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pdfOMB No.: 0970-0402
Expiration Date:
ATTACHMENT 1: FAMILY FOLLOW-UP SURVEY
OMB No.: 0970-0402
Expiration Date:
MIHOPE
40008.A05
MIHOPE
15-Month Follow-Up Survey
CATI Requirements
October 31, 2012
CALL-IN
FILL RESPONDENT PHONE NUMBER AND EXTENSION FROM PRELOAD
MakeDialPhone.
PHONE NUMBER DETAILS:
PHONE NUMBER= [PHONE NUMBER]
EXTENSION= [EXTENSION]
CODE ONE ONLY
AUTO DIAL ........................................................................................................... 1
CallDialer
MANUAL DIAL ...................................................................................................... 2
DialResult
QUICK EXIT .......................................................................................................... 3
Finished
RESPONDENT CALLING IN ................................................................................ 4
Hello
MAKEDIALPHONE=1
CallDialer.
INTERVIEWER: PLEASE CLICK ON THE BUTTON IN THE FIELD WITH THREE DOTS TO
MAKE THE CALL.
CALL OUT
DialResult.
INTERVIEWER: CODE RESULT OF DIALING
CODE ONE ONLY
SOMEONE ANSWERS......................................................................................... 1
Hello
NO ANSWER ........................................................................................................ 2
LeaveCase
BUSY..................................................................................................................... 3
LeaveCase
ANSWERING MACHINE ...................................................................................... 4
Verified
ANSWERING SERVICE ....................................................................................... 5
AnsService
PRIVACY MANAGER ........................................................................................... 6
Finished
PHONE/LINE PROBLEMS ................................................................................... 7
PhoneProb
CHANGED TO NEW NUMBER ............................................................................ 8
PhoneNumber
DIALRESULT=4
NAME FROM PRELOAD
Verified.
INTERVIEWER:
DID RECORDING VERIFY [NAME] AT THIS NUMBER?
CODE ONE ONLY
YES ....................................................................................................................... 1
Finished
NO ......................................................................................................................... 0
Finished
DIALRESULT=5
AnsService.
INTERVIEWER: IS THIS THE ANSWERING SERVICE FOR [NAME]?
CODE ONE ONLY
YES, [NAME]’S ANSWERING SERVICE ............................................................. 1
Finished
NO, DEFINITELY NOT [NAME]’S ANSWERING SERVICE ................................ 2
Finished
DON’T KNOW, WOULDN’T SAY, NO NAME WAS GIVEN ................................. 3
AnsOther
ANSSERVICE=3
AnsOther.
INTERVIEWER:
PLEASE ENTER WHAT WAS SAID
___________________________________________________ (STRING 100)
AnsOther
Finished
DIALRESULT=7
PhoneProb.
INTERVIEWER:
CODE PHONE PROBLEM
NOT IN SERVICE; DISCONNECTED; NOT WORKING ...................................... 1
Finished
TEMPORARILY NOT IN SERVICE ...................................................................... 2
Finished
CIRCUIT PROBLEMS; CIRCUITS OVERLOADED ............................................. 3
Finished
FAST BUSY; FAST RING; NO RING ................................................................... 4
Finished
COMPUTER/FAX LINE......................................................................................... 5
Finished
PAGER .................................................................................................................. 6
Finished
CELL PHONE ....................................................................................................... 7
Finished
OTHER PHONE DEVICE………………………………………………………8 .......
Finished
DIALRESULT=1
Hello. Hello, my name is [INTERVIEWER NAME]. I am calling on behalf of Mathematica Policy
Research in Princeton, New Jersey. May I please speak to [NAME]?
CODE ONE ONLY
SPEAKING TO [NAME] ........................................................................................ 1
SampMemb
[NAME] COMES TO THE PHONE ....................................................................... 2
SampMemb
PERSON ASKS WHAT CALL IS ABOUT ............................................................. 3
WhatAbout
NEED TO CALL BACK ......................................................................................... 4
CallBack
NEVER HEARD OF [NAME]/WRONG NUMBER ................................................. 5
PhoneCheck
HELLO=3
WhatAbout.
