17.6 Survey

Attach B11. LOI2-QUEX-14 Infant Feeding Questionniare



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The National Children’s Study
12 Month Follow-up Questionnaire

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
Centers for Disease Control and Prevention
U.S. Environmental Protection Agency

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

Thank you for agreeing to participate in the National Children’s Study. This self-administered questionnaire will
take about 10 minutes to complete. There are questions about your relationships and questions about your
child’s diet.
Your answers are important to us. There are no right or wrong answers. You can skip over any question. We
will keep everything that you tell us confidential.
If you are married or have a partner, please read the instructions below.
If you are not married or do not have a partner, go to the instructions following Question 6.
The first set of items are about your relationship with your spouse or partner. Please indicate the extent to
which you agree or disagree with each statement.
1. My spouse/partner listens to me when I need someone to talk to.
 Strongly disagree
 Somewhat disagree
 Neither agree nor disagree
 Somewhat agree
 Strongly agree
2. I can state my feelings without him getting defensive.
 Strongly disagree
 Somewhat disagree
 Neither agree nor disagree
 Somewhat agree
 Strongly agree
3. I often feel distant from my spouse/partner.
 Strongly disagree
 Somewhat disagree
 Neither agree nor disagree
 Somewhat agree
 Strongly agree
4. My spouse/partner can really understand my hurts and joys.
 Strongly disagree
 Somewhat disagree
 Neither agree nor disagree
 Somewhat agree
 Strongly agree
5. I feel neglected at times by my spouse/partner.
 Strongly disagree
 Somewhat disagree
 Neither agree nor disagree
 Somewhat agree
 Strongly agree
6. I sometimes feel lonely when we’re together.
 Strongly disagree
 Somewhat disagree
 Neither agree nor disagree
 Somewhat agree
 Strongly agree
QUE
(EHPBHIPBS),
MDES 3.1 Summer
2012,
V3.0 2012,

QUE12-Month
12-MonthSAQ
Mother
SAQ (EHPBHIPBS),
MDES 3.1
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The next questions will ask about the milk, formula, and food your child has eaten in the past 7 days. In
answering include feedings by everyone who feeds the baby. Include snacks and night-time feedings.
Use these guidelines in choosing how to respond:
•
•
•

If the baby was fed this item once a day or more, write the number of feedings per day in the boxes
and then mark the box before “Day.”
If the baby was fed the item less than once a day, write the number of feedings per week in the
boxes and then mark the box before “Week.”
If the baby was not fed the item at all during the past 7 days, write “00” in the boxes.

7. In the past 7 days, how often was your baby fed breast milk (include breast fed and expressed or pumped
breast milk)?

 Number of times per (select one below)
 Day
 Week

8. In the past 7 days, how often was your baby fed formula?

 Number of times per (select one below)
 Day
 Week

9. In the past 7 days, how often was your baby fed cow’s milk?

 Number of times per (select one below)
 Day
 Week

10. In the past 7 days, how often was your baby fed other milk (soy milk, rice milk, goat milk)?

 Number of times per (select one below)
 Day
 Week

11. Please tell me which best describes what your baby has been fed. My baby…
 …is not drinking breast milk now, but was fed breast milk in the past
 …is drinking breast milk now
 …was never fed breast milk
If you answered “My baby is drinking breast milk now” for Question 11, go to Question 14.
If you answered “My baby was never fed breast milk” for Question 11, go to Question 15.
Otherwise go to Question 12.

QUE
12-Month
SAQ
(EHPBHIPBS),
MDES 3.1 Summer
2012,
V3.0 2012, V3.0
QUE
12-Month
Mother
SAQ (EHPBHIPBS),
MDES 3.1
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22

12. How old was your baby when you completely stopped breastfeeding and pumping or expressing breast
milk? (If your baby was less than one month, enter age in weeks. If your baby was older than one month,
enter age in months.)

