Form 1.1 Survey
Provider-Based Sampling Feasibility Study for the Vanguard (Pilot) Study and Data Collection Updates for the National Children's Study (NICHD)
Provider Based Sampling Eligibility Screener 20120413
Provider-Based Sampling Eligibility Screener (PBS)
OMB: 0925-0593
OMB #: 0925-0593
OMB Expiration Date: 07/31/ 2013
Provider Based Sampling Eligibility Screener (PBS)
Provider Based Sampling Eligibility Screener
Event:
Participant:
|
Pregnancy Screener
Pregnant Woman |
Respondent:
|
Pregnant Woman |
Domain:
|
Questionnaire |
Type of Document:
Allowable Mode:
Allowable Method:
|
Interview
In Person, Telephone, Mail
CAPI/PAPI |
Recruitment Groups: |
PB Sampling (PBS) |
Version: |
1.0 |
Release:
|
MDES 3.0 |
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Provider Based Sampling Eligibility Screener (PBS)
TABLE OF CONTENTS
PROVIDER BASED SAMPLING ELIGIBILITY SCREENER (PBS) 1
INTERVIEWER COMPLETED QUESTION 1
INITIAL CONVERSATION WITH OUTGOING CALLER 2
Provider Based Sampling Eligibility Screener (PBS)
Practice number (PSU#, Practice #, Location #)
|___|___|___|___|___|___|___|___| P |___|___|___| L|___|___|___
PSU# PRACTICE# LOCATION#
(PSU_ID) (PRACT_ID) (LOCAT_ID)
programmer instruction:
preload AND DISPLAY PSU_NUM, PRACT_NUM AND LOCAT_NUM.
CATI, CAPI, and papi
INSTRUCTIONS TO INTERVIEWER: QUESTIONNAIRE AND OTHER REQUIRED TEXT IS SHOWN IN REGULAR FONT. INTERVIEWER INSTRUCTIONS AND TEXT NOT TO BE READ TO RESPONDENTS IS SHOWN IN ALL CAPS. VARIABLE NAMES ARE SHOWN IN BOLD CAPS.
INTERVIEWER COMPLETED QUESTION:
ICO001. WHAT IS THE FULL NAME OF THE PRENATAL PROVIDER THAT IS ASSOCIATED WITH THE SAMPLED WOMAN?
______________________ _______________________
FIRST NAME LAST NAME
(REC_PR_FNAME) (REC_PR_LNAME)
INTERVIEWER INSTRUCTION:
CONFIRM SPELLING OF FIRST AND LAST NAME.
PROGRAMMER INSTRUCTION:
LIMIT FREE TEXT TO 255 CHARACTERS.
INITIAL CONVERSATION WITH OUTGOING CALLER
(TIME_STAMP_ICO_ST1). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
PROGRAMMER INSTRUCTIONS:
IF MODE = CATI, GO TO ICO001.
OTHERWISE, IF MODE = CAPI OR PAPI, GO TO TIME_STAMP_ICO_ST2.
ICO001/(FEMALE_1). Hello, my name is [DATA COLLECTOR’S NAME]. I’m calling from the National Children’s Study. I’d like to speak with {NAME OF WOMAN IDENTIFIED BY PROVIDER}. Is she available?
YES 1 (TIME_STAMP_ICO_ST2)
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
PRELOAD NAME OF POTENTIAL RESPONDENT.
ICO003/(R_PHONE_1). What is a good phone number to reach {NAME OF WOMAN IDENTIFIED BY PROVIDER}?
|___|___|___| - |___|___|___| - |___|___|___|___|
PROGRAMMER INSTRUCTION:
PRELOAD NAME OF POTENTIAL RESPONDENT
REFUSED -1 (R_EMAIL)
DON’T KNOW -2 (R_EMAIL)
RESPONDENT HAS NO TELEPHONE/NOT APPLICABLE -7 (R_EMAIL)
IC003A/(R_PHONE_TYPE1). Is that her home, work, cell, or another phone number?
HOME 1 (R_PHONE_DAY1)
WORK 2 (R_PHONE_DAY1)
CELL 3 (R_PHONE_DAY1)
FRIEND/RELATIVE 4 (R_PHONE_DAY1)
OTHER -5
REFUSED -1 (R_PHONE_DAY1)
DON’T KNOW -2 (R_PHONE_DAY1)
IC003B/(R_PHONE_TYPE1_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
IC003C/(R_PHONE_DAY1). What are the best days of the week to reach the participant?
INTERVIEWER INSTRUCTIONS:
SELECT ALL THAT APPLY.
PROMPT: Any others?
SUNDAY 1
MONDAY 2
TUESDAY 3
WEDNESDAY 4
THURSDAY 5
FRIDAY 6
SATURDAY 7
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
IF R_PHONE_DAY1 = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES.
ICO004/(BEST_TTC1_1). What would be a good time to reach her at this number?
|___|___| : |___|___|
H H M M
REFUSED -1
DON’T KNOW -2
(BEST_TTC1_2)
AM 1
PM 2
REFUSED -1
DON’T KNOW -2
(BEST_TTC1_3)
AFTER TIME REPORTED 1
BEFORE TIME REPORTED 2
REFUSED -1
DON’T KNOW -2
INTERVIEWER INSTRUCTION:
ENTER HOUR AND MINUTE VALUES; THEN SELECT AM OR PM.
ICO005/(R_OTHER_PHONE). Is there another phone number where {NAME OF WOMAN IDENTIFIED BY PROVIDER} can be reached?
PROGRAMMER INSTRUCTION:
PRELOAD NAME OF POTENTIAL RESPONDENT.
YES 1
NO 2 (R_EMAIL)
REFUSED -1 (R_EMAIL)
DON’T KNOW -2 (R_EMAIL)
ICO005A/(R_PHONE_2). What is that phone number?
|___|___|___| - |___|___|___| - |___|___|___|___|
REFUSED -1 (R_EMAIL)
DON’T KNOW -2 (R_EMAIL)
IC005B/(R_PHONE_TYPE2). Is that her home, work, cell, or another phone number?
HOME 1 (R_PHONE_DAY2)
WORK 2 (R_PHONE_DAY2)
CELL 3 (R_PHONE_DAY2)
FRIEND/RELATIVE 4 (R_PHONE_DAY2)
OTHER -5
REFUSED -1 (R_PHONE_DAY2)
DON’T KNOW -2 (R_PHONE_DAY2)
IC005C/(R_PHONE_TYPE2_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
IC005D/(R_PHONE_DAY2). What are the best days of the week to reach the participant?
INTERVIEWER INSTRUCTIONS:
SELECT ALL THAT APPLY.
PROMPT: Any others?
SUNDAY 1
MONDAY 2
TUESDAY 3
WEDNESDAY 4
THURSDAY 5
FRIDAY 6
SATURDAY 7
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
IF R_PHONE_DAY2 = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES.
ICO006/(BEST_TTC2_1). What would be a good time to reach her at this number?
|___|___| : |___|___|
H H M M
REFUSED -1
DON’T KNOW -2
(BEST_TTC2_2)
AM 1
PM 2
(BEST_TTC2_3)
AFTER TIME REPORTED 1
BEFORE TIME REPORTED 2
REFUSED -1
DON’T KNOW -2
INTERVIEWER INSTRUCTION:
ENTER HOUR AND MINUTE VALUES; THEN SELECT AM OR PM.
