Form 23.1 Survey
Provider-Based Sampling Feasibility Study for the Vanguard (Pilot) Study and Data Collection Updates for the National Children's Study (NICHD)
18-Month Interview 20120413
18-Month Interview (PB, EH, TT-HI, TT-LI, PBS)
OMB: 0925-0593
OMB #: 0925-0593
OMB Expiration Date: 07/31/ 2013
18-Month Interview, Phase 2e
18-Month Interview
Event: |
18-Month
|
Respondent: |
Parent/Caregiver
|
Participant:
|
Child
|
Type of Document: |
Interview
|
Allowable Mode:
|
In Person, Telephone, Mail, Web |
Allowable Method:
|
CAPI/CATI |
Recruitment Groups: |
EH, PB, HI, LI, PBS
|
Version: |
x.x |
Release: |
MDES 3.0 |
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18-Month Interview
TABLE OF CONTENTS
18-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 APPROPRIATE NAME IN “C_FNAME” THROUGHOUT THE INSTRUMENT.
USE “the child” IN APPROPRIATE FIELDS 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 18-MONTH INTERVIEW TODAY?
YES 1
NO 2 (CHILD_SEX)
IC005/(CHILD_NUM). HOW MANY CHILDREN IN THIS HOUSEHOLD ARE ELIGIBLE FOR THE 18-MONTH INTERVIEW TODAY?
|___|___|
NUMBER OF CHILDREN
PROGRAMMER INSTRUCTIONS:
IF CHILD_NUM>1, GO TO CHILD_QNUM AND LOOP THROUGH QUESTIONAIRE FROM CHILD_QNUM THROUGH SMOKE_HOURS FOR EACH CHILD UNTIL CHILD_NUM=CHILD_QNUM. THEN GO TO PETS.
IC011/(CHILD_QNUM). WHICH NUMBER CHILD IS THIS INTERVIEW 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 INSTRUCTIONS:
IF CHILD_SEX = 1, DISPLAY “his” AND “he ”IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT
IF CHILD_SEX = 2, DISPLAY “her” AND “she” IN APPROPRIATE FIELDS 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 PROGRAMMER INSTRUCTIONS FOLLOWING RESP_REL_OTH.
OTHERWISE, GO TO RESP_REL_OTH.
IC019/(RESP_REL_OTH).
SPECIFY _____________________________
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
IF CHILD_QNUM = 1 AND RESP_REL = 1, GO TO MARISTAT.
IF CHILD_QNUM >1 AND RESP_REL = 1, GO TO SL001.
IF RESP_REL = 2, GO TO SL001.
IF RESP_REL = 3, GO TO TIME_STAMP_4.
(TIME_STAMP_2) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
DE004/(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, or 5
Widowed? 6
REFUSED -1
DON’T KNOW -2
INTERVIEWER INSTRUCTION:
RECORD THE MOTHER’S CURRENT MARITAL STATUS
DE005. Now I have a few questions about {C_FNAME/the child}’s primary household.
PROGRAMMER INSTRUCTIONS:
IF NUM_HH COMPLETED DURING PREVIOUS INTERVIEW AND VALID RESPONSE PROVIDED, PRELOAD NUM_HH AND HH_MEM_DOB FOR EACH FNAME FROM BIRTH INTERVIEW AND THEN GO TO HHCOMP_CHANGE.
OTHERWISE, GO TO NUM_HH.
DE010/(NUM_HH). How many persons are currently living in or staying in this household, not including the child?
|___|___|
NUMBER OF PERSONS
REFUSED -1 (DE095)
DON’T KNOW -2 (DE095)
DE012/(MILITARY_HH). Have any household members ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard? Active duty does not include training for the Reserves or National Guard, but does include activation, for example, for the Persian Gulf War.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
LOOP THROUGH FNAME_HH, CHILD_RELAT, CHILD_RELAT_OTH_1 (IF CHILD_RELAT = 7), CHILD_RELAT_OTH_2 (IF CHILD_RELAT = 8), HH_MEM_DOB, ACTIVE_DUTY (IF MILITARY_HH = 1 AND EITHER HH_MEM_AGE ≥ 18 YEARS OR HH_MEM_DOB = -1 OR -2), AND BRANCH_SERV (IF ACTIVE_DUTY = 1, 2 OR 3) UNTIL NUMBER OF LOOPS = NUM_HH.
THEN GO TO DE095.
DE015/(FNAME_HH). {What are the names of all the persons living or staying in this household? Start with the name of the person, or one of the persons, who owns or rents this home}/{What is the name of the next person living or staying here?}
INTERVIEWER INSTRUCTION:
CONFIRM SPELLING.
_________________________________
FIRST NAME
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF FIRST LOOP CYCLE, DISPLAY “What are the names of all the persons…”
IF SUBSEQUENT LOOP CYCLE, DISPLAY “What is the name of the next person…”
DE020/(CHILD_RELAT). How is {F_NAME} related to the child?
MOTHER 1 (HH_MEM_DOB)
FATHER 2 (HH_MEM_DOB)
GRANDMOTHER 3 (HH_MEM_DOB)
GRANDFATHER 4 (HH_MEM_DOB)
SISTER 5 (HH_MEM_DOB)
BROTHER 6 (HH_MEM_DOB)
OTHER RELATIVE 7
OTHER NON-RELATIVE 8 (CHILD_RELAT_OTH_2)
REFUSED -1 (HH_MEM_DOB)
DON’T KNOW -2 (HH_MEM_DOB)
PROGRAMMER INSTRUCTION:
DISPLAY F_NAME.
DE025/(CHILD_RELAT_OTH_1).
SPECIFY: _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
LIMIT TEXT TO 255 CHARACTERS.
GO TO HH_MEM_DOB.
DE030/(CHILD_RELAT_OTH_2).
SPECIFY: _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
DE032/(HH_MEM_DOB). What is {F_NAME}’s date of birth?
INTERVIEWER INSTRUCTIONS:
IF PARENT/CAREGIVER REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS
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.
