF EVER_PREG = 2 DO NOT INCLUDE PHRASE “when you’re not pregnant”

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD007/(DIABETES_1). (Have you ever been told by a doctor or other health care provider that you had)…

High blood sugar or Diabetes {when you’re not pregnant}?

INTERVIEWER INSTRUCTION:

• RE-READ INTRODUCTORY STATEMENT AS NEEDED

PROGRAMMER INSTRUCTION:

• IF EVER_PREG = 2 DO NOT INCLUDE PHRASE “when you’re not pregnant”

YES 1

NO 2 THYROID_1)

REFUSED -1 (THYROID_1)

DON’T KNOW -2 (THYROID_1)

MD008/(DIABETES_2). Have you taken any medicine or received other medical treatment for diabetes in the past 12 months?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD009/(DIABETES_3). Have you ever taken insulin?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD010/(THYROID_1). (Have you ever been told by a doctor or other health care provider that you had) Hypothyroidism, that is, an under active thyroid?

YES 1

NO 2 (VITAMIN)

REFUSED -1 (VITAMIN)

DON’T KNOW -2 (VITAMIN)

MD011/(THYROID_2). Have you taken any medicine or received other medical treatment for a thyroid problem in the past 12 months?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD012/(VITAMIN). Do you currently take multivitamins, prenatal vitamins, folic acid, or folate?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD012A. This next question is about where you go for routine health care.

MD13/(HLTH_CARE). What kind of place do you usually go to when you need routine or preventive care, such as a physical examination or check-up?

Clinic or health center 1

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

Hospital emergency room 3

Hospital outpatient department 4

Some other place 5

DOESN'T GO TO ONE PLACE MOST OFTEN 6

DOESN'T GET PREVENTIVE CARE ANYWHERE 7

REFUSED -1

DON'T KNOW -2

HEALTH INSURANCE

(TIME_STAMP_3). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

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

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

YES 1

NO 2 (TIME_STAMP_4)

REFUSED -1 (TIME_STAMP_4)

DON’T KNOW -2 (TIME_STAMP_4)

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

INTERVIEWER INSTRUCTIONS:

• RE-READ INTRODUCTORY STATEMENT AS NEEDED

(Do you currently have…)

HI002A/(INS_EMPLOY). Insurance through an employer or union either through yourself or another family member?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

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

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

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

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI002D/(INS_IHS). Indian Health Service?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

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

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

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

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HOUSING CHARACTERISTICS

(TIME_STAMP_4). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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

PROGRAMMER INSTRUCTIONS:

• IF OWN_HOME WAS ASKED DURING PREGNANCY SCREENER, THEN ASK RECENT_MOVE; ELSE SKIP TO OWN_HOME]

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

YES 1

NO 2 (AGE_HOME)

REFUSED -1 (AGE_HOME)

DON’T KNOW -2 (AGE_HOME)

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

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

WEEKS 1

MONTHS 2

YEARS 3

REFUSED -1

DON’T KNOW -2

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

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 FOR ANY OTHER RESPONSES: 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 (COOLING)

OTHER -5

REFUSED -1 (COOLING)

DON’T KNOW -2 (COOLING)

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.

HC010A/ (HEAT2_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC011/(COOLING). Does your home have any type of cooling or air conditioning besides fans?

YES 1

NO 2 (TIME_STAMP_5)

REFUSED -1 (TIME_STAMP_5)

DON’T KNOW -2 (TIME_STAMP_5)

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

INTERVIEWER INSTRUCTION:

• PROBE FOR ANY OTHER RESPONSES

SELECT ALL THAT APPLY.

Window or wall air conditioners, 1

Central air conditioning, 2

Evaporative cooler (swamp cooler), or 3

NO COOLING OR AIR CONDITIONING REGULARLY USED 4 (TIME_STAMP_5)

Some other cooling system -5

REFUSED -1 (TIME_STAMP_5)

DON’T KNOW -2 (TIME_STAMP_5)

PROGRAMMER INSTRUCTIONS:

• IF COOL CODED WITH ANY COMBINATION OF VALUES 1 - 3, THEN GO TO TIME_STAMP_5.