ICO007/(R_EMAIL). What is the best email address to reach {NAME OF WOMAN IDENTIFIED BY PROVIDER}?
PROGRAMMER INSTRUCTIONS:
PRELOAD NAME OF POTENTIAL RESPONDENT.
SHOW EXAMPLE OF VALID EMAIL ADDRESS SUCH AS [email protected].
ENTER E-MAIL ADDRESS: ___________________________________
REFUSED -1
DON’T KNOW -2
DOES NOT HAVE AN EMAIL ACCOUNT -7
ICO008. Thank you again for speaking with me today. Please ask her to call us at {LOCAL SC PHONE NUMBER}.
(TIME_STAMP_ICO_ET1). PROGRAMMER INSTRUCTIONS:
LOCAL SC PHONE NUMBER.
INSERT DATE/TIME STAMP.
INTERVIEWER INSTRUCTION:
END INTERVIEW.
(TIME_STAMP_ICO_ST2). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
INTERVIEWER INSTRUCTION:
WHEN SPEAKING TO THE POTENTIAL RESPONDENT IDENTIFIED BY A PROVIDER.
ICO009. I’m [NAME] from the National Children’s Study. I’d like to tell you a bit about the Study and see if you are interested and able to take part. I will just need a few minutes of your time. The Information we collect from you is protected by law and we will keep all of it private.
INTERVIEWER INSTRUCTION:
IF ADDITIONAL INFORMATION IS NEEDED, SAY:
The information we get from those who take part in the study may help us learn information that will improve our children’s health for years to come. {INSTITUTION} and {{REC_PR_FNAME} {REC_PR_LNAME}} are part of this important research study aimed at improving the health and well being of children.
PROGRAMMER INSTRUCTIONS:
PRELOAD NAME OF LOCAL ACADEMIC INSTITUTION PARTICIPATING IN THE STUDY AND DISPLAY AS “Institution”.
PRELOAD FIRST AND LAST NAME OF PRENATAL PROVIDER THAT SUBMITTED NAME OF THE POTENTIAL RESPONDENT AND DISPLAY ABOVE AND THEN THROUGHOUT INSTRUMENT.
(TIME_STAMP_ICO_ET2). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
VERBAL PERMISSION TO SCREEN FOR STUDY ELIGIBILITY
VC001. I would like to ask you some questions to determine if you may be able to participate in the Study. You can skip over any question I ask or you can stop the interview at any time. The information we collect from you is protected by law and we will keep all of it private.
(TIME_STAMP_EL_ST). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
EL001/(R_FNAME)/(R_MNAME)/(R_LNAME). What is your full legal name?
________________ ________________ __________________
FIRST NAME MIDDLE NAME LAST NAME
(R_FNAME) (R_MNAME) (R_LNAME)
REFUSED -1
DON’T KNOW -2
INTERVIEWER INSTRUCTIONS:
CONFIRM SPELLING.
IF RESPONDENT REFUSES TO PROVIDE FIRST NAME, ASK FOR INITIALS.
EL003(AGE). How old are you?
ENTER AGE AT LAST BIRTHDAY IN YEARS
|___|___|
AGE
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
INCLUDE A SOFT EDIT/WARNING IF AGE ENTERED IS LESS THAN 18 YEARS.
EL004/(PERSON_DOB). What is your date of birth?
MONTH: |___|___|
M M
DATE: |___|___|
D D
YEAR: |___|___|___|___|
Y Y Y Y
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
INCLUDE A SOFT EDIT/WARNING IF CALCULATED AGE IS LESS THAN 18 YEARS.
FORMAT PERSON_DOB AS YYYYMMDD.
IF FULL DOB IS GIVEN, CALCULATE AGE_RANGE BASED ON RESPONSE; GO TO AGE_ELIG.
IF ONLY MONTH AND YEAR ARE PROVIDED, CALCULATE AGE_RANGE AND GO TO AGE_ELIG.
IF PERSON_DOB = -1 OR -2 AND VALID RESPONSE PROVIDED FOR AGE, CALCULATE AGE_RANGE FROM AGE AND GO TO AGE_ELIG.
IF PERSON_DOB = -1 OR -2 AND AGE = -1 OR -2, GO TO AGE_RANGE.
IF UNDER AGE 18 OR OVER AGE 49, NOT ELIGIBLE FOR THE STUDY, EVEN IF PREGNANT; GO TO AGE_ELIG.
EL005/(AGE_RANGE). Which range best describes your age? Would you say…
INTERVIEWER INSTRUCTION:
DESCRIBE HOW THE ANSWER TO THIS QUESTION DETERMINES RESPONDENT’S ELIGIBILITY AND THAT ALL DATA ARE KEPT CONFIDENTIAL AND SECURE.
Less than 18 1
18-24 2
25-34 3
35-44 4
45-49 5
50-64 6
65 or older 7
REFUSED -1
DON’T KNOW -2
EL006/(AGE_ELIG).
RESPONDENT IS AGE-ELIGIBLE 1
RESPONDENT IS UNDER AGE 18 2
AGE ELIGIBILITY IS UNKNOWN -6
PROGRAMMER INSTRUCTIONS:
IF AGE_RANGE = 1, SET AGE_ELIG = 2 AND PPG_FIRST = 4.
IF AGE_RANGE = 2, 3, 4, 5, 6, OR 7, SET AGE_ELIG = 1.
IF AGE_RANGE = -1 OR -2, SET AGE_ELIG = -6 AND PPG_FIRST = 4.
EL012/(ADDRESS VARIABLES). What is your address?
INTERVIEWER INSTRUCTION:
PROMPT AS NECESSARY TO COMPLETE INFORMATION.
_____________________________________________________
(ADDRESS_1) ADDRESS 1 - STREET/PO BOX
_____________________________________________________
(ADDRESS_2) ADDRESS 2
_____________________________________________________
(UNIT) UNIT
____________________________________________________
(CITY) CITY
|___|___| |___|___|___|___|___| |___|___|___|___
STATE ZIP CODE ZIP+4
(STATE) (ZIP) (ZIP4)
REFUSED -1
DON’T KNOW -2
EL015/(COUNTY). Do you live in {COUNTY}?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
PRELOAD SAMPLED COUNTY.
EL016/(PSU_ELIG_CONFIRM).
LIVES IN {COUNTY} 1
DOES NOT LIVE IN {COUNTY} 2
{COUNTY} ELIGIBILITY IS UNKNOWN -6
INTERVIEWER INSTRUCTION:
THIS QUESTION IS USED TO FLAG ELIGIBILITY.
PROGRAMMER INSTRUCTIONS:
PRELOAD SAMPLED COUNTY.
IF COUNTY = 1, SET PSU_ELIG_CONFIRM = 1.
IF COUNTY = 2, SET PSU_ELIG_CONFIRM = 2.
IF COUNTY = -1 OR -2, SET PSU_ELIG_CONFIRM = -6.
IF AGE_ELIG = 1 AND PSU_ELIG_CONFIRM = 2 OR -6, SET PPG_FIRST = 5.