MONTH: |___|___|
M M
D D
YEAR: |___|___|___|___|
Y Y Y Y
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
FORMAT HH_MEM_DOB AS YYYYMMDD.
DISPLAY F_NAME.
IF MILITARY_HH = 1 AND,
IF VALID RESPONSE PROVIDED FOR HH_MEM_DOB, CALCULATE DERIVED VARIABLE, HH_MEM_AGE, BASED ON HH_MEM_DOB AND DATE OF CURRENT INTERVIEW;
IF HH_MEM_AGE > 18 YEARS, GO TO ACTIVE_DUTY.
IF VALID RESPONSE NOT PROVIDED FOR HH_MEM_DOB, GO TO ACTIVE_DUTY.
OTHERWISE, COMPLETE LOOP:
IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO FNAME_HH.
IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO DE095.
DE035/(ACTIVE_DUTY). Has {F_NAME} ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard?
INTERVIEWER INSTRUCTION:
READ AS NECESSARY: [Active duty does not include training for the Reserves or National Guard, but does include activation, for example, for the Persian Gulf War.]
Yes, they are now on active duty, 1
Yes, they were on active duty during the last 6
months, but not now, 2
Yes, they were on active duty in the past, but not
during the last 6 months, 3
No, they are training for Reserves or National
Guard only, or 4
No, they never served in the military? 5
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
DISPLAY F_NAME.
IF ACTIVE_DUTY = 1, 2, OR 3, GO TO BRANCH_SERV.
OTHERWISE, IF ACTIVE_DUTY = 4, 5, -1, OR -2, COMPLETE LOOP:
IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO FNAME_HH.
IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO DE095.
DE040/(BRANCH_SERV). What {is/was} his or her branch of service?
Air Force, 1
Army, 2
Marine Corps, 3
Navy, or 4
Coast Guard? 5
NOT IN U.S. ARMED FORCES -7
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF ACTIVE_DUTY = 1, DISPLAY “is”.
IF ACTIVE_DUTY = 2 OR 3, DISPLAY “was”.
IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO FNAME_HH TO BEGIN NEXT LOOP.
IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO DE095.
DE045/(HHCOMP_CHANGE). Have there been any changes in your household members since {C_FNAME/the child} was born?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
DE046/(HHCOMP_CHANGE_MIL). Have there been any changes in military status of any household members since {C_FNAME/the child} was born? This includes joining or leaving the military.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF HHCOMP_CHANGE = 2, -1 OR -2, AND HHCOMP_CHANGE_MIL =1, LOOP THROUGH HH_MIL_CHANGE_ROSTER, ACTIVE_DUTY_CHANGE, AND BRANCH_SERV_CHANGE (IF ACTIVE_DUTY_CHANGE = 1, 2, OR 3) FOR EACH F_NAME UNTIL NUMBER OF LOOPS = NUM_HH.
IF HH_COMP_CHANGE = 1 AND HHCOMP_CHANGE_MIL = 2, -1, OR -2, LOOP THROUGH HH_CHANGE_ROSTER FOR EACH F_NAME.
IF HH_COMP_CHANGE = 1 AND HHCOMP_CHANGE_MIL = 1, LOOP THROUGH HH_CHANGE_ROSTER, ACTIVE_DUTY_CHANGE, AND BRANCH_SERV_CHANGE (IF ACTIVE_DUTY_CHANGE = 1, 2, OR 3) FOR EACH F_NAME UNTIL NUMBER OF LOOPS = NUM_HH.
OTHERWISE, IF HHCOMP_CHANGE= 2, -1, OR -2, AND HHCOMP_CHANGE_MIL =2, -1, OR -2, GO TO DE095.
DE050/(HH_CHANGE_ROSTER). We have listed that [READ NAMES FROM MATRIX] lived in this household when {C_FNAME/the child} was born. As I read each person's name again, please tell me whether he or she still lives in this household.
Does {F_NAME} still live in this household?
INTERVIEWER INSTRUCTION:
REMOVE HH MEMBERS.
_________________________________
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
PRELOAD F_NAME.
LIMIT TEXT TO 255 CHARACTERS.
DISPLAY MATRIX PRELOADED WITH FIRST NAMES OF HH MEMBERS AND
LOOP THROUGH EACH NAME LISTED ON MATRIX IF HHCOMP_CHANGE_MIL = 1 AND,
IF HH_MEM_DOB COLLECTED DURING PREVIOUS INTERVIEW AND VALID RESPONSE PROVIDED, CALCULATE DERIVED VARIABLE, HH_MEM_AGE, BASED ON HH_MEM_DOB AND DATE OF CURRENT INTERVIEW;
IF HH_MEM_AGE > 18 YEARS, GO TO ACTIVE_DUTY_CHANGE AND LOOP THROUGH BRANCH_SERVICE_CHANGE (IF ACTIVE_DUTY_CHANGE = 1, 2 OR 3), THEN RETURN TO HH_CHANGE_ROSTER
IF HH_MEM_DOB NOT COLLECTED DURING PREVIOUS INTERVIEW OR VALID RESPONSE NOT PROVIDED, GO TO ACTIVE_DUTY_CHANGE AND LOOP THROUGH BRANCH_SERVICE_CHANGE (IF ACTIVE_DUTY_CHANGE = 1, 2 OR 3), THEN RETURN TO HH_CHANGE_ROSTER
WHEN NUMBER OF LOOPS = NUM_HH, GO TO OTHER_CHANGE_ROSTER.
DE052/(HH_MIL_CHANGE_ROSTER). As I read each household member's name, please tell me whether he or she has had a change in military status. Has {F_NAME} had a change in military status?
INTERVIEWER INSTRUCTIONS:
READ NAMES FROM MATRIX.
SELECT THE APPROPRIATE RESPONSE FOR EACH HOUSEHOLD MEMBER.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
PRELOAD F_NAME.
LIMIT TEXT TO 255 CHARACTERS.
