Form 22.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/ 2013

12-Month Interview, Phase 2e

12-Month Interview

Event:	12-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, PBS
Version:	X.X
Release:	MDES 3.0

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12-Month Interview

TABLE OF CONTENTS

INTERVIEWER-COMPLETED QUESTIONS 1

CHILD DEVELOPMENT AND PARENTING 3

CHILD CARE ARRANGEMENTS 11

HEALTH CARE 13

MEDICAL CONDITIONS 19

HEALTH INSURANCE 22

PRODUCT USE 24

IN-HOME EXPOSURES 25

HEALTH BEHAVIORS 30

NEIGHBORHOOD CHARACTERISTICS 32

12-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 APPROPIRATE NAME IN “C_FNAME” THROUGHOUT THE INSTRUMENT.

• Use “the child” IN APPROPRIATE FIELDSD 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 12 MONTH INTERVIEW TODAY?

YES 1

NO 2 (CHILD_SEX)

IC005/(CHILD_NUM). HOW MANY CHILDREN IN THIS HOUSEHOLD ARE ELIGIBLE FOR THE 12-MONTH INTERVIEW TODAY?

|___|___|

NUMBER OF CHILDREN

PROGRAMMER INSTRUCTION:

• IF CHILD_NUM > 1, GO TO CHILD_QNUM AND LOOP THROUGH QUESTIONNIARE THROUGH SMOKE_HOURS FOR EACH CHILD UNTIL CHILD_NUM = CHILD_QNUM, THEN GO TO DRINK

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 FEMALE?

MALE 1

FEMALE 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• USE CHILD_SEX TO CODE {his/her} AND {he/she} FIELDS AS APPROPRIATE THROUGHOUT INSTRUMENT

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

MOTHER……………………………. 1

FATHER…………………………….. 2

OTHER………………………………. 3

PROGRAMMER INSTRUCTIONS:

• IF RESP_REL = 1 OR 2, GO TO CDP001.

• OTHERWISE, GO TO RESP_REL_OTH.

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’d like to ask about {C_FNAME/the child} and you. You may notice your child’s personality developing a bit more now that he or she is twelve months old.

CDP003/(CALM). Overall, would you describe the child as calm?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP004/(WORRIED). Worried?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP005/(SOCIAL). Sociable or outgoing?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP006/(ANGRY). Angry?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP007/(SHY). Shy or quiet?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP008/(STUBBORN). Stubborn?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP009/(HAPPY). Happy?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP010/(C_HEALTH). Would you say {C_FNAME/the child}’s health is poor, fair, good, or excellent?

POOR 1

FAIR 2

GOOD . 3

EXCELLENT 4

REFUSED -1

DON’T KNOW -2

CDP013. 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 the child

CDP016/(EYES_FOLLOW). Follow you with {his/her} eyes?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP017/(SMILE). Smile when you smile at {him/her}?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP018/(REACH_1). Try to get a toy that is out of reach?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP019/(FEED). Feed {him/herself} a cracker or cereal?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP020/(WAVE). Wave goodbye?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP021/(REACH_2). Reach for toys or food held to {him/her}?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP022/(GRAB). Grab an object like a block or rattle from you?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP023/(SWITCH_HANDS). Move a toy or block from one hand to the other?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP024/(PICKUP). Pick up a small object like a Cheerio or raisin?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP025/(HOLD). Hold two toys or blocks at a time, one in each hand?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP026/(SOUND_1). Startle or react to a sound?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP027/(SOUND_2). Turn towards a sound?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP028/(SOUND_3). Turn toward someone when they’re speaking?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP029/(SPEAK_1). Make sounds as though {he/she} is trying to speak?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP030/(SPEAK_2). Say mama or dada?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP031/(HEADUP). Keep head steady when sitting or held up?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP032/(ROLL_1). Roll over from stomach to back?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CDP033/(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

PROGRAMMER INSTRUCTIONS:

• IF RESP_REL = 1 OR 2, GO TO CDP042.

• OTHERWISE, GO TO TIME_STAMP_3.

CDP042. These next questions are about different things you may do as a parent. How often do you feel the following ways or do the following things?