I’m calling to conduct a follow-up interview for the MIHOPE study. May I speak with
[NAME]? IF RE-ENTRY: I’m calling to finish the interview we are conducting with
[NAME]. When is a good time to reach [NAME]?
CODE ONE ONLY
[NAME] COMES TO THE PHONE ............................................................. 1
SampMemb
NEED TO CALL BACK ............................................................................... 2
CALLBACK
SUPERVISOR REVIEW ............................................................................. 3
Finished
WHATABOUT=1 OR HELLO=1,2 AND RE-ENTRY
SampMemb.
I’m calling to finish the interview we are conducting for the MIHOPE study. Is now a
good time?
CONTINUE INTERVIEW ...................................................................................... 1
NextQuestion
NOT A GOOD TIME……………………………….. ................................................ 2
CallBack
INSERT UNIVERSE
CallBack.
When would be a good time to call back?
INTERVIEWER:
MAKE APPOINTMENT USING THE PARALLEL BLOCK
HELLO=5
Fill PHONE NUMBER from preload
PhoneCheck. I’m sorry, I must have misdialed. I thought I dialed [PHONE NUMBER]. Can you tell
me what number I’ve reached to see what kind of mistake I made?
CODE ONE ONLY
RIGHT NUMBER, NO SUCH PERSON ............................................................... 1
WRONGNUMBER
WRONG CONNECTION/MISDIAL ....................................................................... 2
THANKS
SUPERVISOR REVIEW REQUIRED ................................................................... 3
THANKS
REFUSED TO CONFIRM NUMBER .................................................................... 4
THANKS
PHONECHECK=1 AND RE-ENTRY
WrongNumber.
I’m [INTERVIEWER NAME] from Mathematica Policy Research in Princeton,
New Jersey. I thought we’d recently spoken to someone there and according to the
information I have, we were supposed to call back to interview [NAME]. There must have
been some mistake.
Thanks you for your help. I’ll turn this over to my supervisor.
DIALRESULT=8
PhoneNumber. Please give me the telephone number, area code first.
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HaveExten
DIALRESULT=8 OR
HaveExten.
Is there an extension number?
PROGRAMMER: DISPLAY PHONE NUMBER
YES ....................................................................................................................... 1
EXTENSION
NO ......................................................................................................................... 0
TIMEZONE
HAVEEXTEN=1
Extension.
What is the extension number?
PROGRAMMER: DISPLAY PHONE NUMBER
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(0-9999)
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| EXTENSION
TIMEZONE
DIALRESULT=8
FILL TIMEZONE FROM PRELOAD
TimeZone.
What time zone is that in?
PROGRAMMER:
DISPLAY CURRENT TIME ZONE
CODE ONE ONLY
HAWAII/ALEUTIAN TIME ZONE .......................................................................... 2
ALASKA TIME ZONE............................................................................................ 3
PACIFIC TIME ZONE ........................................................................................... 4
MOUNTAIN TIME ZONE ...................................................................................... 5
CENTRAL TIME ZONE ......................................................................................... 6
EASTERN TIME ZONE......................................................................................... 7
ATLANTIC TIME ZONE ........................................................................................ 8
NEWFOUNDLAND ............................................................................................... 9
OTHER INTERNATIONAL TIME ZONE ............................................................... 98
INSERT UNIVERSE
ObserveDST. Is Daylight Saving Time observed in the area?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
INSERT UNIVERSE
PhoneType.
Is this a home phone, business phone or a cell phone?
CODE ONE ONLY
HOME PHONE ...................................................................................................... 1
OFFICE PHONE ................................................................................................... 2
HOME AND OFFICE PHONE ............................................................................... 3
CELL PHONE ....................................................................................................... 4
PAGER .................................................................................................................. 5
COMPUTER/FAX LINE......................................................................................... 6
OTHER .................................................................................................................. 7
INSERT UNIVERSE
TimeOfDay.