(ELIG). PROGRAMMER INSTRUCTIONS:
PROGRAM SKIP PATTERNS ACCORDING TO TABLE BELOW:
-
PSU_ELIG_CONFIRM
1
2
3
AGE_ELIG
SAMPLED PSU
PSU NOT SAMPLED
UNKNOWN PSU STATUS
1
AGE-ELIGIBLE
TIME_STAMP_EL_ET
TIME_STAMP_CS_ST
TIME_STAMP_CS_ST
2
YOUNGER THAN AGE 18
TIME_STAMP_CS_ST
TIME_STAMP_CS_ST
TIME_STAMP_CS_ST
-6
UNKNOWN
TIME_STAMP_CS_ST
TIME_STAMP_CS_ST
TIME_STAMP_CS_ST
(TIME_STAMP_EL_ET). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
PREGNANCY SCREENER
(TIME_STAMP_PS_ST). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
PS001. We are asking women of childbearing age a few questions about pregnancy. Not all women who answer these questions will be able to take part in the National Children’s Study. We first want to know….
PS004/(PREGNANT). IF ADULT IS KNOWN TO BE PREGNANT, ADD “(Just to confirm)… are you pregnant now?”
YES 1
NO, NO ADDITIONAL INFORMATION PROVIDED 2
(IF VOLUNTEERED BY RESPONDENT)
NO, RECENTLY LOST PREGNANCY (MISCARRIAGE/ABORTION) 3
NO, RECENTLY GAVE BIRTH 4
NO, UNABLE TO HAVE CHILDREN (HYSTERECTOMY, TUBAL LIGATION) 5
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF PREGNANT = 1, GO TO (ORIG_DUE_DATE_MM)/(ORIG_DUE_DATE_DD)/(ORIG_DUE_DATE_YY).
IF PREGNANT = 3, SET PPG_FIRST = 2 AND GO TO TIME_STAMP_DE_ST.
IF PREGNANT = 2, 4, 5, -1, OR -2, SET PPG_FIRST = 3 AND GO TO TIME_STAMP_DE_ST.
INTERVIEWER INSTRUCTION:
IF NOT PREGNANT, NOT ELIGIBLE FOR THE STUDY.
PS006/(ORIG_DUE_DATE_MM)/(ORIG_DUE_DATE_DD)/(ORIG_DUE_DATE_YY). Congratulations. When is your baby due?
-
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
INTERVIEWER INSTRUCTIONS:
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.
PROGRAMMER INSTRUCTIONS:
CHECK REPORTED DUE DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:
IF DATE IS MORE THAN 9 MONTHS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 9 MONTHS FROM TODAY. RE-ENTER DATE.”
IF DATE IS MORE THAN 1 MONTH BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT OCCURRED MORE THAN A MONTH BEFORE TODAY. RE-ENTER DATE.”
IF VALID DUE DATE WAS PROVIDED, SET (ORIG_DUE_DATE_MM)/(ORIG_DUE_DATE_DD)/(ORIG_DUE_DATE_YY) = YYYYMMDD AS REPORTED.
PS008/(DATE_PERIOD_MM)/(DATE_PERIOD_DD)/(DATE_PERIOD_YY). What was the first day of your last menstrual period?
-
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
INTERVIEWER INSTRUCTIONS:
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.
PROGRAMMER INSTRUCTIONS:
CHECK REPORTED MENSTRUAL DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:
IF DATE IS MORE THAN 10 MONTHS BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 10 MONTHS BEFORE TODAY.
CONFIRM DATE. IF DATE IS CORRECT, ENTER ‘DON’T KNOW’.
IF DATE IS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT HAS NOT OCCURRED YET. RE-ENTER DATE.”
IF VALID DATE WAS PROVIDED, CALCULATE DUE DATE FROM THE FIRST DATE OF LAST MENSTRUAL PERIOD AND SET (ORIG_DUE_DATE_MM)/(ORIG_DUE_DATE_DD)/(ORIG_DUE_DATE_YY) (YYYYMMDD) = (DATE_PERIOD_MM) (DATE_PERIOD_DD)/ (DATE_PERIOD_YY) + 280 DAYS AND GO TO FIRST_VISIT.
IF RESPONDENT PROVIDED VALID DATE IN (ORIG_DUE_DATE_MM), (ORIG_DUE_DATE_DD), AND (ORIG_DUE_DATE_YY), GO TO FIRST_VISIT.
OTHERWISE, IF ORIG_DUE_DATE_MM AND/OR ORIG_DUE_DATE_DD AND/OR ORIG_DUE_DATE_YY = -1 OR -2 , GO TO WEEKS_PREG.
PS009/(WEEKS_PREG). How many weeks pregnant are you now? If you’re not sure, please make your best guess.
|___|___|
NUMBER OF WEEKS
REFUSED -1
DON’T KNOW -2
INTERVIEWER INSTRUCTION:
IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE.
PROGRAMMER INSTRUCTIONS:
REJECT RESPONSES THAT ARE EITHER < 1 WEEK OR GREATER THAN 43 WEEKS.
IF WEEKS_PREG = 1 – 42 , SET (ORIG_DUE_DATE_MM)/(ORIG_DUE_DATE_DD)/(ORIG_DUE_DATE_YY) (YYYYMMDD) =TODAY’S DATE + (280 DAYS – WEEKS_PREG *7) AND GO TO FIRST_VISIT.
IF NO VALID DATE IS CALCULABLE, GO TO MONTH_PREG.
PS010/(MONTH_PREG). How many months pregnant are you now? If you’re not sure, please make your best guess.
|___|___|
NUMBER OF MONTHS
REFUSED -1
DON’T KNOW -2
INTERVIEWER INSTRUCTION:
IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE.
PROGRAMMER INSTRUCTIONS:
REJECT RESPONSES THAT ARE EITHER < 1 MONTH OR GREATER THAN 10 MONTHS.
IF VALID RESPONSE WAS PROVIDED, CALCULATE DUE DATE FROM NUMBER OF MONTHS PREGNANT WHERE (YYYYMMDD) =TODAY’S DATE + (280 DAYS –(MONTH_PREG*30) -15)) AND GO TO FIRST_VISIT.
IF NO VALID RESPONSE IS CALCULABLE, GO TO TRIMESTER.
PS011/(TRIMESTER). Are you currently in your First, Second, or Third trimester?
1ST TRIMESTER (1-3 MONTHS PREGNANT) 1
2ND TRIMESTER (4-6 MONTHS PREGNANT) 2
3RD TRIMESTER (7-9 MONTHS PREGNANT) 3
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
CALCULATE DUE DATE AS FROM REPORTED TRIMESTER:
1ST TRIMESTER: (ORIG_DUE_DATE_MM)/(ORIG_DUE_DATE_DD)/(ORIG_DUE_DATE_YY) = TODAY’S DATE + (280 DAYS – 46 DAYS).
2ND TRIMESTER: (ORIG_DUE_DATE_MM)/(ORIG_DUE_DATE_DD)/(ORIG_DUE_DATE_YY) = TODAY’S DATE + (280 DAYS – 140 DAYS).