INTERVIEWER INSTRUCTION:

• IF USING SHOWCARDS, REFER PARENT TO APPROPRIATE SHOWCARD FOR THE NEXT FIVE QUESTIONS.

• OTHERWISE, READ RESPONSE CATEGORIES TO PARENT.

PROGRAMMER INSTRUCTION:

• IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS. OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE.

CDP045/(TALK_ABOUT). How often do you talk a lot about {C_FNAME/the child} to friends and family?

ALL OF THE TIME 1

SOME OF THE TIME 2

RARELY 3

NEVER 4

REFUSED -1

DON’T KNOW -2

CDP050/(PICTURES). How often do you carry pictures of {C_FNAME/the child} with you wherever you go?

ALL OF THE TIME 1

SOME OF THE TIME 2

RARELY 3

NEVER 4

REFUSED -1

DON’T KNOW -2

CDP055/(THINKOF). How often do you find yourself thinking about {C_FNAME/the child}?

ALL OF THE TIME 1

SOME OF THE TIME 2

RARELY 3

NEVER 4

REFUSED -1

DON’T KNOW -2

CDP057/(HOLD_FUN). How often do you think holding and cuddling {C_FNAME/the child} is fun?

ALL OF THE TIME 1

SOME OF THE TIME 2

RARELY 3

NEVER 4

REFUSED -1

DON’T KNOW -2

CDP059/(GIVE_FUN). How often do you think it’s more fun to get {C_FNAME/the child} something new than to get yourself something new?

ALL OF THE TIME 1

SOME OF THE TIME 2

RARELY 3

NEVER 4

REFUSED -1

DON’T KNOW -2

CDP061/(READ). Do you read to or look at books with {C_FNAME/the child}?

YES 1

NO 2 (WATCH_TV)

REFUSED -1 (WATCH_TV)

DON’T KNOW -2 (WATCH_TV)

CDP062/(READ_FREQ). How often do you read or look at books with {C_FNAME/the child}?

Every day 1

5-6 days a week 2

2-4 days a week 3

Once a week or less 4

REFUSED -1

DON’T KNOW -2

CDP066/(WATCH_TV). Does {C_FNAME/the child} watch TV and/or DVDs?

YES 1

NO 2 (PLAY_FREQ)

REFUSED -1 (PLAY_FREQ)

DON’T KNOW -2 (PLAY_FREQ)

CDP068/(TV_FREQ). How often does {C_FNAME/the child} watch TV and/or DVDs?

Every day 1

5-6 days a week 2

2-4 days a week 3

Once a week or less 4

REFUSED -1

DON’T KNOW -2

CDP080/(PLAY_FREQ). How often do you play with toys with {C_FNAME/the child}?

Every day 1

5-6 days a week 2

2-4 days a week 3

Once a week or less 4

REFUSED -1

DON’T KNOW -2

CDP082/(WALKS). How often do you go for walks with {C_FNAME/the child}?

Every day 1

5-6 days a week 2

2-4 days a week 3

Once a week or less 4

REFUSED -1

DON’T KNOW -2

CHILD CARE ARRANGEMENTS

(TIME_STAMP_3) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

CC001. Next, I’d like to ask you about different types of child care {C_FNAME/the child} may receive from someone other than parents or guardians. This includes regularly scheduled care arrangements with relatives and non-relatives, and day care or early childhood programs, whether or not there is a charge or fee, but not occasional baby-sitting.

CC005/(CHILDCARE). Does {C_FNAME/the child} currently receive any regularly scheduled care from someone other than a parent or guardian, for example from relatives, friends or other non-relatives, or a child care center or program?

YES 1

NO 2 (TIME_STAMP_4)

REFUSED -1 (TIME_STAMP_4)

DON’T KNOW -2 (TIME_STAMP_4)

CC008/(FAMILY_CARE). Does {C_FNAME/the child} receive any care from relatives, for example, from grandparents, brothers or sisters, or any other relatives. This includes all regularly scheduled care arrangements with relatives that happen at least weekly, but does not include occasional baby-sitting.