Should this number be used only at certain times of day?
CODE ONE ONLY
ANYTIME .............................................................................................................. 1
DAYTIME ONLY ................................................................................................... 2
EVENING ONLY ................................................................................................... 3
INSERT UNIVERSE
FILL CONTACT INFORMATION FROM PREVIOUS ITEMS
Confirm.
PROGRAMMER: FILL CONTACT INFORMATION FROM PREVIOUS ITEMS
INTERVIEWER: CONFIRM THE INFO ABOVE WITH RESPONDENT, THEN PRESS ENTER.
ALL
IF RESPONDENT=NAME, ‘As you may remember, the’; IF NEW RESPONDENT, ‘The’
SC2.
We previously interviewed you for the MIHOPE study in (MONTH) of (YEAR). Now that your
child is about 15 months old, we’d like to speak with you again to learn about [CHILD]’s
development and to ask some questions about your family.
I will ask you some questions and type in your answers. This interview should take about
an hour to complete. There are no right or wrong answers to these questions. The things
you tell me are very important, so please be as accurate as possible.
You may stop me at any time, and you may ask me to go back to earlier questions to
change your answers. If I ask you something that you are uncomfortable answering, just
tell me and I will move on to the next question.
Everything we talk about today is completely private. Also, you should know that this
interview has been approved by the federal Office of Management and Budget or OMB.
We're not allowed to ask you these questions and you don't have to answer them unless
there is a valid OMB control number. For this interview, the OMB control number is 09700402 and it expires XX/XX/XXXX. All of the study results will be reported for groups of
parents; no results will be analyzed or reported for individuals.
Your participation is completely voluntary. When we finish, Mathematica will send you a
$25 gift card to thank you for your help.
If you have any questions at any time during the interview, please feel free to ask them. Do
you have any questions before we begin?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
FAQ
ALL
SC3.
First, I’d like to confirm the spelling of your name. Could you spell your name for me?
DISPLAY NAME AS INTERVIEWER NOTE
INTERVIEWER:
SPELL NAME FOR RESPONDENT.
PROGRAMMER:
ALLOW RESPONDENT INFO TO BE ENTERED/REVISED IN INFO
SCREEN. FIRST, HAVE INTERVIEWER INDICATE WHETHER THE NAME
IS SPELLED CORRECTLY, THEN IF INCORRECT, ALLOW NAME TO BE
REVISED,
___________________________________________________ (STRING (15))
FIRST NAME
___________________________________________________ (STRING (15))
MIDDLE INITIAL/NAME
___________________________________________________ (STRING (30))
LAST NAME
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
SC4.
Do you go by any other name?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
SC6
DON’T KNOW ....................................................................................................... d
SC6
REFUSED ............................................................................................................. r
SC6
SC4=1
SC5.
What is that name? ENTER NAME
___________________________________________________ (STRING (99))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
PROGRAMMER:
GO TO INFO SCREEN AND LOAD UNDER “OTHER NAME”
NEW RESPONDENTS
Fill PARENT’S DOB from PRELOAD
SC6DOB.
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What is your birth date?
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MONTH DAY
YEAR
(RANGE) (RANGE ) (RANGE)
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IF DOB IS LESS THAN 15 YEARS OLD, GO TO SUPERVISOR REVIEW
DOB CORRECT…………………………………………………………………..1
DOB INCORRECT………………………………………………………………..2
DON’T KNOW ....................................................................................................... d
SC7
REFUSED ............................................................................................................. r
SC7
ALL
Fill PARENT’S DOB from PRELOAD
SC6.
What is your birth date?
PROGRAMMER: DISPLAY DOB AS INTERVIEWER NOTE
PROGRAMMER:
ALLOW BIRTH DATE INFO TO BE ENTERED/REVISED IN INFO SCREEN
INTERVIEWER: COMPARE RESPONSE WITH BIRTH DATE DISPLAYED
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MONTH
DAY
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YEAR
| (1963 – 1998)
IF DOB IS LESS THAN 15 YEARS OLD, GO TO SUPERVISOR REVIEW
DON’T KNOW ....................................................................................................... d
SC7
REFUSED ............................................................................................................. r
SC7
SC6=d, r
SC7.