3RD TRIMESTER: (ORIG_DUE_DATE_MM)/(ORIG_DUE_DATE_DD)/(ORIG_DUE_DATE_YY) = TODAY’S DATE + (280 DAYS – 235 DAYS).
DON’T KNOW/ REFUSED: (ORIG_DUE_DATE_MM)/(ORIG_DUE_DATE_DD)/(ORIG_DUE_DATE_YY) = TODAY’S DATE + (280 DAYS – 140 DAYS).
SET (ORIG_DUE_DATE_MM)/(ORIG_DUE_DATE_DD)/(ORIG_DUE_DATE_YY) = YYYYMMDD AS CALCULATED.
PS012/(FIRST_VISIT). {Is your visit today/{Was your visit on {DATE OF VISIT}} your first visit to this office to see a doctor, nurse or midwife for this pregnancy?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF MODE = CAPI OR PAPI, DISPLAY “Is your visit today”.
IF MODE = CATI, DISPLAY “Was your visit on” AND PRELOAD AND DISPLAY DATE OF VISIT.
IF FIRST_VISIT = 1, -1, OR -2, GO TO OTHER_OFFICE_VISITS.
OTHERWISE, IF FIRST_VISIT =2, THE RESPONDENT IS NOT ELIGIBLE FOR THE STUDY; SET PPG_FIRST = 6, AND GO TO TIME_STAMP_PS_ET.
PS013/(OTHER_OFFICE _VISITS). Not counting this office, have you seen any other providers (doctor, nurse, or midwife) for this pregnancy?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF OTHER_OFFICE_VISITS = 2, -1, OR -2, THE RESPONDENT IS ELIGIBLE FOR THE STUDY; SET PPG_FIRST = 1, AND GO TO TIME_STAMP_PS_ET.
OTHERWISE, IF OTHER_OFFICE_VISITS = 1, GO TO NUM_OTHER_OFFICE.
PS014/(NUM_OTHER_OFFICE). Not counting this office, how many other offices have you visited for this pregnancy?
|___|___|
NUMBER OF OFFICES
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF NUM_OTHER_OFFICE = -1 OR -2, THE RESPONDENT IS ELIGIBLE FOR THE STUDY; SET PPG_FIRST = 1, AND GO TO TIME_STAMP_PS_ET.
OTHERWISE, IF VALID NUMBER ENTERED, LOOP THROUGH OTHER_OFFICE_NAME AND OTHER_OFFICE_ADDRESS FOR EACH PROVIDER UNTIL TOTAL NUMBER OF LOOPS = NUM_OTHER_OFFICE OR RESPONDENT IS DETERMINED TO BE INELIGIBLE BASED ON RESPONSE TO OTHER_OFFICE_LOCATION OR NUM_PRIOR_VISITS_OTHER_OFFICE FOR ANY PROVIDER.
PS015/(OTHER_OFFICE_NAME). What was the name of the {first/next} provider you visited?
_______________________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
LIMIT FREE TEXT TO 255 CHARACTERS.
IF FIRST LOOP, DISPLAY “first”.
IF SUBSEQUENT LOOP, DISPLAY “next”.
PS016/(OTHER_OFFICE_LOCATION). What is the location of [his/her] office?
INTERVIEWER INSTRUCTIONS:
USE “his” OR “her” AS APPROPRIATE.
PROBE RESPONDENT TO COMPLETE ADDRESS INFORMATION.
CONDUCT A SEARCH FOR AND ENTER ANY MISSING ADDRESS INFORMATION FOR EACH PROVIDER.
_____________________________________________________
(PR_ADDRESS_1) ADDRESS 1 - STREET/PO BOX
_____________________________________________________
(PR_ADDRESS_2) ADDRESS 2
_____________________________________________________
(PR_UNIT) UNIT, SUITE, OR ROOM NUMBER
____________________________________________________
(PR_CITY) CITY
|___|___| |___|___|___|___|___| |___|___|___|___
STATE ZIP CODE ZIP+4
(PR_STATE) (PR_ZIP) (PR_ZIP4)
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
USE ADDRESS INFORMATION TO DETERMINE ELIGIBILITY:
IF ANY PROVIDER ADDRESS IS ON THE FRAME, THE RESPONDENT IS NOT ELIGIBLE FOR THE STUDY; SET PPG_FIRST = 5 AND GO TO TIME_STAMP_PS_ET.
IF NONE OF THE ADDRESSES ARE ON THE FRAME, OR IF ALL ADDRESSES = -1 OR -2, THE RESPONDENT IS ELIGIBLE FOR THE STUDY; SET PPG_FIRST = 1 AND GO TO TIME_STAMP_PS_ET.
PS017/(NUM_PRIOR_VISITS_OTHER_OFFICE). How many prior visits to this office for this pregnancy have you had?
|___|___|
NUMBER OF VISITS
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF NUM_PRIOR_VISITS_OTHER_OFFICE = 2 FOR ANY PROVIDER, THE RESPONDENT IS NOT ELIGIBLE FOR THE STUDY; SET PPG_FIRST = 6, AND GO TO TIME_STAMP_PS_ET.
IF NUM_PRIOR_VISITS_OTHER_OFFICE = 1, -1, OR -2 FOR ANY PROVIDER:
CONTINUE TO LOOP UNTIL TOTAL NUMBER OF LOOPS =
NUM_OTHER_OFFICE OR RESPONDENT IS DETERMINED TO BE INELIGIBLE BASED ON RESPONSES TO OTHER_OFFICE_LOCATION OR NUM_PRIOR_VISITS_OTHER_OFFICE FOR ANY PROVIDER.
IF NUM_PRIOR_VISITS_OTHER_OFFICE = 1 FOR FINAL LOOP, THEN THE RESPONDENT IS ELIGIBLE FOR THE STUDY; SET PPG_FIRST = 1 AND GO TO TIME_STAMP_PS_ET.
(TIME_STAMP_PS_ET). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
DEMOGRAPHIC QUESTIONS
(TIME_STAMP_DE_ST). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
PROGRAMMER INSTRUCTIONS:
IF PPG_FIRST = 2, GO TO LOSS_CONTINUE.
OTHERWISE, GO TO DE002.
DE001/(LOSS_CONTINUE). I’m so sorry about your loss. Would it be all right to ask some additional questions?
YES 1
NO 2 (TIME_STAMP_CS_ST)
REFUSED -1 (TIME_STAMP_CS_ST)
DON’T KNOW -2 (TIME_STAMP_CS_ST)
DE002/(MARISTAT). I’d like to ask about your marital status. Are you
INTERVIEWER INSTRUCTION:
RECORD THE RESPONDENT’S CURRENT MARITAL STATUS.
Married, 1
Not married but living together with a partner 2
Never been married, 3
Divorced, 4
Separated 5
Widowed, 6
REFUSED -1
DON’T KNOW -2
DE003/(EDUC). What is the highest degree or level of school you have completed?
INTERVIEWER INSTRUCTION:
IF USING SHOWCARDS, REFER RESPONDENT TO SHOWCARD DE001. OTHERWISE, READ RESPONSE CATEGORIES TO RESPONDENT.
PROGRAMMER INSTRUCTION:
IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS. OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE.
