Postpartum Survey for Mothers; 6, 9, and 12 months

Prospective Birth Cohort Study Involving Environmental Uranium Exposure in the Navajo Nation

Attach 3f Postpart 6 9 12Mo 2-6-13

Postpartum Survey - 6, 9, 12 months

OMB: 0923-0046

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Shape1

Form Approved:

OMB No. 0923-xxxx

Exp. Date xx/xx/20xx






Shape2 Participant Number: Version 1 _


POSTPARTUM SURVEY FOR MOTHERS: 6, 9, 12 MONTHS

[Pregnancy & Delivery History. Tobacco Use, Alcohol Use sections should be completed only if not completed on a previous month survey]

INTERVIEWERS: PLEASE PRINT CLEARLY]


Date of Interview:


Interviewer Name:


Location of Interview:


Is there any change in your contact information since we last spoke to you?

Yes No Dont Know

UPDATED CONTACT INFORMATION Mailing Address



Telephone Number – Home Cell Message


Are you willing to give us the name of the person who will be providing care for your baby, so that we may contact them to do babys growth and development questionnaires if you are unavailable?

Yes

No

Dont know

Refused

If you dont mind if we contact them please provide their name and contact information below: Name


Phone number


Location of home


1. Where did you deliver your newborn?

Chinle Comprehensive Health Care Facility

Ft. Defiance Indian Hospital

Gallup Indian Medical Center

Kayenta Health Center

Northern Navajo Medical Center (i.e., Shiprock Hospital)

Tuba City Regional Health Care Corporation


2. What is babys birth date? / / DD MM YYYY

Shape3

Public reporting burden of 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX).











Shape4 Participant Number: Version 1 _


3. Did you ever breastfeed your baby?

Yes If yes, 3a. Infant age when first breastfed: days old

No [ If No, skip to 7.]

Refused


4. Since your babys birth, have you ever fed your baby exclusively (ONLY) with breast milk?

Yes If yes, 4a. For how long? months days

No

Refused


5. Are you currently breastfeeding your baby?

Yes If yes, 5a. Number of times breastfeed baby per day

No, [ skip to 7.]

Refused


6. Do you currently feed your baby exclusively (ONLY) with breast milk?

Yes

No

Refused


PREPARATION OF INFANT FOOD/FORMULA


7. Do you use baby formula to feed your baby?

Yes If yes, specify below:

7a. Brand of baby formula

7b. Number of times per day

No

Refused


8. Do you use water to mix or prepare baby formula?

Yes If yes, specify type of water below:

8a. Type of water used to prepare baby formula

Unfiltered tap water

Filtered tap water

Bottled water

Other 8b. Specify

No

Refused


CESSATION OF BREASTFEEDING


9. Have you completely stopped breastfeeding?

Yes If Yes,9a. How old was your baby when you completely stopped breastfeeding?

months weeks

No

Refused


10. Are you currently receiving WIC assistance?

Yes

No

Dont know

Refused





Shape5 Participant Number: Version 1 _


PREGNANCY AND DELIVERY HISTORY

At any time during this recent pregnancy did the doctor or other healthcare provider tell you that you have any of the following conditions?


11.Diabetes

Yes

No

Dont know

Refused





12. High Blood Pressure?

Yes

No

Dont know

Refused


13. Protein in your urine?

Yes

No

Dont know

Refused


14. Preeclampsia or toxemia?

Yes

No

Dont know

Refused


15. Early or premature labor?

Yes

No

Dont know

Refused


16. Anemia or low blood count?

Yes

No

Dont know

Refused


17. Severe nausea or vomiting (hyperemesis)?

Yes

No

Dont know

Refused


18. Bladder or kidney infection?

Yes

No

Dont know

Refused




Participant Number:_______________ Version 1 _


19. Rh disease or isoimmunization?

Yes

No

Dont know

Refused


20. Infection with bacteria called Group B strep?

Yes

No

Dont know

Refused



21. Infection with a Herpes virus?

Yes

No

Dont know

Refused


22. Infection of the vagina with bacteria (bacterial vaginosis)?

Yes

No

Dont know

Refused


23. Any other serious condition?

Yes specify

No


Dont know


Refused



MEDICATION AND SUBSTANCE USE


24. Any change in medications, vitamins, or over the counter medications since your first survey?

Yes if yes go to question 25

No if no go to question 27

Dont know

Refused


25. Are you currently taking doctor-prescribed medications and/or vitamins on a daily basis?

Yes What [prescribed] medications do you take?

25a.


25b.


25c.


25d.



No

25e.






26. Are you currently taking over-the-counter (non-prescription) medications and/or vitamins on a daily basis?

Yes What [over the counter medications] do you take?

26a.


26b.


26c.


26d.



No

26e.


27. Are you currently taking herbal supplements on a daily basis?

Yes What herbal supplements do you take?

27a.


27b.


27c.


27d.



No

27e.