How old are you?
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IF AGE IS LESS THAN 15 YEARS, GO TO SUPERVISOR REVIEW
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
PREGNANT AT BASELINE
Fill CHILD from PRELOAD
SC11. Now, I would like to make sure we have [CHILD]’s name recorded correctly. (IF MULTIPLE
BIRTH =1: We realize that [CHILD] was part of a multiple birth. For the purposes of this
study, all questions we ask will pertain to [CHILD].
PROGRAMMER:
DISPLAY CHILD’S NAME AS INTERVIEWER NOTE
INTERVIEWER:
VERIFY SPELLING
NAME CORRECT ................................................................................................. 1
SC13
NAME INCORRECT ............................................................................................. 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
INTERVIEWER:
IF RESPONDENT GIVES DIFFERENT NAME, MAKE SURE YOU ARE
TALKING ABOUT THE RIGHT CHILD AND CORRECT FIRST NAME.
IF THE NAME IS CORRECT, PRESS ENTER.
NON-PREGNANT MOMS OR SC8=0
Fill CHILD from SC11 OR SC12
SC13. Is [CHILD] a boy or a girl?
INTERVIEWER:
CONFIRM IF ALREADY KNOWN
CODE ONE ONLY
BOY ....................................................................................................................... 1
GIRL ...................................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
NON-PREGNANT MOMS OR SC8=0
Fill CHILD from SC11 OR SC12
SC14. What is [CHILD]’s birth date?
DISPLAY CHILD’S DOB AS INTERVIEWER NOTE
| | / | | | / | | | | | (2011 – 2014; DATE MUST BE BEFORE DATE OF
MONTH DAY
YEAR
INTERVIEW; FUTURE DATES NOT ALLOWED; DATE
MUST BE 6 MONTHS OR SOONER FROM DATE OF INTERVIEW)
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IF DATE OUT OF RANGE, GO TO SUPERVISOR REVIEW
PROGRAMMER: ALLOW BIRTH DATE INFO TO BE ENTERED/REVISED
IN INFO SCREEN
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HH. ABOUT THE HOUSEHOLD
ALL
HHIntro.
The next questions are about the makeup of your house where [CHILD] lives.
INTERVIEWER:
ENTER 1 TO CONTINUE
NEW RESPONDENTS
HH1.
Are you of Hispanic, Latino, or Spanish origin?
INTERVIEWER: IF YES, ASK: What is your origin?
CODE ONE ONLY
NO, NOT OF HISPANIC, LATINO OR SPANISH ORIGIN ................................... 0
YES, MEXICAN, MEXICAN AMERICAN, CHICANO ........................................... 1
YES, PUERTO RICAN .......................................................................................... 2
YES, CUBAN ........................................................................................................ 3
YES, ANOTHER HISPANIC, LATINO OR SPANISH ORIGIN ............................. 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
NEW RESPONDENTS
HH2.
What is your race? You may name one or more.
INTERVIEWER: CODE ALL RESPONSES. ASK: Any other?
CODE ALL THAT APPLY
WHITE ................................................................................................................... 11
BLACK OR AFRICAN AMERICAN ....................................................................... 12
AMERICAN INDIAN OR ALASKA NATIVE .......................................................... 13
ASIAN INDIAN ...................................................................................................... 14
CHINESE .............................................................................................................. 15
FILIPINO ............................................................................................................... 16
JAPANESE ........................................................................................................... 17
KOREAN ............................................................................................................... 18
VIETNAMESE ....................................................................................................... 19
OTHER ASIAN ...................................................................................................... 20
NATIVE HAWAIIAN .............................................................................................. 21
GUAMANIAN OR CHAMORRO ........................................................................... 22
SAMOAN ............................................................................................................... 23
OTHER PACIFIC ISLANDER .............................................................................. 24
OTHER (SPECIFY) ............................................................................................... 99
______________________________________________________ (STRING (20))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
NEW RESPONDENTS
HH3.