YES 1

NO 2 (CC014)

REFUSED -1 (CC014)

DON’T KNOW -2 (CC014)

CC011/(FAMILY_CARE_HRS). Approximately how many total hours each week does {C_FNAME/the child} receive care from relatives?

|___|___|

NUMBER OF HOURS PER WEEK

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• INCLUDE SOFT EDIT IF RESPONSE EXCEEDS 50 HOURS PER WEEK

CC014. Now I’d like to ask you about any regularly scheduled care {C_FNAME/the child} receives from someone not related to {him/her}, either in your home or someone else’s home. This includes all regularly scheduled care arrangements with non-relatives that happen at least weekly, including home child care providers, regularly scheduled sitter arrangements, or neighbors. This does not include day care centers, early childhood programs, or occasional babysitting.

CC017/(HOMECARE). Does {C_FNAME/the child} receive any regularly scheduled care either in your home or someone else’s home from someone not related to {him/her}?

INTERVIEWER INSTRUCTION:

• IF NECESSARY READ “This includes arrangements with non-relatives including home child care providers, regularly scheduled sitter arrangements, or neighbors. This does not include day care centers, early childhood programs, or occasional babysitting.”

YES 1

NO 2 (CC023)

REFUSED -1 (CC023)

DON’T KNOW -2 (CC023)

CC020/(HOMECARE_HRS). Approximately how many total hours each week does {C_FNAME/the child} receive care in a home from non-relatives?

|___|___|

NUMBER OF HOURS PER WEEK

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• INCLUDE SOFT EDIT IF RESPONSE EXCEEDS 50 HOURS PER WEEK

CC023. Now I want to ask you about child care centers {C_FNAME/the child} may attend on a regular basis. Such centers include day care centers, early learning centers, nursery schools, and preschools.

CC026/(DAYCARE). Does {C_FNAME/the child} receive any care in child care centers? Such centers include day care centers, early learning centers, nursery schools, and preschools.

YES 1

NO 2 (TIME_STAMP_4)

REFUSED -1 (TIME_STAMP_4)

DON’T KNOW -2 (TIME_STAMP_4)

CC029/(DAYCARE_HRS). Approximately how many total hours each week does {C_FNAME/the child} receive care in child care centers?

|___|___|

NUMBER OF HOURS PER WEEK

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• INCLUDE SOFT EDIT IF RESPONSE EXCEEDS 50 HOURS PER WEEK.

Health Care

(TIME_STAMP_4) 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 (USE_IC_LOG)

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

Hospital emergency room 3 (USE_IC_LOG)

Hospital outpatient department 4 (USE_IC_LOG)

Some other place -5

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

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

REFUSED -1 (USE_IC_LOG)

DON’T KNOW -2 (USE_IC_LOG)

HL002A/(R_HCARE_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• LIMIT FREE TEXT TO 255 CHARACTERS.

• IF RESP_REL = 1, GO TO USE_IC_LOG. OTHERWISE, GO TO HL009.

HL003/(USE_IC_LOG). 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 (HL009)

DON’T KNOW -2 (HL009)

HL004/(REASON_NO_IC_LOG). Is that because…

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

You’ve misplaced the log 2 (HL005)

You’ve forgotten to bring it to the child’s medical visits 3 (HL006)

The log was too much trouble to complete, or 4 (HL006)

The log was too difficult to understand? 5 (HL009)

OTHER -5

REFUSED -1 (HL006)

DON’T KNOW -2 (HL006)

HL004A/(REASON_NO_IC_LOG_OTH).

OTHER: SPECIFY _______________________________(HL009)

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

HL005. We’ll get another Infant and Child Health Care Log in the mail to you today. (HL009)

HL006. 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. (HL009)

HL007/(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

HL008/(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

HL009. 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.

HL010/(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

HL011/(VISIT_WT). What was {C_FNAME/the child}’s weight at that visit?

|___|___|

POUNDS

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• INCLUDE A SOFT EDIT IF WEIGHT < 15 OR > 30 POUNDS.

• IF USE_IC_LOG=1, GO TO HL012.

• OTHERWISE, GO TO SAME_CARE.

HL012. 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.

HL013/(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_5)

REFUSED -1

DON’T KNOW -2

HL014/(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_5)

REFUSED -1 (HOSPITAL)

DON’T KNOW -2 (HOSPITAL)

HL014A/(HCARE_SICK_ OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• LIMIT FREE TEXT TO 255 CHARACTERS.