DISPLAY MATRIX PRELOADED WITH FIRST NAMES OF HH MEMBERS AND LOOP THROUGH EACH NAME LISTED ON MATRIX
IF HH_MEM_DOB COLLECTED DURING PREVIOUS INTERVIEW AND VALID PROVIDED, CALCULATE DERIVED VARIABLE, HH_MEM_AGE, A BASED ON HH_MEM_DOB AND DATE OF CURRENT INTERVIEW;
IF HH_MEM_AGE > 18 YEARS, GO TO ACTIVE_DUTY_CHANGE AND LOOP THROUGH BRANCH_SERVICE_CHANGE
(IF ACTIVE_DUTY_CHANGE = 1, 2 OR 3), THEN RETURN TO HH_MIL_CHANGE_ROSTER.
IF HH_MEM_DOB NOT COLLECTED DURING PREVIOUS INTERVIEW OR VALID RESPONSE NOT PROVIDED, GO TO ACTIVE_DUTY_CHANGE AND LOOP THROUGH BRANCH_SERVICE_CHANGE (IF ACTIVE_DUTY_CHANGE = 1, 2 OR 3), THEN RETURN TO HH_MIL_CHANGE_ROSTER
WHEN NUMBER OF LOOPS = NUM_HH, GO TO DE095.
DE055/(OTHER_CHANGE_ROSTER). In addition to the people discussed earlier, are there any persons living in the household that we have not mentioned?
YES 1
NO 2 (DE095)
REFUSED -1 (DE095)
DON’T KNOW -2 (DE095)
DE060/(NUM_CHANGE_HH). How many persons are currently living in or staying in this this household that were not listed above?
|___|___|
NUMBER OF PERSONS
REFUSED -1 (DE095)
DON’T KNOW -2 (DE095)
DE062/(MILITARY_HH_CHANGE). Have any of these persons who are now living or staying in this household ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard? Active duty does not include training for the Reserves or National Guard, but does include activation, for example, for the Persian Gulf War.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
LOOP THROUGH FNAME_CHANGE_ROSTER, CHILD_RELAT_CHANGE, CHILD_RELAT_CHANGE_OTH_1 (IF CHILD_RELAT_CHANGE_OTH = 7), CHILD_RELAT_OTH_CHANGE_2 (IF CHILD_RELAT_CHANGE = 8), HH_MEM_DOB
_CHANGE, ACTIVE_DUTY_CHANGE (IF MILITARY_HH_CHANGE = 1 AND EITHER HH_MEM_AGE_CHANGE ≥ 18 YEARS OR HH_MEM_DOB_CHANGE = -1 OR -2), AND BRANCH_SERV_CHANGE (IF ACTIVE_DUTY_CHANGE = 1, 2 OR 3) UNTIL NUMBER OF LOOPS = NUM_CHANGE_HH.
THEN GO TO DE095.
DE065/(FNAME_CHANGE_ROSTER). {Start with the name of the person, or one of the persons, who lives or stays in this home}/{What is the name of the next person living or staying here?}
INTERVIEWER INSTRUCTIONS:
ADD NEW HH MEMBERS AND RELATIONSHIP TO CHILD AS NEEDED.
CONFIRM SPELLING.
________________________________
FIRST NAME
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF FIRST LOOP CYCLE, DISPLAY “Start with the name of the person…”
IF SUBSEQUENT LOOP CYCLE, DISPLAY “What is the name of the next person…”
DE070/(CHILD_RELAT_CHANGE). How is {F_NAME} related to the child?
MOTHER 1 (HH_MEM_DOB_CHANGE)
FATHER 2 (HH_MEM_DOB_CHANGE)
GRANDMOTHER 3 (HH_MEM_DOB_CHANGE)
GRANDFATHER 4 (HH_MEM_DOB_CHANGE)
SISTER 5 (HH_MEM_DOB_CHANGE)
BROTHER 6 (HH_MEM_DOB_CHANGE)
OTHER RELATIVE 7
OTHER NON-RELATIVE 8 (CHILD_RELATE_CHANGE_OTH_2)
REFUSED -1 (HH_MEM_DOB_CHANGE)
DON’T KNOW -2 (HH_MEM_DOB_CHANGE)
PROGRAMMER INSTRUCTION:
DISPLAY F_NAME.
DE075/(CHILD_RELATE_CHANGE_OTH_1).
SPECIFY: _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
LIMIT FREE TEXT TO 255 CHARACTERS.
GO TO HH_MEM_DOB_CHANGE.
DE080/(CHILD_RELATE_CHANGE_OTH_2).
SPECIFY: _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT FREE TEXT TO 255 CHARACTERS.
DE032/(HH_MEM_DOB_CHANGE). What is {F_NAME}’s date of birth?
INTERVIEWER INSTRUCTIONS:
IF PARENT/CAREGIVER REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS
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.
MONTH: |___|___|
M M
DAY: |___|___|
D D
YEAR: |___|___|___|___|
Y Y Y Y
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
FORMAT HH_MEM_DOB_CHANGE AS YYYYMMDD.
DISPLAY F_NAME.
IF MILITARY_HH_CHANGE = 1 AND,
VALID RESPONSE PROVIDED FOR HH_MEM_DOB_CHANGE, CALCULATE DERIVED VARIABLE, HH_MEM_AGE_CHANGE, BASED ON HH_MEM_DOB_CHANGE AND DATE OF CURRENT INTERVIEW;
IF HH_MEM_AGE_CHANGE > 18 YEARS, GO TO ACTIVE_DUTY_CHANGE.
IF VALID RESPONSE NOT PROVIDED FOR HH_MEM_DOB_CHANGE, GO TO ACTIVE_DUTY_CHANGE
IF NUMBER OF COMPLETED LOOPS < NUM_CHANGE_HH, GO TO FNAME_CHANGE_ROSTER.
OTHERWISE, IF NUMBER OF COMPLETED LOOPS = NUM_CHANGE_HH, GO TO DE095.