 Number of

(select one below)

 Weeks
 Months
13. Have you ever fed your baby pumped or expressed breast milk?
 Yes
 No → Go to Question 15
14. In the past 7 days, about how often was your baby fed pumped or expressed breast milk? Include feedings
by everyone who feeds the baby and include snacks and nighttime feedings.









1 time per week
2 to 4 times per week
Nearly every day
1 time per day
2 to 3 times per day
4 to 6 times per day
More than 6 times per day
Not applicable/ I have not fed my baby breast milk in the past 7 days

15. How old was your baby when he/she was first fed formula on a daily basis?







less than 1 month old
1 to 2 months old
3 to 4 months old
5 to 6 months old
More than 6 months old
Not applicable (never fed formula to baby)

If you answered “00” to Question 8 and “Not applicable (never fed formula to baby)” for Question
15, go to the instructions following Question 21.
If you answered any number “01” or more to Question 8, go to Question 17.
If you were unable to answer Question 8, go to Question 16.
16. Has your baby had formula in the last seven days?
 Yes
 No → Go to Instructions following Question 21
 Not applicable (never fed formula to baby) → Go to Instructions following Question 21

QUE
(EHPBHIPBS),
MDES 3.1 MDES
Summer
2012,
V3.0 2012,

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12-MonthSAQ
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SAQ (EHPBHIPBS),
3.1
Summer
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17. What kind of infant formula was your baby fed in the past 7 days? Select all of the formulas that you feed
your baby. Include any formula the baby was fed in the past 7 days that is not included on the list under
“Other.”
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Baby’s Only Organic Dairy
Baby’s Only Organic Soy
Baby’s Only Organic Lactose Free
Bright Beginnings milk-based
Bright Beginnings Gentle milk-based
Bright Beginnings Organic
Bright Beginnings milk-based 2
Bright Beginnings NeoCare
Earth’s Best Organic Infant Formula with DHA & ARA
Earth’s Best Organic Soy Infant Formula with DHA & ARA
EleCare®
Enfamil® Premium with Triple Health Guard
Enfamil® Premium Next Step
Enfamil® ProSobee®
Enfamil® RestFull
Enfamil AR®
Enfamil® Gentlease®
Enfamil® Gentlease® Next Step
Enfamil® Enfacare
Enfamil® Premature
Enfamil® Premium Vanilla or Chocolate
Enfamil® Soy Next Step
Gerber® Good Start® Gentle Plus
Gerber® Good Start® Gentle Plus 2
Gerber® Good Start® Protect Plus
Gerber® Good Start® Protect Plus 2
Gerber® Good Start® Soy Plus
Gerber® Good Start® Soy Plus 2
Nutramigen® with Enflora LGG
Nutramigen® AA
Pregestimil®
Similac® Advance® EarlyShield
Similac Isomil® Advance®
Similac Isomil® DF
Similac® Organic
Similac® Go & Grow
Similac® Go & Grow EarlyShield
Similac® Sensitive
Similac® Sensitive R.S.
Similac® Alimentum®
Similac® Neosure®
Store brand Milk based (like Member’s Mark, Kirkland, Target up & up)
Store brand Gentle or partially broken down whey protein formula
(like Member’s Mark or Target up & up)
Store brand Soy based (like Target up & up)
Store brand Next step (like Target up & up)
Store brand Lacto sensitive (like Target up & up)
Store brand Prebiotic (like Target up & up)
Other ________________________________________________________________________

QUE
(EHPBHIPBS),
MDES 3.1 MDES
Summer
2012,
V3.0 2012,

QUE12-Month
12-MonthSAQ
Mother
SAQ (EHPBHIPBS),
3.1
Summer
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18. Was the formula ready-to-feed, liquid concentrate, powder from a can that makes a single serving, or
powder from single serving packets? Select all of the formulas you feed your baby.





