8.2 Survey

OMB #: 0925-0593

OMB Expiration Date: 08/31/2014

Pregnancy Visit 1 SAQ, Phase 2f

Pregnancy Visit 1 SAQ Specification

Event:	Pregnancy Visit 1
Participant: Respondent:	Pregnant Woman Pregnant Woman
Domain:	Questionnaire
Type of Document:	Specification
Allowable Mode:	In-person (PAPI)*
Allowable Method:	Self-Administered
Recruitment Groups:	EH, PB, HI, PBS
Version:	x.x
Release:	MDES 3.x

*This instrument is being submitted for OMB-approval for In-person PAPI at this time.

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Thank you for agreeing to participate in this study. This self-administered questionnaire will take about 10 minutes to complete. There are questions about your current pregnancy and your lifestyle. We will also ask you about your satisfaction with our visit with you today.

Your answers are important to us. There are no right or wrong answers. You can always refuse to answer any question or group of questions, and your answers will be kept confidential.

1. 

   PLANNED

   Regarding this pregnancy, were you trying to become pregnant?

1  Yes

2  No → Go to Question 3

2. 

   MONTH_TRY

   For about how many months were you trying to become pregnant?

 (If less than 1 month, enter 01.)

3. 

   WANTED

   When you became pregnant, did you yourself actually want to have a baby at some time?

1  Yes

2  No → Go to Question 5

4. 

   TIMING

   Would you say you became pregnant too soon, at about the right time, or later than you wanted?

1  Too soon

2  Right time

3  Later

4  Didn’t Care

5. Part of the National Children’s Study includes a planned study visit with the baby’s father. What is the first and last name of your baby’s father?

F_F_NAME First Name:
F_L_NAME Last Name:

FATHER_SAME_HH

6. Is the father of your baby living in the same household as you?

1  Yes

2  No

7. 

   FATHER_KNOW_PREG

   Is the father aware of your pregnancy?

1  Yes

2  No → Go to Question 9

8. 

   CONTACT_F_NOW

   May we have your permission to contact the father and invite him to participate in the Study?

1  Yes

2  No

If the father of your baby is not living in the same household and you give us permission to contact him, go to Question 10.

If the father of your baby is living in the same household and you give us permission to contact him, go to Question 11.

If you do not want us to contact the father of your baby, go to Question 13.

9. 

   CONTACT_F_LATER

   Once you have shared the information about your pregnancy with the father, may we have your permission to contact him and invite him to participate in the Study?

1  Yes

2  No → Go to Question 13

The next time we follow up with you, we will ask if you have shared the information about your pregnancy with the father so that we know if it is the right time to contact him.

F_ADDR

10. What is the father’s home address?

Street Address

F_ADDR1_2, F_ADDR2_2

F_UNIT_2 Apartment/Unit Number

F_CITY_2 City

F_STATE_2 State

Zip Code

+

F_ZIPCODE_2

F_ZIP4_2

F_PHONE

11. What is the father’s telephone number?

()--

F_AGE

12. What is the father’s age?

 Years

If this is your first pregnancy that is being followed by the study, go to Question 13.

If this is not your first pregnancy that is being followed by the study, go to Questions 16.

These next questions are about any previous pregnancies you may have had.

PAST_PREG

13. Before this pregnancy, have you ever been pregnant? Please include live births, miscarriages, stillbirths, ectopic pregnancies, abortions and pregnancy terminations.

1  Yes

2  No → Go to Question 19

NUM_PREG

14. Including this pregnancy, how many times total have you been pregnant?

Times

AGE_FIRST

15. How old were you when you became pregnant for the first time?

 Years → Go to Question 17

NUM_PREG_SUBPREG

16. Including this pregnancy, how many times total have you been pregnant? Please include live births, miscarriages, stillbirths, ectopic pregnancies, abortions and pregnancy terminations.

Times

PREMATURE

17. Did any of your previous pregnancies end in the birth of a child more than 3 weeks early, before his or her due date?

1  Yes

2  No

MISCARRY

18. Did any of your previous pregnancies end in a miscarriage or stillbirth?

1  Yes

2  No

The next questions are about your use of cigarettes and alcohol just before your current pregnancy.

CIG_PAST

19. In the 3 months before you knew you were pregnant, did you smoke any cigarettes?

1  Yes

2  No → Go to Question 22

CIG_PAST_FREQ

20. Did you smoke cigarettes:

1  Every day

2  5 or 6 days a week

3  2-4 days a week

4  Once a week

5  1-3 days a month

6  Less than once a month

CIG_PAST_NUM

21. On days that you smoked, how many cigarettes did you smoke per day? If you smoked 1 cigarette or less each day, please enter “01.”

 Number per day

CIG_NOW

22. Currently, do you smoke cigarettes?

1  Yes

2  No → Go to Question 25

CIG_NOW_FREQ

23. Do you smoke cigarettes:

1  Every day

2  5 or 6 days a week

3  2-4 days a week

4  Once a week

5  1-3 days a month

6  Less than once a month

CIG_NOW_NUM

24. On days that you smoke, how many cigarettes do you smoke per day? If you smoke 1 cigarette or less each day, please enter “01.”