DE085/(ACTIVE_DUTY_CHANGE). Has {F_NAME} ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard?
INTERVIEWER INSTRUCTION:
READ AS NECESSARY: [Active duty does not include training for the Reserves or National Guard, but does include activation, for example, for the Persian Gulf War.]
Yes, they are now on active duty, 1
Yes, they were on active duty during the last 6
months, but not now, 2
Yes, they were on active duty in the past, but not
during the last 6 months, 3
No, they were training for Reserves or National
Guard only, or 4
No, they never served in the military? 5
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
DISPLAY F_NAME.
IF ACTIVE_DUTY_CHANGE = 1, 2, OR 3, GO TO BRANCH_SERV_CHANGE.
IF HHCOMP_CHANGE = 2, -1, OR 2, AND HHCOMP_CHANGE_MIL = 1:
IF ACTIVE_DUTY_CHANGE = 4, 5, -1, OR -2, AND
IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO ACTIVE_DUTY_CHANGE.
IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO DE095.
IF HHCOMP_CHANGE = 1, AND HHCOMP_CHANGE_MIL = 1:
IF ACTIVE_DUTY_CHANGE = 4, 5, -1, OR -2, AND
IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO HH_CHANGE_ROSTER.
IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO OTHER_CHANGE_ROSTER.
OTHERWISE, IF ACTIVE_DUTY_CHANGE = 4, 5, -1, OR -2, COMPLETE LOOP:
IF NUMBER OF COMPLETED LOOPS < NUM_CHANGE_HH, GO TO FNAME_CHANGE_ROSTER.
IF NUMBER OF COMPLETED LOOPS = NUM_CHANGE_HH, GO TO DE095.
DE090/(BRANCH_SERV_CHANGE). What {is/was} his or her branch of service?
Air Force, 1
Army, 2
Marine Corps, 3
Navy, or 4
Coast Guard? 5
NOT IN U.S. ARMED FORCES -7
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF ACTIVE_DUTY_CHANGE= 1, DISPLAY “is”.
IF ACTIVE_DUTY_CHANGE = 2 OR 3, DISPLAY “was”.
IF HHCOMP_CHANGE = 2, -1, OR 2, AND HHCOMP_CHANGE_MIL = 1:
IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO ACTIVE_DUTY_CHANGE.
IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO DE095.
IF HHCOMP_CHANGE = 1, AND HHCOMP_CHANGE_MIL = 1:
IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO HH_CHANGE_ROSTER.
IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO OTHER_CHANGE_ROSTER.
IF NUMBER OF COMPLETED LOOPS < NUM_CHANGE_HH, GO TO FNAME_CHANGE_ROSTER TO BEGIN NEXT LOOP.
IF NUMBER OF COMPLETED LOOPS = NUM_CHANGE_HH, GO TO DE095.
DE095. 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.
DE100/(HH_MEMBERS). How many household members are supported by your total combined family income?
|___|___|
NUMBER
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
PRELOAD CURRENT YEAR MINUS 1.
RESPONSE MUST BE > 0; INCLUDE A SOFT EDIT IF RESPONSE IS > 15.
IF HH_MEMBERS = 1, -1, or -2, GO TO INCOME.
OTHERWISE, IF HH_MEMBERS > 1, GO TO NUM_CHILD.
DE105/(NUM_CHILD). How many of those people are children? Please include anyone under 18 years or anyone 18 years and 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.
DE0110/(INCOME). Of these income groups, which category best represents your total combined family income during the last calendar year?
Less than $30,000 1
$30,000-$49,999 2
$50,000-$99,999 3
$100,000 or more 4
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_3) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
SL001. I’m now going to ask you about {C_FNAME/the child}’s sleeping habits.
SL014/(SLEEP_HRS_DAY). Approximately how many hours does {C_FNAME/the child} sleep during the day?
|___|___|
HOURS
REFUSED -1
DON’T KNOW -2
SL016/(SLEEP_HRS_NIGHT). Approximately how many hours does {C_FNAME/the child} sleep at night?
|___|___|
HOURS
REFUSED -1
DON’T KNOW -2
SL018/(SLEEP_TIME_NIGHT)/(SLEEP_TIME_NIGHT_UNIT). On a normal day, what time in the evening does {C_FNAME/the child} go to sleep?
|___|___|:|___|___|
TIME
AM 1
PM 2
REFUSED -1
DON’T KNOW -2
INTERVIEWER INSTRUCTIONS:
PROMPT PARENT/CAREGIVER AS TO WHETHER TIME PROVIDED IS “AM” OR “PM”.
RECORD THE TIME AS HH:MM, BE SURE TO FILL THE SPACE WITH A ZERO WHEN NECESSARY AND THEN CHOOSE “AM” OR “PM”.
SL020/(SLEEP_TIME_WAKE)/(SLEEP_TIME_WAKE_UNIT). On a normal day, what time does {C_FNAME/the child} wake up in the morning?
|___|___|:|___|___|
TIME
AM 1
PM 2
REFUSED -1
DON’T KNOW -2
INTERVIEWER INSTRUCTIONS:
PROMPT PARENT/CAREGIVER AS TO WHETHER TIME PROVIDED IS “AM” OR “PM”.
RECORD THE TIME AS HH:MM, BE SURE TO FILL THE SPACE WITH A ZERO WHEN NECESSARY AND THEN CHOOSE “AM” OR “PM”.
SL022/(SLEEP_DIFFICULT). How often is {C_FNAME/the child} difficult when {he/she} is put to bed?
Most of the time 1
Often 2
Sometimes 3
Rarely 4
Never 5
REFUSED -1
DON’T KNOW -2
SL024/(SLEEP_THROUGH). How often does {C_FNAME/the child} wake at night?