• IF COOL CODED 4, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO TIME_STAMP_5.

• IF COOL 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 TIME_STAMP_5.

HC012A/(COOL_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_5). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

HC017. 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.

HC018/(WATER). In the past 12 months, have you seen any water damage inside your home?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HC019/(MOLD). In the past 12 months, have you seen any mold or mildew on walls or other surfaces other than the shower or bathtub, inside your home?

YES 1

NO 2 (TIME_STAMP_6)

REFUSED -1 (TIME_STAMP_6)

DON’T KNOW -2 (TIME_STAMP_6)

HC020/(ROOM_MOLD). In which rooms have you seen the mold or mildew?

INTERVIEWER INSTRUCTION:

• PROBE FOR ANY OTHER RESPONSES: 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 (TIME_STAMP_6)

DON’T KNOW -2 (TIME_STAMP_6)

PROGRAMMER INSTRUCTIONS:

• IF ROOM_MOLD CODED WITH ANY COMBINATION OF VALUES 1 – 7, GO TO TIME_STAMP_6.

• 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 TIME_STAMP_8.

HC020A/(ROOM_MOLD_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_6). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

HC021. The next few questions ask about any recent additions or renovations to your home.

HC022/(RENOVATE). In the past 12 months, 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 (DECORATE)

REFUSED -1 (DECORATE)

DON’T KNOW -2 (DECORATE)

HC024/(RENOVATE_ROOM). Which rooms were renovated?

INTERVIEWER INSTRUCTION:

• PROBE FOR ANY OTHER RESPONSES: 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 (DECORATE)

DON’T KNOW -2 (DECORATE)

PROGRAMMER INSTRUCTIONS:

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

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

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

HC024A/(RENOVATE_ROOM_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC025/(DECORATE). In the past 12 months, were any smaller projects done in your home, such as painting, wallpapering, refinishing floors, or installing new carpet?

YES 1

NO 2 (TIME_STAMP_7)

REFUSED -1 (TIME_STAMP_7)

DON’T KNOW -2 (TIME_STAMP_7)

HC026/(DECORATE_ROOM). In which rooms were these smaller projects done?

INTERVIEWER INSTRUCTION:

PROBE FOR ANY OTHER RESPONSES: 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 (TIME_STAMP_7)

DON’T KNOW -2 (TIME_STAMP_7)

PROGRAMMER INSTRUCTIONS:

• IF DECORATE_ROOM CODED WITH ANY COMBINATION OF VALUES 1 – 7, THEN GO TO TIME_STAMP_7.

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

• IF DECORATE_ROOM CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO TIME_STAMP_7.

HC026A/(DECORATE_ROOM_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_7). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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

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

Tap water, 1 (TIME_STAMP_8)

Filtered tap water, 2 (TIME_STAMP_8)

Bottled water, or 3 (TIME_STAMP_8)

Some other source? -5

REFUSED -1 (TIME_STAMP_8)

DON’T KNOW -2 (TIME_STAMP_8)

HC035A/(WATER_COOK_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS

(TIME_STAMP_8) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

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

HCD001A/(EDUC). What is the highest degree or level of school that you have completed?

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT.

LESS THAN A HIGH SCHOOL DIPLOMA OR GED 1

HIGH SCHOOL DIPLOMA OR GED 2

SOME COLLEGE BUT NO DEGREE 3

ASSOCIATE DEGREE 4

BACHELOR’S DEGREE (e.g., BA, BS) 5

POST GRADUATE DEGREE (e.g., Masters or Doctoral) 6

REFUSED -1

DON’T KNOW -2

HCD001B/(WORKING). Are you currently working at any full or part time jobs?

YES 1

NO 2 (TIME_STAMP_9)

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

HCD002a/(HOURS). . Approximately how many hours each week are you working?

|___|___|___|

NUMBER OF HOURS

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: INCLUDE A SOFT EDIT IF RESPONSE > 60

HCD002b/(SHIFT_WORK). Do you work a shift that starts after 2 pm?

YES 1

NO 2

SOMETIMES 3

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_9) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

HCD004. The next questions may be similar to those asked the last time we contacted you, but we are asking them again because sometimes the answers change.