LESS THAN A HIGH SCHOOL DIPLOMA OR GED 1
HIGH SCHOOL DIPLOMA OR GED 2
SOME COLLEGE BUT NO DEGREE 3
ASSOCIATE DEGREE 4
BACHELOR’S DEGREE (FOR EXAMPLE, BA, BS) 5
POST GRADUATE DEGREE (FOR EXAMPLE, MASTERS OR DOCTORAL) 6
REFUSED -1
DON’T KNOW -2
DE004/(EMPLOY). Last week were you working full time, part time, going to school, keeping house, or something else?
INTERVIEWER INSTRUCTION:
SELECT ALL THAT APPLY.
PROBE AS NEEDED.
WORKING FULL TIME 1 (ETHNIC_ORIGIN)
WORKING PART TIME 2 (ETHNIC_ORIGIN)
WITH A JOB, BUT NOT AT WORK BECAUSE OF TEMPORARY ILLNESS, VACATION, STRIKE 3 (ETHNIC_ORIGIN)
UNEMPLOYED/LAID OFF/LOOKING FOR WORK 4 (ETHNIC_ORIGIN)
RETIRED 5 (ETHNIC_ORIGIN)
IN SCHOOL 6 (ETHNIC_ORIGIN)
KEEPING HOUSE 7 (ETHNIC_ORIGIN)
OTHER -5
REFUSED -1 (ETHNIC_ORIGIN)
DON’T KNOW -2 (ETHNIC_ORIGIN)
DE004A/(EMPLOY_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT FREE TEXT TO 255 CHARACTERS.
DE005/(ETHNIC_ORIGIN). Do you consider yourself to be of Hispanic, Latina, or Spanish origin?
No, not of Hispanic, Latina, or Spanish origin 1
Yes, Mexican, Mexican American, Chicana 2
Yes, Puerto Rican 3
Yes, Cuban 4
Yes, Another Hispanic, Latino, or Spanish origin 5
REFUSED -1
DON’T KNOW -2
DE006/(RACE). What race do you consider yourself to be? You may select one or more.
INTERVIEWER INSTRUCTIONS:
IF USING SHOWCARDS, REFER RESPONDENT TO SHOWCARD DE002. OTHERWISE, READ RESPONSE CATEGORIES TO RESPONDENT.
PROBE: Anything else?
SELECT ALL THAT APPLY.
PROGRAMMER INSTRUCTION:
IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS. OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE.
WHITE 1
BLACK OR AFRICAN AMERICAN 2
AMERICAN INDIAN OR ALASKA NATIVE 3
ASIAN INDIAN 4
CHINESE 5
FILIPINO 6
JAPANESE 7
KOREAN 8
VIETNAMESE 9
OTHER ASIAN 10
NATIVE HAWAIIAN 11
GUAMIAN OR CHAMORRO 12
SAMOAN 13
OTHER PACIFIC ISLANDER 14
SOME OTHER RACE -5
REFUSED -1
DON’T KNOW -2
INTERVIEWER INSTRUCTION:
CODE “MULTI-RACIAL” OR “SOME OTHER RACE” ONLY IF VOLUNTEERED.
PROGRAMMER INSTRUCTIONS:
IF RACE CODED WITH ANY COMBINATION OF VALUES 1 – 14, THEN GO TO PERSON_LANG.
IF RACE CODED -5, OR ANY COMBINATION OF VALUES 1 – 14 AND -5, GO TO RACE_OTH.
IF RACE CODED 15, -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO PERSON_LANG.
DE006A/(RACE_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT FREE TEXT TO 255 CHARACTERS.
DE007/(PERSON_LANG). What is the primary language spoken in your home?
ENGLISH 1 (TIME_STAMP_DE_ET)
SPANISH 2 (TIME_STAMP_ DE_ET)
ARABIC 3 (TIME_STAMP_ DE_ET)
CHINESE 4 (TIME_STAMP_ DE_ET)
FRENCH 5 (TIME_STAMP_ DE_ET)
FRENCH CREOLE 6 (TIME_STAMP_ DE_ET)
GERMAN 7 (TIME_STAMP_ DE_ET)
ITALIAN 8 (TIME_STAMP_ DE_ET)
KOREAN 9 (TIME_STAMP_ DE_ET)
POLISH 10 (TIME_STAMP_ DE_ET)
RUSSIAN 11 (TIME_STAMP_ DE_ET)
TAGALOG 12 (TIME_STAMP_ DE_ET)
VIETNAMESE 13 (TIME_STAMP_ DE_ET)
URDU 14 (TIME_STAMP_ DE_ET)
PUNJABI 15 (TIME_STAMP_ DE_ET)
BENGALI 16 (TIME_STAMP_ DE_ET)
FARSI 17 (TIME_STAMP_ DE_ET)
JAPANESE 18 (TIME_STAMP_ DE_ET)
MANDARIN 19 (TIME_STAMP_ DE_ET)
PORTUGUESE 20 (TIME_STAMP_ DE_ET)
TAIWANESE 21 (TIME_STAMP_ DE_ET)
TURKISH 22 (TIME_STAMP_ DE_ET)
OTHER -5
REFUSED -1 (TIME_STAMP_ DE_ET)
DON’T KNOW -2 (TIME_STAMP_ DE_ET)
DE008/(PERSON_LANG_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT FREE TEXT TO 255 CHARACTERS.
DE009. 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.
PROGRAMMER INSTRUCTION:
PRELOAD CURRENT YEAR - 1.
DE010/(HH_MEMBERS). How many household members are supported by your total combined family income?
|___|___|
NUMBER
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
RESPONSE MUST BE > 0; INCLUDE A SOFT EDIT IF RESPONSE IS > 15.
IF HH_MEMBERS = 1, -1, or -2, GO TO INCOME_4CAT.
OTHERWISE, IF HH_MEMBERS > 1, GO TO NUM_CHILD.
DE010A/(NUM_CHILD). How many of those people are children? Please include anyone under 18 years and anyone 18 years of age or 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.
DE011/(INCOME_4CAT). Of these income groups, which category best represents your total combined family income during the last calendar year?
INTERVIEWER INSTRUCTION:
IF USING SHOWCARDS, REFER RESPONDENT TO SHOWCARD DE003. OTHERWISE, READ RESPONSE CATEGORIES TO RESPONDENT.
PROGRAMMER INSTRUCTION:
IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS. OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE.
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
PROGRAMMER INSTRUCTIONS:
IF AGE_ELIG = 3, GO TO TIME_STAMP_CS_ST.
OTHERWISE, GO TO TIME_STAMP_DE_ET.
(TIME_STAMP_DE_ET). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
TRACING QUESTIONS
(TIME_STAMP_TR_ST). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
TR001. Finally, I would like to ask you a few questions so that staff from the National Children’s Study may contact you again. All information we collect will only be used to stay in touch with you.
TR002/(HOME_PHONE). What is your home phone number?
ENTER PHONE NUMBER AND CONFIRM.
|___|___|___| - |___|___|___| - |___|___|___|___|
REFUSED -1
DON’T KNOW -2
DOES NOT HAVE A HOME PHONE -7
TR003/(CELL_PHONE). What is your cell phone number?