Is any language other than English spoken in your home?
YES ....................................................................................................................... 1
HH4
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HH3=1
HH4.
What other languages are spoken in your home?
CODE ALL THAT APPLY
FRENCH ............................................................................................................... 11
SPANISH .............................................................................................................. 12
CAMBODIAN (KHMER) ........................................................................................ 13
CHINESE .............................................................................................................. 14
HAITIAN CREOLE ................................................................................................ 15
HMONG................................................................................................................. 16
JAPANESE ........................................................................................................... 17
KOREAN ............................................................................................................... 18
VIETNAMESE ....................................................................................................... 19
ARABIC ................................................................................................................. 20
OTHER (SPECIFY) ............................................................................................... 99
______________________________________________________ (STRING (20))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What other language? (STRING 100)
RESPONDENT REPORTED MORE THAN ONE LANGUAGE IN HH4
HH4a. Which of these languages is spoken most often in your home?
PROGRAMMER: DISPLAY ONLY LANGUAGES PROVIDED IN C4
CODE ONE ONLY
French .................................................................................................................. 11
Spanish ................................................................................................................ 12
Cambodian (Khmer) ............................................................................................ 13
Chinese ................................................................................................................ 14
Haitian Creole ...................................................................................................... 15
Hmong .................................................................................................................. 16
Japanese .............................................................................................................. 17
Korean .................................................................................................................. 18
Vietnamese .......................................................................................................... 19
Arabic ................................................................................................................... 20
Other (Specify) .................................................................................................... 99
______________________________________________________ (STRING (20))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HH3=1
Fill LAN from HH4
HH5.
How well do you speak [LAN]? Would you say . . .
CODE ONE ONLY
Very well, .............................................................................................................. 1
Well, ...................................................................................................................... 2
Not very well, or .................................................................................................. 3
Not at all? ............................................................................................................. 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HH3=1
Fill LAN from HH4
HH6.
How well do you speak English? Would you say . . .
CODE ONE ONLY
Very well, .............................................................................................................. 1
Well, ...................................................................................................................... 2
Not very well, or .................................................................................................. 3
Not at all? ............................................................................................................. 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
NEW RESPONDENTS
HH7.
In what country were you born?
CODE ONE ONLY
USA ....................................................................................................................... 059
MEXICO ................................................................................................................ 303
GUATEMALA ........................................................................................................ 313
CUBA .................................................................................................................... 327
DOMINICAN REPUBLIC....................................................................................... 329
INDIA ..................................................................................................................... 210
CHINA ................................................................................................................... 207
PHILIPPINES ........................................................................................................ 233
JAPAN ................................................................................................................... 215
KOREA .................................................................................................................. 217
VIETNAM .............................................................................................................. 247
GUAM.................................................................................................................... 066
SAMOA ................................................................................................................. 527
OTHER (SPECIFY) ............................................................................................... 600
___________________________________________________ (STRING (NUM))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (600): What other country?
ALL
HH8.
Besides you and [CHILD] does anyone else live in your household?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
PROGRAMMER BEGIN LOOP
START BY COLLECTING ALL PERSONS NAMES FIRST. THEN ASK FOR DOB, GENDER, AND
RELATIONSHIP TO [CHILD] FOR EACH MEMBER OF THE HOUSEHOLD.
DISPLAY THE RESPONDENT’S NAME IN ROW 1 OF THE ROSTER AND DISPLAY CHILD IN ROW 2.
MAX NUMBER OF PEOPLE IN HOUSEHOLD =18.
DOB RANGES: MONTH= 1-12; DAY= 1-31
YEAR= 1900-2012
AT DOB, DISPLAY INTERVIEWER NOTE: ENTER A DK TO GET TO YEAR OF BIRTH QUESTION
HH9.
Starting with the oldest person, please tell me the names of all the other people who .
normally live here.