Ready-to-feed
Liquid concentrate
Powder from a can that makes more than one bottle
Powder from single serving packets

If your baby was ONLY fed ready-to-feed formula, go to Question 21.
Otherwise, go to Question 19.
19. During the past 7 days, what types of water have you and others who care for your baby used for mixing
your baby’s formula? Select all of the types of water you have used for mixing your baby’s formula. If you
have used any other type of water, please list the water type on the line below.





Tap water from the cold faucet
Warm tap water from the hot faucet
Bottled water
Other type of water used _____________________________________________

20. Was the water used to mix the formula boiled?
 Yes
 No
21. In the past 7 days, on the average, how many ounces of formula did your baby drink at each feeding?


 Ounces.

In the past 7 days, about how often did your baby drink from each of the following types of bottles and cups?
22. Plastic baby bottle with disposable bottle liner.
 Never
 Sometimes
 Most of the time
 Always
23. Plastic baby bottle without disposable liner.
 Never
 Sometimes
 Most of the time
 Always
24. Other plastic bottle (for example, a water bottle).
 Never
 Sometimes
 Most of the time
 Always
25. Glass baby bottle.
 Never
 Sometimes
 Most of the time
 Always
QUE
(EHPBHIPBS),
MDES 3.1 MDES
Summer
2012,
V3.0 2012,

QUE12-Month
12-MonthSAQ
Mother
SAQ (EHPBHIPBS),
3.1
Summer
V3.0

55

26. Plastic “no spill” cup.
 Never
 Sometimes
 Most of the time
 Always
27. Has your baby used a pacifier in the past 7 days?
 Yes
 No
28. Has your baby ever been fed cow’s milk that was not sold especially for babies? (This includes whole, lowfat, nonfat, or chocolate milk.)
 Yes
 No → Go to Question 30
29. How old was your baby when he/she was first fed cow’s milk that was not sold especially for babies?

.
 Age in months.
30. How old was your baby when he/she was first fed cereal, including baby cereal, on a daily basis?
 less than 1 month old
 1 to 2 months old
 3 to 4 months old
 5 to 6 months old
 More than 6 months old
 Not applicable (never fed cereal)
31. How old was your baby when he/she was first fed pureed baby food on a daily basis? Please include
commercial (store bought) and homemade baby food.
 less than 1 month old
 1 to 2 months old
 3 to 4 months old
 5 to 6 months old
 More than 6 months old
 Not applicable (never fed pureed baby food)
32. How old was your baby when he/she was first fed table food such as eggs, cheese, or potatoes on a daily
basis?
 less than 1 month old
 1 to 2 months old
 3 to 4 months old
 5 to 6 months old
 More than 6 months old
 Not applicable (never fed table food)
33. Which of the following supplements was your child given at least 3 days a week during the past 2 weeks?
Select all of the supplements your child has taken during the past 2 weeks for at least 3 days a week. If
your child has taken any other vitamins or supplements, please list them on the line beside “Other vitamins
or supplements.”






Fluoride
Iron
Vitamin D
Other vitamins or supplements _____________________________________________
Not applicable (child not given supplements)

QUE
(EHPBHIPBS),
MDES 3.1 MDES
Summer
2012,
V3.0 2012,

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12-MonthSAQ
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SAQ (EHPBHIPBS),
3.1
Summer
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34. Was your baby given any herbal or botanical preparations or any kind of tea or home remedy in the past 7
days? Do not count preparations put on the baby’s skin or anything the baby may have gotten from breast
milk after you took an herbal or botanical preparation.
 Yes
 No

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

QUE
(EHPBHIPBS),
MDES 3.1 Summer
2012,
V3.0 2012,

QUE12-Month
12-MonthSAQ
Mother
SAQ (EHPBHIPBS),
MDES 3.1
Summer
V3.0

77

For Office Use Only:

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QUE
(EHPBHIPBS),
MDES 3.1 MDES
Summer
2012,
V3.0 2012,

QUE12-Month
12-MonthSAQ
Mother
SAQ (EHPBHIPBS),
3.1
Summer
V3.0

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