28. Are you currently using any traditional or home remedies?

Yes What remedies do you take?

28a.


28b.


28c.


28d.



No

28e.


29. Have you ever tried or used any other recreational drugs, including illicit or street drugs or drugs that you did not have a doctors prescription for?

Yes 29a. How many times?

Once or twice

10 or more times

Dont know

Refused

No


30. Are you currently smoking marijuana?

Yes

No

Refused







31. Are you currently using other recreational or street drugs, including drugs that you smoke or inject?

Yes What drugs are they?

31a.


31b.


31c.


31d.



No

31e.



32. Have you ever tried or used any other recreational drugs, including illicit or street drugs or drugs that you did not have a doctors prescription for?

Yes →3 2a. How many times?

Once or twice

10 or more times

Dont know

Refused

No

Shape6 Participant Number: Version 1 _



ALCOHOL USE


33. How often did you have a drink containing alcohol in the past year?

Never

Monthly or less

Two to four times a month

Two to three times a week

Four or more times a week


34. How many drinks containing alcohol did you have on atypical day when you were drinking in the past year?

0 drinks

1 or 2

3 or 4

5 or 6

7 to 9


35. How often did you have six or more drinks on one occasion in the past year?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily


TOBACCO USE


36. Do you smoke tobacco only for ceremonial use?

Yes [skip to 45]

No


37. In your lifetime, have you smoked as many as 100 cigarettes?

Yes

No→ [skip to 45]


38. Was there ever a time that you smoked at least 1 cigarette a day for a month or longer?

Yes

No→ [skip to 45]


39. Do you now smoke cigarettes (not including those for ceremonial use only)?

Yes

No






Shape7 Participant Number: Version 1 _


40. For about how many years total would you say that you smoked at least 1 cigarette per day?


| | |................................................. Dont Know

YEARS


41. During the time you smoked at least 1 cigarette a day, about how many cigarettes a day on average?


| | _|

cigarettes/day ......................................... Dont Know


42. When was your last cigarette?

Today

In the past week

More than a week ago

More than a month ago

Before pregnancy

Dont know

Refused


43. Did you ever quit smoking for 6 months or longer?

Yes If Yes: 57a. Did you quit because of your pregnancy?

Yes

No

No


44. If you stopped smoking cigarettes and then started smoking again, for how many years did you quit?


|_ | |

| | |

Dont Know

months quit

years quit



45. Does anyone else in your household smoke on a daily basis?

Yes

No

Dont know

Refused


POSTNATAL DEPRESSION SCALE QUESTIONS


As you have recently had a baby, we would like to know how you are feeling. Please let us know which comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

In the past 7 days:


46. I have been able to laugh and see the funny side of things

As much as I always could

Not quite so much now

Definitely not so much now

Not at all


47. I have looked forward with enjoyment to things

As much as I ever did

Rather less than I used to

Definitely less than I used to

Hardly at all



Shape8 Participant Number: Version 1 _


48 .I have blamed myself unnecessarily when things went wrong

Yes, most of the time

Yes, some of the time

Not very often

No, never


49. I have been anxious or worried for no good reason

No, not at all

Hardly ever

Yes, sometimes

Yes, very often


50. I have felt scared or panicky for no very good reason

Yes, quite a lot

Yes, sometimes

No, not much

No, not at all


51. Things have been getting on top of me

Yes, most of the time I havent been able to cope at all

Yes, sometimes I havent been coping as well as usual

No, most of the time I have coped quite well

No, have been coping as well as ever


52. I have been so unhappy that I have had difficulty sleeping

Yes, most of the time

Yes, sometimes

Not very often

No, not at all


53. I have felt sad or miserable

Yes, most of the time

Yes, quite often

Not very often

No, not at all


54. I have been so unhappy that I have been crying

Yes, most of the time

Yes, quite often

Only occasionally

No, never


55. The thought of harming myself has occurred to me

Yes, quite often

Sometimes

Hardly ever

Never


HOUSING CHARACTERISTICS


50. Has the location of your home changed since your first survey?

Yes

No [Skip to question


Shape9 Participant Number: Version 1 _


Shape10 [The participant may give his or her house number and street/road name, rural address, nearest highway or natural feature, or distance from Chapter House.]





51. Is the house you are living in now…?

Owned or being bought by you or someone in your household

Rented by you or someone in your household, or

Some other arrangement

Dont know

Refused


52. Can you tell us, which of these categories do you think best describes when your home or building was built?

2001 TO present

1981 TO 2000

1961 TO 1980

1941 TO 1960

1940 or before

Dont know

Refused


53. How long have you lived in this home?

| | | Weeks

NUMBER ..... Months

.......... Years

.......... Dont know

.......... Refused


54. What type of home do you live in?

Hogan

Modular or site-built house

Mobile home

Multi-family dwelling or Apartment building

Seasonal camp or lodging

Hotel /motel or other temporary housing

Other Specify

Dont know

Refused


55. What is the construction of your home? (Check all that apply)

Mobile home

Wood frame

Stone

Adobe

Crawlspace or basement

Dirt floor










Shape11 Participant Number: Version 1 _


56. Does your home contain any wood, sheet metal, metal pipes, rocks, sand, tarps, utility poles, railroad ties, or other materials from an abandoned uranium mine or mill?