HL015/(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_5)

REFUSED -1 (TIME_STAMP_5)

DON’T KNOW -2 (TIME_STAMP_5)

PROGRAMMER INSTRUCTIONS:

• IF 9-MONTH INTERVIEW SET TO COMPLETE, PRELOAD 9-MONTH INTERVIEW DATE FOR DATE OF LAST INTERVIEW.

• IF 9-MONTH INTERVIEW NOT SET TO COMPLETE, PRELOAD DATE OF MOST RECENT CHILD INTERVIEW FOR DATE OF LAST INTERVIEW.

HL016/(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_5)

DON’T KNOW -2 (TIME_STAMP_5)

PROGRAMMER INSTRUCTIONS:

• IF 9-MONTH INTERVIEW SET TO COMPLETE, PRELOAD 9-MONTH INTERVIEW DATE FOR DATE OF LAST INTERVIEW.

• IF 9-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 HL021 (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_5.

HL017/(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

HL018/(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.

HL019/(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 HL021.

• OTHERWISE, GO TO TIME_STAMP_5.

HL020/(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 HL021.

• OTHERWISE, GO TO TIME_STAMP_5.

HL021. 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.

Medical Conditions

(TIME_STAMP_5) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

MC001. Now I’d like to ask about some illnesses {C_FNAME/the child} may have had in the last 3 months.

MC004/(EAR_INFECTION). In the past 3 months, has {C_FNAME/the child} had an ear infection?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC007/(GASTRO). In the past 3 months, has {C_FNAME/the child} had diarrhea or vomiting?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC010/(RESPIRATORY). In the past 3 months, has {C_FNAME/the child} had wheezing or whistling in the chest?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC013/(FEVER). In the past 3 months, on how many days has {C_FNAME/the child} had a fever over 101 degrees, not related to receiving immunizations?

INTERVIEWER INSTRUCTION:

• IF NECESSARY READ “or 38.3 degrees Celsius?”

|___|___|

NUMBER OF DAYS

INTERVIEW INSTRUCTION:

• ENTER “0” IF NONE

REFUSED -1

DON’T KNOW -2

MC014. Now I have some questions about specific conditions or health problems {C_FNAME/the child} may have.

MC016/(BLIND). Has a doctor ever told you that {C_FNAME/the child} is blind?

YES 1 (DEAF)

NO 2

REFUSED -1

DON’T KNOW -2

MC017/(EYESIGHT). Has a doctor ever told you that {C_FNAME/the child} has difficulty seeing, including nearsightedness or farsightedness?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC018/(DEAF). Has a doctor ever told you that {C_FNAME/the child} has difficulty hearing or deafness? Do not include a temporary loss of hearing due to a cold or congestion.

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC019/(BIRTH_DEFECT). Has a doctor ever told you that {C_FNAME/the child} has any congenital anomaly or birth defect such as a cleft lip or palate, heart defect, or spina bifida?

YES 1

NO 2 (GENETIC)

REFUSED -1 (GENETIC)

DON’T KNOW -2 (GENETIC)

MC020/(DEFECT_TYPE). What type of congenital anomaly or birth defect have you been told {C_FNAME/the child} has?

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

MC021/(GENETIC). Has a doctor ever told you that {C_FNAME/the child} has Down Syndrome, Turner Syndrome, or other inherited or genetic condition?

YES 1

NO 2 (FAIL_THRIVE)

REFUSED -1 (FAIL_THRIVE)

DON’T KNOW -2 (FAIL_THRIVE)

MC022/(GENETIC_TYPE). What type of condition have you been told {C_FNAME/the child} has?

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

MC023/(FAIL_THRIVE). Has a doctor ever told you that {C_FNAME/the child} has failure to thrive, or concern about proper growth?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HEALTH INSURANCE

(TIME_STAMP_6) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

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

HI004/(INSURE). Is {C_FNAME/the child} currently covered by any kind of health insurance or some other kind of health care plan?