Never 1
Occasionally 2
Most nights 3
Every night 4
More than once per night 5
REFUSED -1
DON’T KNOW -2
SL025/(TV_FREQ_HRS). Over the past 30 days, on average, how many hours per day did {C_FNAME/the child} sit and watch TV and/or DVDs? Would you say …
Less than 1 hour, 1
2 hours 2
3 hours, 3
4 hours, 4
5 hours or more, or 5
None, {C_FNAME/the child} does not watch TV or DVDs 6
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_4) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
CC001/(CHILDCARE_CHANGE). Has there been a change in the childcare arrangements for {C_FNAME/the child} since our last interview?
YES 1
NO 2 (TIME_STAMP_5)
REFUSED ……………… -1 (TIME_STAMP_5)
DON’T KNOW -2 (TIME_STAMP_5)
CC003. 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_5)
REFUSED -1 (TIME_STAMP_5)
DON’T KNOW -2 (TIME_STAMP_5)
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)
CC018/(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_5)
REFUSED -1 (TIME_STAMP_5)
DON’T KNOW -2 (TIME_STAMP_5)
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
(TIME_STAMP_5) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
HL001. The next questions are about where {C_FNAME/the child} goes for health care.
HL004/(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 (C_HEALTH)
Doctor's office or Health Maintenance Organization (HMO) 2 (C_HEALTH)
Hospital emergency room 3 (C_HEALTH)
Hospital outpatient department 4 (C_HEALTH)
Some other place -5
DOESN'T GO TO ONE PLACE MOST OFTEN 6 (C_HEALTH)
DOESN'T GET WELL-CHILD CARE ANYWHERE 7 (C_HEALTH)
REFUSED -1 (C_HEALTH)
DON’T KNOW -2 (C_HEALTH)
HL004A/(R_HCARE_OTH).
SPECIFY ________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
HL005/(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
PROGRAMMER INSTRUCTIONS:
IF RESP_REL = 1, GO TO USE_IC_LOG.
OTHERWISE, GO TO HL014.
HL008/(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 (HL014)
DON’T KNOW -2 (HL014)
HL009/(REASON_NO_IC_LOG). Is that because…
The child hasn’t had a medical visit since our last interview, 1 (HOSPITAL)
You’ve misplaced the log 2 (HL010)
You’ve forgotten to bring it to the child’s medical visits 3 (HL011)
The log was too much trouble to complete, or 4 (HL011)
The log was too difficult to understand? 5 (HL014)
OTHER -5
REFUSED -1 (HL011)
DON’T KNOW -2 (HL011)
HL009A/(REASON_NO_IC_LOG_OTH).
OTHER: SPECIFY _____________________________________ (HL014)
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
HL010. We’ll get another Infant and Child Health Care Log in the mail to you today. (HL014)
HL011. 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. (HL014)
HL012/(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
HL013/(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
HL014. 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} any other personal record or 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.
HL015/(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 (HOSPTIAL)
REFUSED -1 (HOSPITAL)
DON’T KNOW -2
-
DAY:
|___|___|
D D
REFUSED -1 (HOSPITAL)
DON’T KNOW -2
-
YEAR:
|___|___|___|___|
Y Y Y Y
REFUSED -1 (HOSPITAL)
DON’T KNOW -2 (HOSPITAL)
INTERVIEWER INSTRUCTIONS:
SHOW CALENDAR TO ASSIST IN DATE RECALL.
ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR
HL016/(VISIT_WT). What was {C_FNAME/the child}’s weight at that visit?
|___|___|
POUNDS
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
INCLUDE A SOFT EDIT IF WEIGHT < 18 OR > 33 POUNDS.
IF USE_IC_LOG=1, GO TO HL017.
OTHERWISE, GO TO HOSPITAL.
HL017. 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.
HL018/(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_6)
REFUSED -1 (TIME_STAMP_6)
DON’T KNOW -2 (TIME_STAMP_6)
PROGRAMMER INSTRUCTIONS:
IF 12-MONTH INTERVIEW SET TO COMPLETE, PRELOAD 12-MONTH INTERVIEW DATE FOR DATE OF LAST INTERVIEW.
IF 12-MONTH INTERVIEW NOT SET TO COMPLETE, PRELOAD DATE OF MOST RECENT CHILD INTERVIEW FOR DATE OF LAST INTERVIEW.
HL019/(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_6)
DON’T KNOW -2 (TIME_STAMP_6)
PROGRAMMER INSTRUCTIONS:
IF 12-MONTH INTERVIEW SET TO COMPLETE, PRELOAD 12-MONTH INTERVIEW DATE FOR DATE OF LAST INTERVIEW.
IF 12-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 HL024 (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_6.
HL020/(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
HL021/(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.
HL022/(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 HL024.
OTHERWISE, GO TO TIME_STAMP_6.
HL023/(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 INSTRUCTIONS:
LIMIT TEXT TO 255 CHARACTERS.
IF USE_IC_LOG = 1, GO TO HL024.
OTHERWISE, GO TO TIME_STAMP_6.
HL024. 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_6) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
MC001. Now I’d like to ask about {C_FNAME/the child}’s health and about some illnesses {he/she} may have had in the last 3 months.
MC004. During the past 3 months, has {C_FNAME/the child} had any of the following conditions?
MC004A/(COND_EAR). Three or more ear infections?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MC004B/(COND_WHEEZE). Wheezing or whistling in the chest?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MC004C/(COND_DIARRHEA). Frequent or repeated diarrhea?
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
INTERVIEWER INSTRUCTION:
ENTER “0” IF NONE
REFUSED -1
DON’T KNOW -2
MC015. Now I have some questions about specific conditions or health problems {C_FNAME/the child} may have.
MC016/(ASTHMA). Has a doctor ever told you that {C_FNAME/the child} has asthma?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MC024/(IHMOB). Does {C_FNAME/the child} have an impairment or health problem that limits {his/her} ability to crawl, walk, run, or play?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MEDICATIONS
(TIME_STAMP_7) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
MED001. Now, I’d like to ask about medications that may have been prescribed by a doctor or other healthcare provider for {C_FNAME/the child}.