Yes












No

56a.If yes which materials were used Wood

Sheet metal

Metal pipes

Rocks

Sand

Tarps

Utility poles

Railroad ties

Other:

Dont know

Refused


57. Does your home contain any wood, sheet metal, metal pipes, rocks, sand, utility poles, railroad ties, or other materials from oil and gas operations?

Yes











No

57a.If yes which materials were used Wood

Sheet metal

Metal pipes

Rocks

Sand

Utility poles

Railroad ties

Other:

Dont know

Refused


58. Including yourself, how many people live in your home?


| | | NUMBER


59. Excluding bathrooms, how many total rooms are in your home?


| | | NUMBER


60. Which of these types of heat /fuel sources do you use to heat your home?

Electric

Gas-Natural

Gas-Propane or LP

Oil

Wood

Kerosene or diesel fuel

Coal

Solar energy

No heating source

Other specify

Dont know

Refused

Shape12 Participant Number: Version 1 _


60a.If you burn wood or coal in your home, what is the approximate age of your stove.

1-5 yrs

5-10 yrs

10-15 yrs

>15 yrs


60b.If you burn wood or coal in your home, how often do you personally tend the fire?

Once per day

1-5 x per day or more

Once per week

1-3 times per week

Occasionally


61. How do you cool your home? SELECT ALL THAT APPLY.

Fan

Window or wall air conditioners

Central air conditioning

Evaporative cooler (swamp cooler)

No cooling or air conditioning used

Other specify

Dont know

Refused


62. In the past 12 months, have you seen any water damage inside your home?

Yes

No

Dont know

Refused


63. In the past 12 months, have you seen any mold or mildew on walls or other surfaces inside your home?

Yes

No

Dont know

Refused


64. Since you became pregnant, have any additions been built onto your home to make it bigger, or have any renovations or other construction been done in your home? Include all projects such as painting, wallpapering, carpeting or re-finishing floors.

Yes

No

Dont know

Refused


65. Do you have any pets that spend any time inside your home?

Yes

No

Dont know

Refused









Shape13 Participant Number: Version 1 _


66. What kind of pets are these? SELECT ALL THAT APPLY.

Dog

Cat

66a. Do you change the cat box? Yes No

Lambs or baby goats

Small mammal (rabbit, gerbil, hamster, guinea pig, ferret)

Bird (including chicks)

Fish or reptile (turtle, snake lizard)

Other specify

Dont know

Refused


67. Do you tend livestock on a regular basis in a corral or around your home now?

Yes

No


WATER USAGE


Please answer the following questions if you have moved and/or are hauling water from a new location not mentioned previously. If there is no change since the first survey this survey is complete.


68. Is your home connected to a community water system? Yes No Dont Know


68a. If yes, what is the name of the water system?


68b. If yes, is this your main source of drinking water? Yes No Dont Know


69. Do you haul water? Yes No Refused


69a. If you haul water, what type of container do you use to haul water?

Plastic

Metal

Glass

Wood

Other Specify

Dont know


69b. If you haul water, where do you haul water from? [Check all that apply]

Lake/pond

Stream/river

Spring

Rain Water

Irrigation Water

Cistern or tank at windmill

Windmill

Private well

Grocery or convenience store/ trading post

Navajo Tribal Utility Authority (NTUA) or other public water supply

Other Specify

Dont know






Shape14 Participant Number: Version 1 _


69c. If yes, in what types of containers do you store this hauled water?

Plastic

Metal

Glass

Wood

Concrete

Other Specify

Dont know


69d.If you haul water, do you filter the water you haul?

Yes

If yes, what filters do you use?

Charcoal filter

Ceramic filter

Distillation

Boil

Disinfect

No, dont do anything to the water

Dont know


69e. How many places do you currently haul water from? | | |

............................................................................. NUMBER


70. Using the map, can you identify the location of any water sources from which you or someone in your household has hauled water for drinking or other household use?


Please note all uses of this water for each source identified.


Name/Number of Uses of the water (drinking, cooking, livestock Number of years

Water Source watering, irrigation, bathing, other household uses)


| | |


| | |


| | |


| | |


71. What water source in your home do you use most of the time for drinking?

Hauled water

Tap or piped in water

Filtered tap/piped in water

Bottled water

Other specify

Dont know

Refused










Shape19 Participant Number: Version 1 _


72. What water source in your home is used most of the time for cooking?

Hauled water

Tap or piped in water

Filtered tap/piped in water

Bottled water

Other specify

Dont know

Refused













THANK YOU FOR YOUR TIME AND PARTICIPATION













































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