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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. Regarding this pregnancy, were you trying to become pregnant?
1  Yes
2  No → Go to Question 3
    2. For about how many months were you trying to become pregnant? 
 (If less than 1 month, enter 01.)
    3. 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. 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? 

First Name:



Last Name:




    6. Is the father of your baby living in the same household as you? 
1  Yes
2  No
    7. Is the father aware of your pregnancy? 
1  Yes
2  No → Go to Question 9
    8. 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. 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.

    10. What is the father’s home address?
Street Address


Apartment/Unit Number


City


State


Zip Code





+



















    11. What is the father’s telephone number? 
()--
    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.

    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
    14. Including this pregnancy, how many times total have you been pregnant? 
Times
    15. How old were you when you became pregnant for the first time? 
 Years → Go to Question 17
    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
    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
    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.

    19. In the 3 months before you knew you were pregnant, did you smoke any cigarettes? 
1  Yes
2  No → Go to Question 22
    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
    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
    22. Currently, do you smoke cigarettes? 
1  Yes
2  No → Go to Question 25
    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
    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
    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
    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
    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
    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.
    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
    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?

    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
    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
    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
    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
    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
    36. How important was… Feeling part of my community? 
1  Not at all important
2  Somewhat important
3  Very important
    37. How important was… Knowing other women in the study? 
1  Not at all important
2  Somewhat important
3  Very important
    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
    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
    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?

    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
    42. Other family members
1  Very Negative
2  Somewhat Negative
3  Neither Positive or Negative
4  Somewhat Positive
5  Very Positive
6  Not Applicable
    43. Your friends
1  Very Negative
2  Somewhat Negative
3  Neither Positive or Negative
4  Somewhat Positive
5  Very Positive
6  Not Applicable
    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
    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
    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
    47. Did you think the interview was
1  Too short
2  Too long, or
3  Just about right?
    48. Do you think the interview was
1  Not at all stressful
2  A little stressful
3  Somewhat stressful, or
4  Very stressful?
    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.





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