 Number per day

DRINK_PAST

25. In the 3 months before you knew you were pregnant, how often did you drink alcoholic beverages including wine, beer, drinks containing hard liquor, wine coolers, hard lemonade, or hard cider?

1  5 or more times a week

2  2-4 times a week

3  Once a week

4  1-3 times a month

5  Less than once a month

6  Never →Go to Question 28

DRINK_PAST_NUM

26. In the 3 months before you knew you were pregnant, on days that you drank alcoholic beverages, how many did you have per day? If you had one drink or less, please enter “01.”

 Number of drinks

DRINK_PAST_5

27. In the 3 months before you knew you were pregnant, how often did you have 5 or more drinks within a couple of hours?

1  Never

2  About once a month

3  About once a week

4  About once a day

DRINK_NOW

28. How often do you currently drink alcoholic beverages?

1  5 or more times a week

2  2-4 times a week

3  Once a week

4  1-3 times a month

5  Less than once a month

6  Never →Go to the Evaluation Questions immediately following Question 30.

DRINK_NOW_NUM

29. Currently, on days that you drink alcoholic beverages, how many did you have per day? If you have one drink or less, please enter “01.”

 Number of drinks

DRINK_NOW_5

30. Currently, how often do you have 5 or more drinks within a couple of hours:

1  Never

2  About once a month

3  About once a week

4  About once a day

EVALUATION QUESTIONS

We would now like to take a few minutes to ask some questions about your experience in the study. There are no right or wrong answers. You can always refuse to answer any question or group of questions, and your answers will be kept confidential.

How important was each of the following in your decision to take part in the National Children’s Study?

LEARN

31. How important was… Learning more about my health or the health of my child?

1  Not at all important

2  Somewhat important

3  Very important

HELP

32. How important was… Feeling as if I can help children now and in the future?

1  Not at all important

2  Somewhat important

3  Very important

INCENT

33. How important was… Receiving money or gifts for taking part in the study?

1  Not at all important

2  Somewhat important

3  Very important

RESEARCH

34. How important was… Helping doctors and researchers learn more about children and their health?

1  Not at all important

2  Somewhat important

3  Very important

ENVIR

35. How important was… Helping researchers learn how the environment may affect children’s health?

1  Not at all important

2  Somewhat important

3  Very important

COMMUNITY

36. How important was… Feeling part of my community?

1  Not at all important

2  Somewhat important

3  Very important

KNOW_OTHERS

37. How important was… Knowing other women in the study?

1  Not at all important

2  Somewhat important

3  Very important

FAMILY

38. How important was… Having family members or friends support my choice to take part in the study?

1  Not at all important

2  Somewhat important

3  Very important

DOCTOR

39. How important was… Having my doctor or health care provider support my choice to take part in the study?

1  Not at all important

2  Somewhat important

3  Very important

STAFF

40. How important was… Feeling comfortable with the study staff who come to my home?

1  Not at all important

2  Somewhat important

3  Very important

How negative or positive do each of the following people feel about you taking part in the National Children’s Study?

OPIN_SPOUSE

41. Your spouse or partner?

1  Very Negative

2  Somewhat Negative

3  Neither Positive or Negative

4  Somewhat Positive

5  Very Positive

6  Not Applicable

OPIN_FAMILY

42. Other family members

1  Very Negative

2  Somewhat Negative

3  Neither Positive or Negative

4  Somewhat Positive

5  Very Positive

6  Not Applicable

OPIN_FRIEND

43. Your friends

1  Very Negative

2  Somewhat Negative

3  Neither Positive or Negative

4  Somewhat Positive

5  Very Positive

6  Not Applicable

OPIN_DR

44. Your doctor or health care provider

1  Very Negative

2  Somewhat Negative

3  Neither Positive or Negative

4  Somewhat Positive

5  Very Positive

6  Not Applicable

EXPERIENCE

45. In general, has your experience with the National Children’s Study been…

1  Mostly Negative

2  Somewhat Negative

3  Neither Positive or Negative

4  Somewhat Positive

5  Mostly Positive

6  Not Applicable

IMPROVE

46. In your opinion, how much do you think the National Children’s Study will help improve the health of children now and in the future?

1  Not at all

2  A little

3  Some

4  A lot

INT_LENGTH

47. Did you think the interview was

1  Too short

2  Too long, or

3  Just about right?

INT_STRESS

48. Do you think the interview was

1  Not at all stressful

2  A little stressful

3  Somewhat stressful, or

4  Very stressful?

INT_REPEAT

49. If you were asked, would you participate in an interview like this again?

1  Yes

2  No

Thank you for participating in the National Children’s Study and for taking the time to complete this survey.

For Office Use Only:

Click here to insert local Study Center contact information.

Click here to insert Participant ID.

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.