INTERVIEWER: IF R IS UNCOMFORTABLE, YOU CAN ASK THEM TO PROVIDE INITIALS
ONLY AND NO NAMES. IF R IS UNCOMFORTABLE GIVING DATES OF BIRTH, SHE CAN
JUST GIVE YEAR OF BIRTH
PROBE:
Who else lives here?
WHAT IS [NAME]’S AGE?
IS [NAME] MALE OR FEMALE?
WHAT IS [NAME]’S RELATIONSHIP TO ([CHILD]/YOUR UNBORN
CHILD)?
PROBE; IF RESPONDENT SAYS “MOTHER”, PROBE: Are you the
biological mother, adoptive mother or step mother?
PROBE: IF RESPONDENT SAYS “FATHER”, PROBE: Are you the
biological father, adoptive father or step father?
RELATIONSHIP CODES:
BIOLOGICAL FATHER ......................................................................................... 12
ADOPTIVE MOTHER ........................................................................................... 13
ADOPTIVE FATHER............................................................................................. 14
STEPMOTHER ..................................................................................................... 15
STEPFATHER ...................................................................................................... 16
GRANDMOTHER. ................................................................................................. 17
GRANDFATHER ................................................................................................... 18
GREAT GRANDMOTHER .................................................................................... 19
GREAT GRANDFATHER ..................................................................................... 20
SISTER/STEPSISTER .......................................................................................... 21
BROTHER/STEPBROTHER ................................................................................ 22
OTHER RELATIVE OR IN-LAW (FEMALE) ......................................................... 23
OTHER RELATIVE OR IN-LAW (MALE) .............................................................. 24
FOSTER PARENT (FEMALE) .............................................................................. 25
FOSTER PARENT (MALE). .................................................................................. 26
OTHER NON-RELATIVE (FEMALE) .................................................................... 27
OTHER NON-RELATIVE (MALE) ......................................................................... 28
PARENT’S PARTNER (FEMALE) ........................................................................ 29
PARENT’S PARTNER (MALE) ............................................................................. 30
Q#
Q#
Q#
Q#
NAME
(DOB)
GENDER
RELATIONSHIP
a.
___________ (STRING (20))
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___________ (STRING (20))
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END LOOP
END LOOP AT LAST HOUSEHOLD MEMBER.
ALL RESPONDENTS GO TO HH9
ALL
HH10. Do you have a spouse or partner who lives in this household?
YES .......................................................................... 1
NO ............................................................................ 0
DON’T KNOW .......................................................... d
REFUSED ................................................................ r
HH10 = 1
HH11. What is your spouse or partner’s first name?
________________________________ (STRING 15)
DON’T KNOW .......................................................... d
REFUSED ................................................................ r
HH10 = 1
HH12. How old is [SPOUSE FIRST NAME]?
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DON’T KNOW .......................................................... d
REFUSED ................................................................ r
HH10 = 1
HH13. Is [SPOUSE FIRST NAME] male or female?
MALE ....................................................................... 1
FEMALE ................................................................... 2
DON’T KNOW .......................................................... d
REFUSED ................................................................ r
HH9 = 1
HH14. What is [SPOUSE FIRST NAME]’s relationship to [CHILD]?
MOTHER/FEMALE GUARDIAN .............................. 1
FATHER/MALE GUARDIAN .................................... 6
SISTER .................................................................... 11
BROTHER ............................................................... 17
GIRLFRIEND OR PARTNER OF CHILD’S
PARENT/GUARDIAN .............................................. 23
BOYFRIEND OR PARTNER OF CHILD’S
PARENT/GUARDIAN .............................................. 24
GRANDMOTHER .................................................... 25
GRANDFATHER...................................................... 26
AUNT ....................................................................... 27
UNCLE ..................................................................... 28
COUSIN ................................................................... 29
OTHER RELATIVE .................................................. 30
OTHER NON-RELATIVE ......................................... 31
DON’T KNOW .......................................................... d
REFUSED ................................................................ r
CH. CHILD HEALTH AND DEVELOPMENT
ALL
CHIntro.