HCD004A/(MARISTAT). I’d like to ask about your marital status. Are you:

INTERVIEWER INSTRUCTION:

• PROBE FOR CURRENT MARITAL STATUS

Married, 1

Not married but living together with a partner 2

Never been married, 3 (TIME_STAMP_10)

Divorced, 4 (TIME_STAMP_10)

Separated, or 5 (TIME_STAMP_10)

Widowed? 6 (TIME_STAMP_10)

REFUSED -1 (TIME_STAMP_10)

DON’T KNOW -2 (TIME_STAMP_10)

HCD005/(SP_EDUC). What is the highest degree or level of school that your spouse or partner has completed?

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT.

LESS THAN A HIGH SCHOOL DIPLOMA OR GED 1

HIGH SCHOOL DIPLOMA OR GED 2

SOME COLLEGE BUT NO DEGREE 3

ASSOCIATE DEGREE 4

BACHELOR’S DEGREE (e.g., BA, BS) 5

POST GRADUATE DEGREE (e.g., Masters or Doctoral) 6

REFUSED -1

DON’T KNOW -2

HCD006/(SP_ETHNICITY). Does your spouse or partner consider himself [OR HERSELF, IF VOLUNTEERED] to be Hispanic, or Latino [LATINA]?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HCD007/(SP_RACE). What race does your spouse (or partner) consider himself [OR HERSELF, IF VOLUNTEERED] to be? You may select one or more.

PROBE: Anything else?

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT. PROBE: Anything else?

SELECT ALL THAT APPLY. ONLY USE “SOME OTHER RACE” IF VOLUNTEERED.

WHITE, 1

BLACK OR AFRICAN AMERICAN, 2

AMERICAN INDIAN OR ALASKA NATIVE, 3

ASIAN, OR 4

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER? 5

SOME OTHER RACE? -5

REFUSED -1 (TIME_STAMP_10)

DON’T KNOW -2 (TIME_STAMP_10)

PROGRAMMER INSTRUCTIONS:

• IF SP_RACE CODED WITH ANY COMBINATION OF VALUES 1 – 5, THEN GO TO TIME_STAMP_10.

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

• IF SP_RACE CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO TIME_STAMP_10.

HCD007a/(SP_RACE_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

FAMILY INCOME

(TIME_STAMP_10). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

FI001. Now I’m going to ask a few questions about your income. Family income is important in analyzing the data we collect and is often used in scientific studies to compare groups of people who are similar. Please remember that all the information you provide is confidential.

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

FI010/(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

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

|___|___|

NUMBER

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• INCLUDE HARD EDIT IF RESPONSE > HH_MEMBERS

• INCLUDE SOFT EDIT IF RESPONSE > 10

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

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT.

LESS THAN $4,999 1

$5,000-$9,999 2

$10,000-$19,999 3

$20,000-$29,999 4

$30,000-$39,999 5

$40,000-$49,999 6

$50,000-$74,999 7

$75,000-$99,999 8

$100,000-$199,000 9

$200,000 OR MORE 10

REFUSED -1

DON’T KNOW -2

TRACING QUESTIONS

(TIME_STAMP_11) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TR001. The next set of questions asks about different ways we might be able to keep in touch with you. Please remember that all the information you provide is confidential and will not be provided to anyone outside the National Children’s Study.

TR101/(HAVE_EMAIL). Do you have an email address?

YES 1

NO 2 (CELL_PHONE_1)

REFUSED -1 (CELL_PHONE_1)

DON’T KNOW -2 (CELL_PHONE_1)

TR102/(EMAIL_2). May we use your personal email address to make future study appointments or send appointment reminders?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

TR103/(EMAIL_3). May we use your personal email address for questionnaires (like this one) that you can answer over the Internet?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

TR104/(EMAIL). What is the best email address to reach you?

PROGRAMMER INSTRUCTION:

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

ENTER E-MAIL ADDRESS: ___________________________________

REFUSED -1

DON’T KNOW -2

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

YES 1

NO 2 (CONTACT_1)

REFUSED -1 (CONTACT_1)

DON’T KNOW -2 (CONTACT_1)

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?