YES 1

NO 2 (TIME_STAMP_7)

REFUSED -1 (TIME_STAMP_7)

DON’T KNOW -2 (TIME_STAMP_7)

HI007. Now I’ll read a list of different types of insurance. Please tell me which types {C_FNAME/the child} currently has. Does {C_FNAME/the child} currently have

INTERVIEWER INSTRUCTION:

• RE-READ INTRODUCTORY STATEMENT AS NEEDED

HI010/(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

HI011/(INS_MEDICAID). Medicaid or any government-assistance plan for those with low incomes or a disability?

INTERVIEWER INSTRUCTION:

• PROVIDE EXAMPLES OF LOCAL MEDICAID PROGRAMS

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI012/(INS_TRICARE). TRICARE, VA, or other military health care?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI013/(INS_IHS). Indian Health Service?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI014/(INS_MEDICARE). Medicare, for people with certain disabilities?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI015/(INS_OTH). Any other type of health insurance or health coverage plan?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• IF RESP_REL = 1, GO TO TIME_STAMP_7.

• OTHERWISE, GO TO TIME_STAMP_12.

Product Use

(TIME_STAMP_7) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PU001. The next questions ask about lice exposure and treatment.

PU008/(LICE_1). In the past 6 months, have you treated {C_FNAME/the child} or other people in your home for lice or scabies?

YES 1

NO 2 (TIME_STAMP_8)

REFUSED -1 (TIME_STAMP_8)

DON’T KNOW -2 (TIME_STAMP_8)

PU010/(LICE_2). Who did you treat, was it {C_FNAME/the child}, someone else, or both?

INTERVIEWER INSTRUCTION:

• PROBE: “Anyone else?”

{C_FNAME/the child} 1

SOMEONE ELSE 2

BOTH {C_FNAME/the child} AND SOMEONE ELSE 3

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF LICE_2 = 2 OR 3, GO TO LICE_2_OTH.

• OTHERWISE, GO TO TIME_STAMP_8.

PU013/(LICE_2_OTH).

OTHER: SPECIFY _______________________________

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

In-Home Exposures

(TIME_STAMP_8) PROGRAMMER INSTRUCTIONS:

• INSERT DATE/TIME STAMP

• IF CHILD_QNUM = 1, GO TO IHE001.

• IF CHILD_QNUM>1:

  • AND ROOM_MOLD =4 FOR FIRST LOOP, GO TO ROOM_MOLD_CHILD.

  • AND ROOM_MOLD ≠ 4 FOR FIRST LOOP, GO TO SMOKE_HOURS.

IHE001. Do you use any methods to “allergy-proof” your home? Please answer “yes” or “no” to each method I describe.

IHE004/(TANNIC_ACID). Tannic acid or other mite control chemicals?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

IHE006/(COVERS). Impermeable mattress and/or pillow covers on the child’s bed or crib?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

IHE008/(VACUUM). Use a special vacuum such as a HEPA vacuum?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

IHE010/(REMOVAL). Intentionally removed rugs or upholstered furniture?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

IHE012/(METHOD). Any other methods?

YES 1

NO 2 (AIR_FILTER)

REFUSED -1 (AIR_FILTER)

DON’T KNOW -2 (AIR_FILTER)

IHE013/(METHOD_OTH).

SPECIFY: ____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

IHE016/(AIR_FILTER). Does your furnace or air conditioning system use a special HEPA (High Efficiency Particulate Air) or other type of allergy filter to filter the air?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

IHE018/(OPEN_WINDOW). Thinking about the past 7 days, approximately how many hours a day did you keep the windows or doors open in your home (for ventilation or to let air in)? Was it

Less than 1 hour per day 1

1-3 hours per day 2

4-12 hours per day 3

More than 12 hours per day 4

Not at all 5

REFUSED -1

DON’T KNOW -2

IHE020. I would now like to ask about whether you have seen signs of rodents or seen cockroaches in your home in the last 6 months.

IHE046/(RODENT). In the last 6 months, have you seen signs of mice, rats, or other rodents in your home (not including pets)?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

IHE047/(ROACH). In the last 6 months, have you seen cockroaches in your home?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

IHE050. 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.

IHE052/(WATER). In the last 6 months, have you seen any water damage inside your home?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

IHE053/(MOLD). In the last 6 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_9)

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

IHE054/(ROOM_MOLD). In which rooms have you seen the mold or mildew?