MED003/(PRESCR_TAKE). In the past 30 days, has {C_FNAME/the child} used or taken any medication for which a prescription is needed? Include only those products prescribed by a health professional such as a doctor or dentist. [Do not include prescription vitamins or minerals.]
YES 1
NO 2 (MED008)
REFUSED -1 (MED008)
DON’T KNOW -2 (MED008)
MED004/(PRESCRMED). Please list the name of all prescription medications taken in the past 30 days:
INTERVIEWER INSTRUCTIONS:
ENTER UP TO 10 MEDICATIONS.
IF MORE THAN 10 MEDICATIONS PROVIDED, ENTER FIRST 10 PROVIDED BY PARENT/CAREGIVER.
REFUSED -1 (MED008)
DON’T KNOW -2 (MED008)
PROGRAMMER INSTRUCTIONS:
LIMIT TEXT TO 100 CHARACTERS PER MEDICATION.
LOOP THROUGH PRESCR_ADMIN THROUGH PRESCRIP_FREQ/PRESCRIP_FREQ_UNIT FOR EACH PRESCRIPTION.
IF FIRST LOOP, GO TO INTRO_PRESCRMED_1.OTHERWISE, GO TO INTRO_PRESCRMED_2_10.
FOR INTRO_PRESCRMED_1, INTRO_PRESCRMED_2_10, PRESCR_ADMIN, PRESCR_TAKESTILL and PRESCRIP_FREQ, INSERT CORRECT MEDICATION PRESCRMED for appropriate cycle.
INTERVIEWER INSTRUCTION:
PROBE: Anything else?
MED004A/(INTRO_PRESCRMED_1). Let’s first talk about the {PRESCRMED}.
MED004B/(INTRO_PRESCRMED_2_10). Now let’s talk about the {PRESCRMED}.
MED005/(PRESCR_ADMIN). How is the {PRESCRMED} taken?
By mouth, 1 (PRESCR_TAKESTILL)
Inhaled either by mouth or nose, 2 (PRESCR_TAKESTILL)
Injected, 3 (PRESCR_TAKESTILL)
Applied to the skin, such as a patch or creams, or 4 (PRESCR_TAKESTILL)
Some other way? -5
REFUSED -1 (PRESCR_TAKESTILL)
DON’T KNOW -2 (PRESCR_TAKESTILL)
MED005A/(PRESCR_ADMIN_OTH).
SPECIFY __________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
MED006/(PRESCR_TAKESTILL). Is {C_FNAME/the child} still taking the {PRESCRMED}?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MED007/(PRESCRIP_FREQ)/PRESCRIP_FREQ_UNIT). How often {does/did} {C_FNAME/the child} use or take the {PRESCRMED}?
PROGRAMMER INSTRUCTION:
If PRESCR_TAKESTILL = 1, DISPLAY “does”; OTHERWISE, DISPLAY “did”
|___|___|
ENTER NUMBER
REFUSED -1
DON’T KNOW -2
ENTER UNIT:
PER DAY 1
PER WEEK 2
PER MONTH 3
PER YEAR 4
AS NEEDED 5
MED008. Now I’d like to ask about non-prescription medications, over the counter medications, and dietary supplements that {C_FNAME/the child} may have taken in the last 30 days.
MED009/(OTC_TAKE). Has {C_FNAME/the child} used or taken any non-prescription medications in the past 30 days? Include only those products purchased over the counter that do not require a prescription. [Do not include over-the counter vitamins or minerals.]
YES 1
NO 2 (MED014)
REFUSED -1 (MED014)
DON’T KNOW -2 (MED014)
MED010/(OTCMED). Please list the names of all non-prescription medications taken in the past 30 days:
INTERVIEWER INSTRUCTION:
ENTER UP TO 10 MEDICATIONS; IF MORE THAN 10 MEDICATIONS PROVIDED, ENTER FIRST 10 PROVIDED BY PARENT/CAREGIVER.
REFUSED -1 (MED014)
DON’T KNOW -2 (MED014)
PROGRAMMER INSTRUCTIONS:
LIMIT TEXT TO 100 CHARACTERS PER MEDICATION.
LOOP THROUGH OTC_ADMIN THROUGH OTC_FREQ/OTC_FREQ_UNIT FOR EACH PRESCRIPTION.
IF FIRST LOOP, GO TO INTRO_OTCMED_1.OTHERWISE, GO TO INTRO_OTCMED_2_10.
FOR INTRO_OTCMED_1, INTRO_OTCMED_2_10, OTC_ADMIN, OTC_TAKESTILL and OTC_FREQ, INSERT CORRECT MEDICATION OTCMED for appropriate cycle.
INTERVIEWER INSTRUCTION:
PROBE: Anything else?
MED010A/(INTRO_OTCMED_1) Let’s first talk about the {OTCMED}.
MED010B/(INTRO_OTCMED_2_10). Now let’s talk about the {OTCMED}.
MED011/(OTC_ADMIN). How is the {OTCMED} taken?
By mouth, 1 (OTC_TAKESTILL)
Inhaled either by mouth or nose, 2 (OTC_TAKESTILL)
Injected, 3 (OTC_TAKESTILL)
Applied to the skin, such as a patch or creams, or 4 (OTC_TAKESTILL)
Some other way? -5
REFUSED -1 (OTC_TAKESTILL)
DON’T KNOW -2 (OTC_TAKESTILL)
MED011A/(OTC_ADMIN_OTH).
SPECIFY __________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
MED012/(OTC_TAKESTILL). Is {C_FNAME/the child} still taking the {OTCMED}?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MED013/(OTC_FREQ)/OTC_FREQ_UNIT). How often {does/did} {C_FNAME/the child} use or take the {OTCMED}?
PROGRAMMER INSTRUCTION:
IF OTC_TAKESTILL = 1, DISPLAY “does”; OTHERWISE, DISPLAY “did”
|___|___|
ENTER NUMBER
REFUSED -1
DON’T KNOW -2
ENTER UNIT
PER DAY 1
PER WEEK 2
PER MONTH 3
PER YEAR 4
AS NEEDED 5
MED014. Now I would like to ask about dietary supplements.