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

PHONE NUMBER

REFUSED -1

DON’T KNOW -2

TR110/(CONTACT_1). sometimes if people move or change their telephone number, we have difficulty reaching them. Could I have the name of a friend or relative not currently living with you who should know where you could be reached in case we have trouble contacting you?

YES 1

NO 2 (TIME_STAMP_12)

REFUSED -1 (TIME_STAMP_12)

DON’T KNOW -2 (TIME_STAMP_12)

TR11/(CONTACT_FNAME_1)/(CONTACT_LNAME_1). What is this person’s name?

__________________ __________________

FIRST NAME LAST NAME

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• IF PARTICIPANT DOES NOT WANT TO PROVIDE NAME OF CONTACT, ASK FOR INITIALS

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

TR112/(CONTACT_RELATE_1). What is his/her relationship to you?

MOTHER/FATHER 1 (CONTACT_ADDR_1)

BROTHER/SISTER 2 (CONTACT_ADDR_1)

AUNT/UNCLE 3 (CONTACT_ADDR_1)

GRANDPARENT 4 (CONTACT_ADDR_1)

NEIGHBOR 5 (CONTACT_ADDR_1)

FRIEND 6 (CONTACT_ADDR_1)

OTHER -5

REFUSED -1 (CONTACT_ADDR_1)

DON’T KNOW -2 (CONTACT_ADDR_1)

TR014A/(CONTACT_RELATE1_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

TR114/(CONTACT_ADDR_1). What is his/her address?

INTERVIEWER INSTRUCTIONS:

PROMPT AS NECESSARY TO COMPLETE INFORMATION

____________________________________________________

STREET (C_ADDR1_1)/(C_ADDR_2_1)/(C_UNIT_1)

____________________________________________________

CITY (C_CITY_1)

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

STATE ZIP CODE +4

(C_STATE_1) (C_ZIPCODE_1) (C_ZIP4_1)

REFUSED -1

DON’T KNOW -2

TR115/(CONTACT_PHONE_1). What is his/her telephone number?

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

PHONE NUMBER

CONTACT HAS NO TELEPHONE 1

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

TR116/(CONTACT_2). Now I’d like to collect information on a second contact who does not currently live with you. What is this person’s name?

INTERVIEWER INSTRUCTION:

CONFIRM SPELLING OF FIRST AND LAST NAMES.

______________ __________________

FIRST NAME LAST NAME

(CONTACT_FNAME_2) (CONTACT_LNAME_2)

NO SECOND CONTACT PROVIDED 1 (TIME_STAMP_12)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• IF PARTICIPANT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

TR117(CONTACT_RELATE_2). What is his/her relationship to you?

MOTHER/FATHER 1 (CONTACT_ADDR_2)

BROTHER/SISTER 2 (CONTACT_ADDR_2)

AUNT/UNCLE 3 (CONTACT_ADDR_2)

GRANDPARENT 4 (CONTACT_ADDR_2)

NEIGHBOR 5 (CONTACT_ADDR_2)

FRIEND 6 (CONTACT_ADDR_2)

OTHER -5

REFUSED -1 (CONTACT_ADDR_2)

DON’T KNOW -2 (CONTACT_ADDR_2)

TR118/(CONTACT_RELATE2_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

TR119/(CONTACT_ADDR_2). What is his/her address?

INTERVIEWER INSTRUCTIONS:

• PROMPT AS NECESSARY TO COMPLETE INFORMATION

____________________________________________________

STREET (C_ADDR1_2)/(C_ADDR_2_2)/(C_UNIT_2)

____________________________________________________

CITY (C_CITY_2)

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

STATE ZIP CODE +4

(C_STATE_2) (C_ZIPCODE_2) (C_ZIP4_2)

REFUSED -1

DON’T KNOW -2

TR120/(CONTACT_PHONE_2). what is his/her telephone number?

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

PHONE NUMBER

CONTACT HAS NO TELEPHONE 1

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

(TIME_STAMP_12). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

(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.

INTERVIEWER INSTRUCTION: explain SAQS and RETURN process

Public reporting burden for this collection of information is estimated to average 20 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.