INTERVIEWER INSTRUCTION:

• PROBE: Any other rooms?

• SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

CHILD’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF ROOM_MOLD CODED 4 OR 4 AND ANY COMBINATION OF VALUES 1 – 7, THEN GO TO ROOM_MOLD_CHILD.

• IF ROOM_MOLD CODED WITH ANY COMBINATION OF VALUES 1 – 7, NOT INCLUDING VALUE OF 4, THEN GO TO TIME_STAMP_9.

• IF ROOM_MOLD CODED -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, BUT NOT INCLUDING 4, GO TO ROOM_MOLD_OTH THEN GO TO TIME_STAMP_9.

• IF ROOM_MOLD CODED -5 AND 4, OR ANY COMBINATION OF VALUES 1 – 7 THAT INCLUDES 4, AND -5, GO TO ROOM_MOLD_OTH AND THEN ROOM_MOLD_CHILD.

• IF ROOM_MOLD CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO TIME_STAMP_9.

IHE055/(ROOM_MOLD_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• LIMIT FREE TEXT TO 255 CHARACTERS.

• LOOP THROUGH ROOM_MOLD_CHILD UNTIL CHILD_NUM = CHILD_QNUM.

• ONLY ASK ROOM_MOLD_CHILD IF ROOM_MOLD INCLUDES “4.”

• OTHERWISE, GO TO IHE055B.

IHE055A/(ROOM_MOLD_CHILD). Was the mold in {C_FNAME/the child}’s bedroom?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• IF CHILD_NUM>1, GO TO SMOKE_HOURS.

(TIME_STAMP_9) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

IHE055B. The next few questions ask about any recent additions or renovations to your home.

IHE056/(RENOVATE). In the last 6 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 re-finishing floors.

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF RENOVATE = 1, GO TO RENOVATE_ROOM.

• IF RENOVATE = 2, -1, OR -2, AND CHILD_NUM > 1, GO TO SMOKE_HOURS.

IHE057/(RENOVATE_ROOM). Which rooms were renovated?

INTERVIEWER INSTRUCTIONS:

• PROBE: Any others?

• SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

THE CHILD’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF RENOVATE_ROOM CODED WITH ANY COMBINATION OF VALUES 1 – 7, THEN GO TO TIME_STAMP_10.

• 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 TIME_STAMP_10.

IHE058/(RENOVATE_ROOM_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

Health Behaviors

(TIME_STAMP_10) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

HB004/(CIG_NOW). Do you currently smoke cigarettes or use any other tobacco product?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HB006/(NUM_SMOKER). How many smokers live in your home now, {including yourself}?

PROGRAMMER INSTRUCTION:

• DISPLAY BRACKETED TEXT IF CIG_NOW = 1

|___|___|

NUMBER OF SMOKERS

INTERVIEW INSTRUCTION:

• ENTER “0” IF NONE

REFUSED -1

DON’T KNOW -2

HB010/(SMOKE_RULES). Which of the following statements describes the rules about smoking inside your home now?

No one is allowed to smoke anywhere inside my home 1

Smoking is allowed in some rooms at some times 2

Smoking is permitted anywhere inside my home 3

REFUSED -1

DON’T KNOW -2

HB012/(SMOKE_HOURS). On average, about how many hours per day do people smoke in the same room as {C_FNAME/the child}, or near enough that {he/she} can see or smell the smoke? Please consider all the places {C_FNAME/the child} is during the day, including at home, at daycare, or some other place.

INTERVIEWER INSTRUCTION:

IF {HE/SHE} IS NOT EXPOSED TO SMOKE, ENTER “0.”

|___|___|

HOURS

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• IF CHILD_NUM > 1, GO TO CHILD_QNUM AND LOOP THROUGH QUESTIONNIARE THROUGH SMOKE_HOURS FOR EACH CHILD UNTIL CHILD_NUM = CHILD_QNUM.

• THEN GO TO DRINK

HB014/(DRINK). Do you drink any type of alcoholic beverage?

YES 1

NO 2 (TIME_STAMP_11)

REFUSED -1

DON’T KNOW -2

HB015/(DRINK_NOW). How often do you currently drink alcoholic beverages?

