Formative - Developmental

ATTACHMENT B.1.7 Exemplar Interview OMB #: 0925-0593

LOI2-BIO-02 & -05 EXPIRATION DATE: 07/31/2013

BREAST MILK STUDY INTERVIEW
Thank you for agreeing to participate in our study. I am going to begin by asking you for information on how to contact you. Your name and address information will not be included on any data files used for analysis and we will not use your name or address when you are publishing the results of the study. [IF PARTICIPANT IS ENROLLED IN THE NCS VANGUARD STUDY, SKIP THIS SECTION] What is your full name? Participant Name (First, MI, Last): ___________________________________________________________
What is your current address and phone number? Street Address: ___________________________________ City: _______________ State: _____ Zip code:__________ Do you have an e-mail address? E-mail #1: E-mail #2: What is the best way to contact you?	Home Phone Number: -- Cell Phone Number: -- Other Phone Number: --
In case we have difficulty reaching you, we are asking you to give us the name of an individual who would be able to help us find you if we are unable to reach you. This person will only be asked if they have current contact information for you or to relay a message to have you call us. It is best if you can tell us a friend or relative who would be likely to know how to reach you if you move. [IF PARTICIPANT IS ENROLLED IN THE NCS VANGUARD STUDY, SKIP THIS SECTION] Name of an individual who will know how to contact you: (First, MI, Last): ___________________________________________________________
Street Address: ___________________________________ City: _______________ State: _____ Zip code:__________ E-mail #1: E-mail #2:	Home Phone Number: -- Cell Phone Number: -- Other Phone Number: --

Infant Name (First, MI, Last):: _________________________________________________________

Other Infant Names (if multiple birth): __________________________________________________

Infant Birth Date: -- Infant Birth Weight: lbs oz

Other Infant Birth Weight (if multiple birth): lbs oz

Comments:

First I would like to ask you about how the breast milk sample was collected. 1. SAMPLE COLLECTION:
a.	What was the date of the collection? --
b.	What time of day did you collect the sample? : AM/PM
c.	Infant Age: days (Calculate the infant age and fill in)
d.	How was the sample collected, with hand expression or a breast pump?
	Hand Expression
	Manual Pump, If yes, list brand name:_______________________________________
	Electric Pump, If yes, list brand name:______________________________________
e.	What time did you last feed your baby before collecting the sample? : AM/PM
f.	Sample Volume: cc (Fill in the volume of the sample collected.)

g. How was the sample collected?

1. From both breasts

2. From one breast while nursing with the other breast

3. From one breast not while nursing with the other breast

h. How long was the sample kept at room temperature? ________________________

h. How long was the sample refrigerated before pick up? _______________________

Comments:

We are now going to ask you some questions about your baby’s breast feeding pattern. 2. INFANT FEEDING:
2-1. Are you still breastfeeding your baby? Yes No 2-2. What is the average number of breast feedings per day? feedings per day 2-3. On average, how often does your baby nurse? every hours 2-4. How long do you plan on breastfeeding your infant? ____________ (months)