MED015/(SUPPL_TAKE). Has {C_FNAME/the child} used or taken any vitamins, minerals, herbals, or other dietary supplements in the past 30 days? Include only those supplements purchased over the counter that do not require a prescription.
YES 1
NO 2 (TIME_STAMP_8)
REFUSED -1 (TIME_STAMP_8)
DON’T KNOW -2 (TIME_STAMP_8)
MED016/(SUPPLMED). Please list the names of all vitamins, minerals, herbals, and other dietary supplements taken in the past 30 days:
INTERVIEWER INSTRUCTION:
ENTER UP TO 10 SUPPLEMENTS: IF MORE THAN 10 SUPPLEMENTS PROVIDED, ENTER FIRST 10 PROVIDED BY PARENT/CAREGIVER.
REFUSED -1 (TIME_STAMP_8)
DON’T KNOW -2 (TIME_STAMP_8)
PROGRAMMER INSTRUCTIONS:
LIMIT TEXT TO 100 CHARACTERS PER MEDICATION.
LOOP THROUGH SUPPL_ADMIN THROUGH SUPPL_FREQ/SUPPL_FREQ_UNIT FOR EACH PRESCRIPTION.
IF FIRST LOOP, GO TO INTRO_SUPPLMED_1.OTHERWISE, GO TO INTRO_SUPPLMED_2_10.
FOR INTRO_SUPPLMED_1, INTRO_SUPPLMED_2_10, SUPPL_ADMIN, SUppL_TAKESTILL and SUPPL_FREQ, INSERT CORRECT MEDICATION OTCMED for appropriate cycle.
INTERVIEWER INSTRUCTION:
PROBE: Anything else?
MED016A/(INTRO_SUPPLMED_1). Let’s first talk about the {SUPPLMED}.
MED016B/(INTRO_SUPPLMED_2_10). Now let’s talk about the {SUPPLMED}.
MED017/(SUPPL_ADMIN). How is the {SUPPLMED} taken?
By mouth, 1 (SUPPL_TAKESTILL)
Inhaled either by mouth or nose, 2 (SUPPL_TAKESTILL)
Injected, 3 (SUPPL_TAKESTILL)
Applied to the skin, such as a patch or creams, or 4 (SUPPL_TAKESTILL)
Some other way? -5
REFUSED -1 (SUPPL_TAKESTILL)
DON’T KNOW -2 (SUPPL_TAKESTILL)
MED017A/(SUPPL_ADMIN_OTH).
SPECIFY __________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
MED018/(SUPPL_TAKESTILL). Is {C_FNAME/the child} still taking the {SUPPLMED}?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MED019/(SUPPL_FREQ)/SUPPL_FREQ_UNIT). How often {does/did} {C_FNAME/the child} use or take the {SUPPLMED}?
PROGRAMMER INSTRUCTION:
If SUPPL_TAKESTILL = 1, DISPLAY “does”; OTHERWISE, DISPLAY “did”.
|___|___|
ENTER NUMBER
REFUSED -1
DON’T KNOW -2
ENTER UNIT
PER DAY 1
PER WEEK 2
PER MONTH 3
PER YEAR 4
AS NEEDED 5
PROGRAMMER INSTRUCTIONS:
IF RESP_REL = 1 OR 2, GO TO TIME_STAMP_8.
IF RESP_REL = 3 AND MULT_CHILD = 1 AND CHILD_NUM ≠ CHILD_QNUM, GO TO CHILD_QNUM.
IF RESP_REL = 3 AND MULT_CHILD = 1 AND CHILD_NUM = CHILD_QNUM, GO TO TIME_STAMP_13.
Product Use
(TIME_STAMP_8) 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
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF LICE_1 = 1, GO TO LICE_2.
OTHERWISE, GO TO PROGRAMMER INSTRUCTIONS AT START OF “MATERNAL BEHAVIORS” SECTION.
PU010/(LICE_2). Who did you treat, was it {C_FNAME/the child}, someone else, or both?
{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 PROGRAMMER INSTRUCTIONS AT START OF “MATERNAL BEHAVIORS” SECTION.
PU013/(LICE_2_OTH).
OTHER: SPECIFY _______________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
MATERNAL Behaviors
PROGRAMMER INSTRUCTIONS:
IF CHILD_QNUM =1, GO TO TIME_STAMP_9.
IFCHILD_QNUM > 1, GO TO SMOKE_HOURS.
IF RESP_REL = 2 AND MULT_CHILD = 1 AND CHILD_NUM ≠ CHILD_QNUM, GO TO CHILD_QNUM.
IF RESP_REL = 2 AND MULT_CHILD = 1 AND CHILD_NUM = CHILD_QNUM, GO TO TIME_STAMP_13.
(TIME_STAMP_9) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
MB001. The next questions are about your experiences, since our last interview. First, I’d like to ask some questions about work. People’s work situations sometimes change after having a baby.
MB003/(WORK_LAST_CONTACT). Since our last interview, have you been employed at a job or business?
YES 1
NO 2 (R_SMOKE)
REFUSED -1 (R_SMOKE)
DON’T KNOW -2 (R_SMOKE)
MB004/(WORK_CURRENTLY). Are you currently employed?
YES 1
NO 2 (R_SMOKE)
REFUSED -1 (R_SMOKE)
DON’T KNOW -2 (R_SMOKE)
MB008/(WORK_HRS). How many hours per week do you work?
|___|___|
HOURS
REFUSED -1
DON’T KNOW -2
MB009/(R_SMOKE). Do you currently smoke cigarettes or use any other tobacco product?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MB010/(NUM_SMOKER). How many smokers live in your home now, {including yourself}?
PROGRAMMER INSTRUCTION:
DISPLAY bracketed text if R_SMOKE = 1.
|___|___|
NUMBER OF SMOKERS
INTERVIEWER INSTRUCTION:
ENTER “0” IF NONE.