5 or more times a week 1

2-4 times a week 2

Once a week 3

1-3 times a month 4

Less than once a month 5

Never 6 (TIME_STAMP_11)

REFUSED -1 (TIME_STAMP_11)

DON’T KNOW -2 (TIME_STAMP_11)

HB016/(DRINK_NOW_5). How often do you have 5 or more drinks within a couple of hours:

Never 1

About once a month 2

About once a week 3

About once a day 4

REFUSED -1

DON’T KNOW -2

Neighborhood Characteristics

(TIME_STAMP_11) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

NC001. Now I’d like to ask a few questions about your neighborhood.

NC004/(NEIGH_DEFN). When you are talking to someone about your neighborhood, what do you mean? Is it

The block or street you live on 1

Several blocks or streets in each direction 2

The area within a 15 minute walk from your house 3

An area larger than a 15 minute walk from your house 4

REFUSED -1

DON’T KNOW -2

NC006/(NEIGH_FAM). How many of your relatives or in-laws live in your neighborhood? Would you say

None 1

A few 2

Many 3

Most 4

REFUSED -1

DON’T KNOW -2

NC008/(NEIGH_FRIEND). How many of your friends live in your neighborhood? Would you say

None 1

A few 2

Many 3

Most 4

REFUSED -1

DON’T KNOW -2

NC010/(NEIGHBORS). About how many adults do you recognize or know by sight in this neighborhood? Would you say you recognize

None 1

A few 2

Many 3

Most 4

REFUSED -1

DON’T KNOW -2

NC012/(NEIGH_NUM_TALK). In the past 30 days, that is since [INSERT DATE 30 DAYS AGO], how many of your neighbors have you talked with for 10 minutes or more? Would you say

None 1

1 or 2 2

3 to 5 3

6 or more 4

REFUSED -1

DON’T KNOW -2

NC014/(NEIGH_HELP). About how often do you and people in your neighborhood do favors for each other? By favors, we mean such things as watching each other’s children, helping with shopping, lending garden or house tools.

Often 1

Sometimes 2

Rarely 3

Never 4

REFUSED -1

DON’T KNOW -2

NC016/(NEIGH_TALK). How often do you and other people in your neighborhood visit in each other’s homes or speak with each other on the street?

Often 1

Sometimes 2

Rarely 3

Never 4

REFUSED -1

DON’T KNOW -2

NC018/(NEIGH_WATCH_1). If children were skipping school and hanging out, how likely is it that your neighbors would do something about it? Would you say it is

Very Likely 1

Likely 2

Unlikely 3

Very Unlikely 4

REFUSED -1

DON’T KNOW -2

NC020/(NEIGH_WATCH_2). If children were showing disrespect to an adult, how likely is it that your neighbors would do something about it? Would you say it is

Very Likely 1

Likely 2

Unlikely 3

Very Unlikely 4

REFUSED -1

DON’T KNOW -2

NC022. Please tell me if you agree or disagree with the following statements.

NC024/(NEIGH_CLOSE). This is a close-knit neighborhood. Would you say you.

Strongly agree 1

Agree 2

Disagree 3

Strongly disagree 4

REFUSED -1

DON’T KNOW -2

NC026/(NEIGH_TRUST). People in this neighborhood can be trusted. Would you say you

Strongly agree 1

Agree 2

Disagree 3

Strongly disagree 4

REFUSED -1

DON’T KNOW -2

NC028/(NEIGH_SAFE_1). I feel safe walking in my neighborhood, day or night.

Strongly agree 1

Agree 2

Disagree 3

Strongly disagree 4

REFUSED -1

DON’T KNOW -2

NC030/(NEIGH_SAFE_2). Violence is not a problem in my neighborhood.

Strongly agree 1

Agree 2

Disagree 3

Strongly disagree 4

REFUSED -1

DON’T KNOW -2

NC032/(NEIGH_SAFE_3). My neighborhood is safe from crime.

Strongly agree 1

Agree 2

Disagree 3

Strongly disagree 4

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

(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.

INTERVIEWER INSTRUCTION:

• explain SAQS and RETURN process

(TIME_STAMP_13) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 25 minutes, 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.