We are now going to ask you about the foods you have eaten in the last 24 hours. 3. MOTHER DIET:
Please describe what you have eaten for the following meals and snacks over the last 24 hours:
3-1.		Breakfast: _________________________________________________________________
3-2.		Lunch: ___________________________________________________________________
3-3.		Dinner: ___________________________________________________________________
3-4.		Snacks: ___________________________________________________________________
3-5.		Tap Water: Amount ________ glasses
3-6.		Bottled Water: Amount oz Brand Name: _________________________________
	The next set of questions ask about the use of different chemicals that may have been used in your home. 4. HOUSEHOLD USE OF PESTICIDES:
	Does your household use the following?
	4-1.	Herbicides such as weed killers					YES NO (If no, go to 5-1)
		4-2. What was the name of the weed killer used? ____________________________________________________
		4-3. Who was it done/used by?
		Commercial Contractor If so, list name/company: ____________________________________________ Household Member
		4-4. Where was the weed killer used? (i.e. inside/outside home) _______________________________________
		4-5. How often was it used? ___________________________________________________________________
		4-6. When was the last time the weed killer was used? Date: -- Where: ___________________
		4-8. For the most recent application, how was the weed killer used? ___________________________________
		4-9. For the most recent use, did you stay in the place it was applied? YES NO
		If yes, check all that apply and indicate time period:
		During the application							Hours Minutes
		Immediately after the application							Hours Minutes
		A day after the application							Hours Minutes
		Two days after the application							Hours Minutes
		More than two days after the application							Hours Minutes
		4-10. For the most recent application, how much time did you stay/play in the place/room the weed killer was applied?							Hours Minutes
	5-1.	Insecticides or pesticides used to kill insects and rodents, including chemicals used to control fleas and ticks on household pets					YES NO (If no, go to 6-1)
		5-2. What was the name of the chemical used? __________________________________________________
		5-3. Who was it done/used by?
		Commercial Contractor If so, list name/company: ____________________________________________ Household Member
		5-4. Where was the chemical used? (i.e. inside/outside home) _______________________________________
		5-5. How often was it used? ___________________________________________________________________
		5-6. When was the last time the chemical was used? Date: -- Where: ___________________
		5-7. For the most recent application, how was the chemical used? ___________________________________
		5-8. For the most recent application, did you stay in the place it was applied? YES NO
		If yes, check all that apply and indicate time period:
		During the application							Hours Minutes
		Immediately after the application							Hours Minutes
		A day after the application							Hours Minutes
		Two days after the application							Hours Minutes
		More than two days after the application							Hours Minutes
	5-9. For the most recent application, how much time did you stay/play in the place/room the chemical was applied?								Hours Minutes
	6-1.	Fungicides (to kill fungal growth and mold)							YES NO (If no, go to 7-1)
		6-2. What was the name of the fungicide used? ____________________________________________________
		6-3. Who was it done/used by?
		Commercial Contractor If so, list name/company: ___________________________________________ Household Member
		6-4. Where was the fungicide used? (i.e. inside/outside home) _______________________________________
		6-5. How often was it used? ___________________________________________________________________
		6-6. When was the last time the fungicide was used? Date: -- Where: ___________________
		6-7. For the most recent application, how was the fungicide used? ___________________________________
		6-8. For the most recent application, did you stay in the place it was applied? YES NO
		During the application							Hours Minutes
		Immediately after the application							Hours Minutes
		A day after the application							Hours Minutes
		Two days after the application							Hours Minutes
		More than two days after the application							Hours Minutes
		6-9. For the most recent application, how much time did you stay/play in the place/room the fungicide was applied?								Hours Minutes
	6-10 6-11				Did anyone use any pesticides, herbicides, or fungicides inside or around the household in the past 7 days? (including use of medicated lotions or shampoos to control head lice or body lice? Have you used insect repellent in the past 7 days?			YES NO DON’T KNOW If yes, specify:_________________________________________ YES NO DON’T KNOW If yes, specify brand and type (spray, lotion): _________________________________________
	7. HOUSEHOLD LOCATION:
	7-1.	Is your house located within a quarter mile of any major freeway, streets with heavy traffic, or industrial or incineration plants that produce lots of smoke or a strange smell?					YES NO If yes, please specify: _______________________________________
	7-2.	Do you live on a farm?					YES NO If yes, please specify: _______________________________________
	7-3.	Do you have contact with livestock, such as farm animals?					YES NO If yes, please specify: _______________________________________
	7-4. Do you have contact with plants? YES NO If yes, please specify: _______________________________________ 8. MOTHER EMPLOYMENT INFORMATION:
	8-1.	Are you currently employed?					YES NO If no, go to Question 9
	8-2.	Who do you work for? _______________________________________________________
	8-3.	What does the person/company do? ___________________________________________
	8-4.	What kind of work do you do? ________________________________________________
	8-5.	What does the person/company do? ___________________________________________
	9. FATHER EMPLOYMENT INFORMATION:
	9-1.	Is the father of the baby employed?					YES NO If no, go to Question 10
	9-2.	Who does he work for? ______________________________________________________
	9-3.	What does the person/company do? ___________________________________________
	9-4.	What kind of work does he (the father) do? _____________________________________
	9-5. How often does the baby’s father see the baby? Every day, he lives in the household At least once a week More than once a week Never 10. OTHER HOUSEHOLD MEMBER EMPLOYMENT INFORMATION:
	10-1.		Is anyone else living in the household currently employed?			YES NO If no, go to Question 11
	10-2.		If yes, who? _______________________________________________________________
	10-3.		Who does he/she work for? __________________________________________________
	10-4.		What does the person/company do? ___________________________________________
	10-5.		What kind of work does he/she do? ___________________________________________
	11. WATER INFORMATION:
	11-1.			What are the sources of drinking water for your home? (check all that apply)
				City/County
				Well
				Bottled
				Other (specify) __________________________________________________________
	11-2.			Do you filter your drinking water?
				YES
				NO (go to 10e)
				DON’T KNOW (go to 10e)
	11-3.			Do you filter just the drinking water or the entire water supply (that is, for the entire house)
				Just Drinking Water
				Entire Water Supply
	11-4.			What kind of filter do you use?
				Particle Filter Only
				Particle Filter Plus Activated Charcoal
				Don’t Know
	11-5.			What are the sources of cooking water for your home? (check all that apply)
				City/County
				Well
				Bottled
				Other (specify) __________________________________________________________

CONCLUDING STATEMENT:

Thank you very much for your time. That ends our interview for today. We really appreciate your willingness to answer our questions and to participate in the important study. You’ve been very helpful. (We will be in touch with you to set up an additional interview in one month.

GENERAL COMMENTS:

Overall assessment of the quality of the interview

1. Excellent, mother seemed knowledgeable and engaged in the interview

2. Good, mother seemed to understand most questions and was engaged in the interview

3. Fair, mother seemed to lack knowledge but was engaged in the interview

4. Fair, mother had knowledge but was not engaged in the interview

5. Poor, mother did not know responses and was not engaged in the interview

Please comment on any parts the mother had difficulty answering.

Public reporting burden for this collection of information is estimated to average 15 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.