INTERVIEWER INSTRUCTION:
ENTER PHONE NUMBER AND CONFIRM.
|___|___|___| - |___|___|___| - |___|___|___|___|
REFUSED -1
DON’T KNOW -2
DOES NOT HAVE A CELL PHONE... -7
TR003A/(WORK_PHONE). What is your work phone number?
INTERVIEWER INSTRUCTION:
ENTER PHONE NUMBER AND CONFIRM.
|___|___|___| - |___|___|___| - |___|___|___|___|
REFUSED -1
DON’T KNOW -2
DOES NOT HAVE A WORK PHONE... -7
TR004/(EMAIL). What is the best email address to reach you?
PROGRAMMER INSTRUCTION:
SHOW EXAMPLE OF VALID EMAIL ADDRESS SUCH AS [email protected].
ENTER E-MAIL ADDRESS: ___________________________________
REFUSED -1
DON’T KNOW -2
DOES NOT HAVE AN EMAIL ACCOUNT -7
TR005/(SAME_ADDR). Is your mailing address the same as your street address?
YES . 1 (PLAN_MOVE)
NO 2
REFUSED -1
DON’T KNOW -2
TR006/(MAILING ADDRESS VARIABLES). What is your mailing address?
INTERVIEWER INSTRUCTION:
PROMPT AS NECESSARY TO COMPLETE INFORMATION.
_____________________________________________________
(MAIL_ADDRESS_1) ADDRESS 1 - STREET/PO BOX
_____________________________________________________
(MAIL_ADDRESS_2) ADDRESS 2
_____________________________________________________
(MAIL_UNIT) UNIT
____________________________________________________
(MAIL_CITY) CITY
|___|___| |___|___|___|___|___| |___|___|___|___
STATE ZIP CODE ZIP+4
(MAIL_STATE) (MAIL_ZIP) (MAIL_ZIP4)
REFUSED -1
DON’T KNOW -2
TR007/(PLAN_MOVE). Do you plan on moving from your present address in the next few months?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF PLAN_MOVE = 1, GO TO WHERE_MOVE.
OTHERWISE, IF PLAN_MOVE = 2, -1, OR -2, GO TO TR013.
TR008/(WHERE_MOVE). Do you know where you will be moving?
YES 1
NO 2 (WHEN_MOVE)
REFUSED -1 (WHEN_MOVE)
DON’T KNOW -2 (WHEN_MOVE)
TR009/(MOVE_INFO). What is the address of your new home?
ADDRESS KNOWN 1
OUT OF THE COUNTRY 2 (WHEN_MOVE)
PO BOX ADDRESS ONLY 3
REFUSED -1 (WHEN_MOVE)
DON’T KNOW -2 (WHEN_MOVE)
TR010/(NEW_ADDRESS_ID). ENTER ADDRESS
INTERVIEWER INSTRUCTION:
PROBE AND ENTER AS MUCH INFORMATION AS RESPONDENT KNOWS.
_____________________________________________________
(NEW_ADDRESS_1) ADDRESS 1 - STREET/PO BOX
_____________________________________________________
(NEW_ADDRESS_2) ADDRESS 2
_____________________________________________________
(NEW_UNIT) UNIT
____________________________________________________
(NEW_CITY) CITY
|___|___| |___|___|___|___|___| |___|___|___|___
STATE ZIP CODE ZIP+4
(NEW_STATE) (NEW_ZIP) (NEW_ZIP4)
REFUSED -1
DON’T KNOW -2
TR011/(WHEN_MOVE). Do you know when you will be moving?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF WHEN_MOVE = 1, GO TO DATE_MOVE.
OTHERWISE, IF WHEN_MOVE = 2, -1, OR -2, GO TO TR013.
TR012/(DATE_MOVE). When will you move?
MONTH: |___|___|
M M
YEAR: |___|___|___|___|
Y Y Y Y
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
FORMAT DATE_MOVE AS YYYYMM.
TR013. Sometimes if people move or change their telephone number we have difficulty reaching them.
TR014/(CONTACT_1). Could I have the name of a relative not currently living with you who should know where you could be reached in case we have trouble contacting you?
YES 1 (CONTACT_FNAME_1)/(CONTACT_LNAME_1)
NO 2 (TIME_STAMP_TR_ET)
REFUSED -1 (TIME_STAMP_TR_ET)
DON’T KNOW -2 (TIME_STAMP_TR_ET)
DOES NOT HAVE ANY
RELATIVES -7
TR015/(CONTACT_FRND). Could you give me the name and contact information for a friend who does not live with you but would always know how to reach you?
YES 1
NO 2 (TIME_STAMP_TR_ET)
REFUSED -1 (TIME_STAMP_TR_ET)
DON’T KNOW -2 (TIME_STAMP_TR_ET)
TR016/(CONTACT_FNAME_1)/(CONTACT_LNAME_1). What is this person’s name?
________________________ _________________________
FIRST NAME LAST NAME
REFUSED -1 (TIME_STAMP_TR_ET)
DON’T KNOW -2 (TIME_STAMP_TR_ET)
INTERVIEWER INSTRUCTIONS:
IF PARTICIPANT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS
CONFIRM SPELLING OF FIRST AND LAST NAMES.
TR017/(CONTACT_RELATE_1). What is his/her relationship to you?
MOTHER/FATHER 1 (CONTACT_ADDR_1)
BROTHER/SISTER 2 (CONTACT_ADDR_1)
AUNT/UNCLE 3 (CONTACT_ADDR_1)
GRANDPARENT 4 (CONTACT_ADDR_1)
NEIGHBOR 5 (CONTACT_ADDR_1)
FRIEND 6 (CONTACT_ADDR_1)
OTHER -5
REFUSED -1 (CONTACT_ADDR_1)
DON’T KNOW -2 (CONTACT_ADDR_1)
TR018/(CONTACT_RELATE1_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT FREE TEXT TO 255 CHARACTERS.
TR019/(CONTACT_ADDR_1). What is his/her address?
INTERVIEWER INSTRUCTION:
PROMPT AS NECESSARY TO COMPLETE INFORMATION
____________________________________________________
STREET (C_ADDR1_1)/(C_ADDR_2_1)/(C_UNIT_1)
____________________________________________________
CITY (C_CITY_1)
|___|___| |___|___|___|___|___|
STATE ZIP CODE
(C_STATE_1) (C_ZIPCODE_1) (C_ZIP4_1)
REFUSED -1
DON’T KNOW -2
TR020/(CONTACT_PHONE1_1). What is his/her telephone number?
INTERVIEWER INSTRUCTION:
IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS.
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED -1 (CONTACT_FNAME_2)/
(CONTACT_LNAME_2)
DON’T KNOW -2 (CONTACT_FNAME_2)/
(CONTACT_LNAME_2)
CONTACT HAS NO TELEPHONE -7 (CONTACT_FNAME_2)/
(CONTACT_LNAME_2)
TR020A/(CONTACT_PHONE1_TYPE_1). Is that his/her home, work, cell, or another phone number?
HOME 1 (CONTACT_OTHER_PH_1)
WORK 2 (CONTACT_OTHER_PH_1)
CELL 3 (CONTACT_OTHER_PH_1)
FRIEND/RELATIVE 4 (CONTACT_OTHER_PH_1)
OTHER -5
REFUSED -1 (CONTACT_OTHER_PH_1)
DON’T KNOW -2 (CONTACT_OTHER_PH_1)
TR020B/(CONTACT_PHONE1_TYPE_1_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
TR020C/(CONTACT_OTHER_PH_1). Is there another phone number where he/she can be reached?