REFUSED -1
DON’T KNOW -2
MB011/(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, or 2
Smoking is permitted anywhere inside my home 3
REFUSED -1
DON’T KNOW -2
MB012/(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_INSTRUCTIONS:
IF CHILD_NUM =1, GO TO TIME_STAMP_10.
IF CHILD_NUM >1, GO TO CHILD_QNUM AND LOOP THROUGH QUESTIONNAIRE FROM IN011 THROUGH SMOKE_HOURS FOR EACH CHILD UNTIL CHILD_NUM=CHILD_QNUM.
THEN GO TO TIME_STAMP_10.
PETS
(TIME_STAMP_10) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
PT001. Now I’d like to ask about any pets you may have in your home.
PT003/(PETS). Are there any pets that spend any time inside your home?
YES 1
NO 2 (TIME_STAMP_11)
REFUSED -1 (TIME_STAMP_11)
DON’T KNOW -2 (TIME_STAMP_11)
PT005/(PET_TYPE). What kind of pets are these?
INTERVIEWER INSTRUCTIONS:
PROBE FOR MULTIPLE RESPONSES: “Any others?”
SELECT ALL THAT APPLY.
DOG 1
CAT 2
SMALL MAMMAL (RABBIT, GERBIL, HAMSTER, GUINEA PIG, FERRET, MOUSE) 3
BIRD 4
FISH OR REPTILE (TURTLE, SNAKE, LIZARD) 5
OTHER -5
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF PET_TYPE CODED WITH ANY COMBINATION OF VALUES 1 – 5, THEN GO TO PET_MEDS.
IF PET_TYPE CODED -5, OR ANY COMBINATION OF VALUES 1 – 5 AND -5, GO TO PET_TYPE_OTH.
IF PET_TYPE CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO PED_MEDS.
PT007/(PET_TYPE_OTH).
OTHER: SPECIFY _________________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
PT009/(PET_MEDS). Are any products ever used on your pets to control fleas, ticks, or mites? This includes flea collars, flea and tick powders, shampoos, or other flea, tick and mite control products. (This does not include pills given to your pet to control for fleas or other insects.)
YES 1
NO 2 (TIME_STAMP_11)
REFUSED -1 (TIME_STAMP_11)
DON’T KNOW -2 (TIME_STAMP_11)
PT011/(PET_MED_TIME). When were any of these last used on any of your pets?
WITHIN THE LAST MONTH 1
1-3 MONTHS AGO 2
4-6 MONTHS AGO 3
MORE THAN 6 MONTHS AGO 4
REFUSED -1
DON’T KNOW -2
In-Home Exposures
(TIME_STAMP_11) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
IHE001. Do you use any methods to “allergy-proof” your home? Please answer “yes” or “no” to each method I describe.
IHE010/(REMOVAL). Intentionally remove rugs or upholstered furniture?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
IHE012/(METHOD). Any other methods?
YES 1
NO 2 (OPEN_WINDOW)
REFUSED -1 (OPEN_WINDOW)
DON’T KNOW -2 (OPEN_WINDOW)
IHE013/(METHOD_OTH). SPECIFY: ____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
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, or 4
Not at all? 5
REFUSED -1
DON’T KNOW -2
IHE020. I would now like to ask about cockroaches.
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 (IHE055B)
REFUSED -1 (IHE055B)
DON’T KNOW -2 (IHE055B)
IHE054/(ROOM_MOLD). In which rooms have you seen the mold or mildew?
INTERVIEWER INSTRUCTIONS:
PROBE: Any other rooms?
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 ROOM_MOLD CODED WITH ANY COMBINATION OF VALUES 1 – 7, INCLUDING VALUE OF 4, 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 IHE055B.
IF ROOM_MOLD CODED -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, BUT NOT INCLUDING 4, GO TO ROOM_MOLD_OTH.
IF ROOM_MOLD CODED -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, INCLUDING 4, GO TO ROOM_MOLD_OTH, THEN ROOM_MOLD_CHILD.
IF ROOM_MOLD CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO IHE055B.
IHE055/(ROOM_MOLD_OTH). SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
LIMIT 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
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 (TIME_STAMP_12)
REFUSED -1 (TIME_STAMP_12)
DON’T KNOW -2 (TIME_STAMP_12)
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, GO TOTIME_STAMP_12.
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_12.
IHE058/(RENOVATE_ROOM_OTH). SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
HOUSING CHARACTERISTICS
(TIME_STAMP_12) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
HC001. Now I’d like to find out more about your living situation.
HC003/(RECENT_MOVE). Have you moved or changed your housing situation since we contacted you last?
YES 1
NO 2 (TIME_STAMP_13)
REFUSED -1 (TIME_STAMP_13)
DON’T KNOW………… -2 (TIME_STAMP_13)
INTERVIEWER INSTRUCTION:
IF USING SHOWCARDS, REFER MOTHER TO APPROPRIATE SHOWCARD.
OTHERWISE, READ RESPONSE CATEGORIES TO MOTHER .
PROGRAMMER INSTRUCTION:
IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS. OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE PER BELOW.
HC004/(AGE_HOME). Can you tell us, which of these categories do you think best describes when your home or building was built?
2001TO PRESENT 1
1981 TO2000 2
1961 TO1980 3
1941 TO1960 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
REFUSED -1
DON’T KNOW -2
WEEKS 1
MONTHS 2
YEARS 3
HC006/(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)
HC007/(WATER_DRINK_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
HC008/(WATER_COOK). What water source in your home is used most of the time for cooking?
Tap water, 1 (NC001)
Filtered tap water, 2 (NC001)
Bottled water, or 3 (NC001)
Some other source? -5
REFUSED -1 (NC001)
DON’T KNOW -2 (NC001)
HC009/(WATER_COOK_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
Neighborhood Characteristics
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 {DATE 30 DAYS PRIOR TO INTERVIEW DATE}, 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
(TIME_STAMP_13) 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_14) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
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.
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