YES 1
NO 2 (CONTACT_FNAME_2)/
(CONTACT_LNAME_2)
REFUSED -1 (CONTACT_FNAME_2)/
(CONTACT_LNAME_2)
DON’T KNOW -2 (CONTACT_FNAME_2)/
(CONTACT_LNAME_2)
TR020D/(CONTACT_PHONE_2_1). What is that phone number?
|___|___|___| - |___|___|___| - |___|___|___|___|
REFUSED -1 (CONTACT_FNAME_2)/
(CONTACT_LNAME_2)
DON’T KNOW -2 (CONTACT_FNAME_2)/
(CONTACT_LNAME_2)
TR020E/(CONTACT_PHONE2_TYPE_1). Is that his/her home, work, cell, or another phone number?
HOME 1 (CONTACT_FNAME2)/(CONTACT_LNAME_2)
WORK 2 (CONTACT_FNAME2)/(CONTACT_LNAME_2)
CELL 3 (CONTACT_FNAME2)/(CONTACT_LNAME_2)
FRIEND/RELATIVE 4 (CONTACT_FNAME2)/(CONTACT_LNAME_2)
OTHER -5
REFUSED -1 (CONTACT_FNAME2)/(CONTACT_LNAME_2)
DON’T KNOW -2 (CONTACT_FNAME2)/(CONTACT_LNAME_2)
TR020F/(CONTACT_PHONE2_TYPE_1_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
TR021/(CONTACT_FNAME_2)/(CONTACT_LNAME_2). Now I’d like to collect information on a second contact who does not currently live with you. What is this person’s name?
______________ __________________
FIRST NAME LAST NAME
REFUSED -1 (TIME_STAMP_TR_ET)
DON’T KNOW -2 (TIME_STAMP_TR_ET)
NO SECOND CONTACT PROVIDED -7 (TIME_STAMP_TR_ET)
INTERVIEWER INSTRUCTIONS:
IF PARTICIPANT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS
CONFIRM SPELLING OF FIRST AND LAST NAMES.
TR022/(CONTACT_RELATE_2). What is his/her relationship to you?
MOTHER/FATHER 1 (CONTACT_ADDR_2)
BROTHER/SISTER 2 (CONTACT_ADDR_2)
AUNT/UNCLE 3 (CONTACT_ADDR_2)
GRANDPARENT 4 (CONTACT_ADDR_2)
NEIGHBOR 5 (CONTACT_ADDR_2)
FRIEND 6 (CONTACT_ADDR_2)
OTHER -5
REFUSED -1 (CONTACT_ADDR_2)
DON’T KNOW -2 (CONTACT_ADDR_2)
TR023/(CONTACT_RELATE2_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT FREE TEXT TO 255 CHARACTERS.
TR024/(CONTACT_ADDR_2). What is his/her address?
INTERVIEWER INSTRUCTION:
PROMPT AS NECESSARY TO COMPLETE INFORMATION
_____________________________________________________
STREET (C_ADDR1_2)/(C_ADDR_2_2)/(C_UNIT_2)
_____________________________________________________
CITY (C_CITY_2)
|___|___| |___|___|___|___|___|
STATE ZIP CODE
(C_STATE_2) (C_ZIPCODE_2) (C_ZIP4_2)
REFUSED -1
DON’T KNOW -2
TR025/(CONTACT_PHONE1_2). What is his/her telephone number?
INTERVIEWER INSTRUCTION:
IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED -1 (CONTACT_FNAME_3)/
(CONTACT_LNAME_3)
DON’T KNOW -2 (CONTACT_FNAME_3)/
(CONTACT_LNAME_3)
CONTACT HAS NO TELEPHONE -7 (CONTACT_FNAME_3)/
(CONTACT_LNAME_3)
TR025A/(CONTACT_PHONE1_TYPE_2). Is that his/her home, work, cell, or another phone number?
HOME 1 (CONTACT_OTHER_PH_2)
WORK 2 (CONTACT_OTHER_PH_2)
CELL 3 (CONTACT_OTHER_PH_2)
FRIEND/RELATIVE 4 (CONTACT_OTHER_PH_2)
OTHER -5
REFUSED -1 (CONTACT_OTHER_PH_2)
DON’T KNOW -2 (CONTACT_OTHER_PH_2)
TR025B/(CONTACT_PHONE1_TYPE_2_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
TR025C/(CONTACT_OTHER_PH_2). Is there another phone number where he/she can be reached?
YES 1
NO 2 (CONTACT_FNAME_3)/
(CONTACT_LNAME_3)
REFUSED -1 (CONTACT_FNAME_3)/
(CONTACT_LNAME_3)
DON’T KNOW -2 (CONTACT_FNAME_3)/
(CONTACT_LNAME_3)
TR025D/(CONTACT_PHONE_2_2). What is that phone number?
|___|___|___| - |___|___|___| - |___|___|___|___|
REFUSED -1 (CONTACT_FNAME_3)/
(CONTACT_LNAME_3)
DON’T KNOW -2 (CONTACT_FNAME_3)/
(CONTACT_LNAME_3)
TR025E/(CONTACT_PHONE2_TYPE_2). Is that his/her home, work, cell, or another phone number?
HOME 1 (CONTACT_FNAME3)/(CONTACT_LNAME_3)
WORK 2 (CONTACT_FNAME3)/(CONTACT_LNAME_3)
CELL 3 (CONTACT_FNAME3)/(CONTACT_LNAME_3)
FRIEND/RELATIVE 4 (CONTACT_FNAME3)/(CONTACT_LNAME_3)
OTHER -5
REFUSED -1 (CONTACT_FNAME3)/(CONTACT_LNAME_3)
DON’T KNOW -2 (CONTACT_FNAME3)/(CONTACT_LNAME_3)
TR025F/(CONTACT_PHONE2_TYPE_2_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
TR026/(CONTACT_FNAME_3)/(CONTACT_LNAME_3). Now I’d like to collect information on a third contact who does not currently live with you. What is this person’s name?
______________ __________________
FIRST NAME LAST NAME
REFUSED -1 (TIME_STAMP_TR_ET)
DON’T KNOW -2 (TIME_STAMP_TR_ET)
NO THIRD CONTACT PROVIDED -7 (TIME_STAMP_TR_ET)
INTERVIEWER INSTRUCTIONS:
IF PARTICIPANT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS.
CONFIRM SPELLING OF FIRST AND LAST NAMES.
TR027/(CONTACT_RELATE_3). What is his/her relationship to you?
MOTHER/FATHER 1 (CONTACT_ADDR_3)
BROTHER/SISTER 2 (CONTACT_ADDR_3)
AUNT/UNCLE 3 (CONTACT_ADDR_3)
GRANDPARENT 4 (CONTACT_ADDR_3)
NEIGHBOR 5 (CONTACT_ADDR_3)
FRIEND 6 (CONTACT_ADDR_3)
OTHER -5
REFUSED -1 (CONTACT_ADDR_3)
DON’T KNOW -2 (CONTACT_ADDR_3)
TR028/(CONTACT_RELATE3_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT FREE TEXT TO 255 CHARACTERS.
TR029/(CONTACT_ADDR_3). What is his/her address?
INTERVIEWER INSTRUCTIONS:
PROMPT AS NECESSARY TO COMPLETE INFORMATION
_____________________________________________________
STREET (C_ADDR1_3)/(C_ADDR_2_3)/(C_UNIT_3)
_____________________________________________________
CITY (C_CITY_3)
|___|___| |___|___|___|___|___|
STATE ZIP CODE
(C_STATE_3) (C_ZIPCODE_3) (C_ZIP4_3)
REFUSED -1
DON’T KNOW -2
TR030/(CONTACT_PHONE1_3). What is his/her telephone number?
INTERVIEWER INSTRUCTION:
IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED -1 (TIME_STAMP_TR_ET)
DON’T KNOW -2 (TIME_STAMP_TR_ET)
CONTACT HAS NO TELEPHONE -7 (TIME_STAMP_TR_ET)
TR030A/(CONTACT_PHONE1_TYPE_3). Is that his/her home, work, cell, or another phone number?
HOME 1
WORK 2 (TIME_STAMP_TR_ET)
CELL 3 (TIME_STAMP_TR_ET)
FRIEND/RELATIVE 4 (TIME_STAMP_TR_ET)
OTHER -5
REFUSED -1 (TIME_STAMP_TR_ET)
DON’T KNOW -2 (TIME_STAMP_TR_ET)
TR030B/(CONTACT_PHONE1_TYPE_3_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
TR030C/(CONTACT_OTHER_PH_3). Is there another phone number where he/she can be reached?
YES 1
NO 2 (TIME_STAMP_TR_ET)
REFUSED -1 (TIME_STAMP_TR_ET)
DON’T KNOW -2 (TIME_STAMP_TR_ET)
TR030D/(CONTACT_PHONE_2_1). What is that phone number?
|___|___|___| - |___|___|___| - |___|___|___|___|
REFUSED -1 (TIME_STAMP_TR_ET)
DON’T KNOW -2 (TIME_STAMP_TR_ET)
TR030E/(CONTACT_PHONE2_TYPE_1). Is that his/her home, work, cell, or another phone number?
HOME 1 (TIME_STAMP_TR_ET)
WORK 2 (TIME_STAMP_TR_ET)
CELL 3 (TIME_STAMP_TR_ET)
FRIEND/RELATIVE 4 (TIME_STAMP_TR_ET)
OTHER -5
REFUSED -1 (TIME_STAMP_TR_ET)
DON’T KNOW -2 (TIME_STAMP_TR_ET)
TR030F/(CONTACT_PHONE2_TYPE_1_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_TR_ET). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
CLOSING STATEMENTS
(TIME_STAMP_CS_ST). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
CS001/(PPG_FIRST).
PROGRAMMER INSTRUCTION:
DISPLAY APPROPRIATE PPG_FIRST ASSIGNMENT FOR RESPONDENT AS PREVIOUSLY SET.
PREGNANT AND ELIGIBLE 1
RECENT PREGNANCY LOSS 2 (CS003)
NOT PREGNANT 3 (CS004)
AGE-INELIGIBLE 4 (CS004)
INELIGIBLE – NOT SAMPLED PSU 5 (CS004)
INELIGIBLE – PREVIOUS PRE-NATAL VISIT 6 (CS004)
CS002. Thank you for taking the time to answer these questions. You are able to be part of this important study. I would like to tell you more about it and give you all the information you need to decide if you would like to be part of the study. (TIME_STAMP_CS_ET)
CS003. I’m so sorry to hear that you’ve lost your baby. I know this can be a hard time. Thank you for taking the time to answer these questions. Based on what you’ve told me, we will not ask you to take part in the study. Thank you for your time. (TIME_STAMP_CS_ET)
CS004. Thank you for taking the time to answer these questions. Based on what you’ve told me, we will not ask you to take part in the study. Thank you for your time.
(TIME_STAMP_CS_ET). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
FINAL INTERVIEWER-COMPLETED QUESTIONS
(TIME_STAMP_IC_ST). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
IC001/(ENGLISH). WAS THIS DATA COLLECTION SESSION CONDUCTED IN ENGLISH?
YES 1 (INTERPRET)
NO 2
IC003/(CONTACT_LANG). WHAT OTHER LANGUAGE WAS USED TO CONDUCT THIS SESSION?
SPANISH 1 (INTERPRET)
ARABIC 2 (INTERPRET)
CHINESE 3 (INTERPRET)
FRENCH 4 (INTERPRET)
FRENCH CREOLE 5 (INTERPRET)
GERMAN 6 (INTERPRET)
ITALIAN 7 (INTERPRET)
KOREAN 8 (INTERPRET)
POLISH 9 (INTERPRET)
RUSSIAN 10 (INTERPRET)
TAGALOG 11 (INTERPRET)
VIETNAMESE 12 (INTERPRET)
URDU 13 (INTERPRET)
PUNJABI 14 (INTERPRET)
BENGALI 15 (INTERPRET)
FARSI 16 (INTERPRET)
MANDARIN 19 (INTERPRET)
PORTUGUESE 20 (INTERPRET)
TAIWANESE 21 (INTERPRET)
TURKISH 22 (INTERPRET)
OTHER -5
IC004/(CONTACT_LANG_OTH).
SPECIFY _____________________________
PROGRAMMER INSTRUCTION:
LIMIT FREE TEXT TO 255 CHARACTERS.
IC005/(INTERPRET). WAS AN INTERPRETER USED?
YES 1
NO 2 (TIME_STAMP_IC_ET)
IC006/(CONTACT_INTERPRET). WHAT TYPE OF INTERPRETER WAS USED?
BILINGUAL INTERVIEWER 1 (TIME_STAMP_IC_ET)
IN-PERSON PROFESSIONAL INTERPRETER 2 (TIME_STAMP_IC_ET)
IN-PERSON FAMILY MEMBER INTERPRETER 3 (TIME_STAMP_IC_ET)
LANGUAGE-LINE INTERPRETER 4 (TIME_STAMP_IC_ET)
VIDEO INTERPRETER 5 (TIME_STAMP_IC_ET)
SIGN LANGUAGE INTERPRETER 6 (TIME_STAMP_IC_ET)
OTHER -5
IC007/(CONTACT_INTERPRET_OTH).
SPECIFY _____________________________
PROGRAMMER INSTRUCTION:
LIMIT FREE TEXT TO 255 CHARACTERS.
(TIME_STAMP_IC_ET). PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP.
PROGRAMMER INSTRUCTION:
ATTEMPT TO ENROLL WOMAN IF SHE IS PREGNANT AND MEETS AGE AND RESIDENCE ELIGIBILITY REQUIREMENTS.
IF PPG_FIRST = 1 AND AGE_ELIG = 1 OR 3 AND PSU_ELIG_CONFIRM = 1, GO TO APPROPRIATE CONSENT FORM FOR PREGNANT WOMEN.
Public reporting burden for this collection of information is estimated to average 25 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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |
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