The next questions are about [CHILD]’s health.
INTERVIEWER:
ENTER 1 TO CONTINUE
PREGNANT AT BASELINE
FILL CHILD’S GENDER, CHILD’S NAME FROM PRELOAD
CH1.
After [CHILD] was born, how long did [he/she] stay in the hospital?
CODE ONE ONLY
LESS THAN 24 HOURS (LESS THAN 1 DAY), ................................................... 1
24 TO 48 HOURS (1 TO 2 DAYS), ....................................................................... 2
3 TO 5 DAYS, ....................................................................................................... 3
6 TO 14 DAYS, ..................................................................................................... 4
MORE THAN 14 DAYS, ........................................................................................ 5
BABY NOT BORN IN HOSPITAL ......................................................................... 6
BABY IS STILL IN THE HOSPITAL ...................................................................... 7
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
CH1 LT 6
CH2.
Were any of these days in the Neonatal Intensive Care Unit (NICU), or were they all in the
regular nursery?
PROBE:
NICU-also known as a newborn intensive care unit, intensive care nursery
(ICN), or special care baby unit (SCBU)—is an intensive care unit specializing
in the care of ill or premature newborn infants
YES, ALL IN NICU ................................................................................................ 1
YES, SOME IN NICU ............................................................................................ 2
NO, ALL IN REGULAR NURSERY ....................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
CH2=1 OR 2
CH3.
How long did [CHILD] stay in the neonatal intensive care unit (NICU) after birth?
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(1-180)
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DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF GT CH2; I recorded that [CHILD] was in the hospital for [CH1] but was in the NICU
for [CH3]. Is that correct?
ALL
CH4.
Is there a place you usually take [CHILD] for well child care, such as shots (vaccinations)
and routine exams?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
CH5.
Was [CHILD] seen by a doctor, nurse, or other health care worker for a one week check-up
after (he/she) was born?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
CH6.
Was [CHILD] seen by a doctor, nurse, or other health care worker for (his/her) 12-month
well-child check-up?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
CH7.
Was [CHILD] seen by a doctor, nurse, or other health care worker for (his/her) 15-month
well-child check-up?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
CH8.
Has [CHILD] gone as many times as you wanted for a well-baby checkup?
YES ....................................................................................................................... 1
CH10
NO ......................................................................................................................... 0
CH9
DON’T KNOW ....................................................................................................... d
CH10
REFUSED ............................................................................................................. r
CH10
CH8=0
CH9.
What kept [CHILD] from having a well-baby checkup?
CODE ALL THAT APPLY
I DIDN’T HAVE ENOUGH MONEY OR INSURANCE TO PAY FOR IT .............. 1
I HAD NO WAY TO GET MY BABY TO THE CLINIC OR OFFICE...................... 2
I DIDN’T HAVE ANYONE TO TAKE CARE OF MY OTHER CHILDREN ............ 3
I COULDN’T GET AN APPOINTMENT ................................................................ 4
MY BABY WAS TOO SICK TO GO FOR ROUTINE CARE ................................. 5
OTHER (SPECIFY) ............................................................................................... 99
___________________________________________________ (STRING 200)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What other reason?
ALL
CH10. Do you think [CHILD] is missing any of the immunizations or shots for children (his/her)
age?
YES ....................................................................................................................... 1
CH11
NO ......................................................................................................................... 0
CH12
DON’T KNOW ....................................................................................................... d
CH12
REFUSED ............................................................................................................. r
CH12
CH10=1
CH11. Why is that?
___________________________________________________ (STRING 300)
Reason
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
CH12. A personal doctor or nurse is a health professional who knows your child well and is
familiar with your child's health history. This can be a general doctor, a pediatrician, a
specialist doctor, a nurse practitioner, or a physician's assistant. Do you have one or more
persons you think of as [CHILD]'s personal doctor or nurse?
CODE ONE ONLY
Yes, one person .................................................................................................. 1
[SKIP]
Yes, more than one person ................................................................................ 2
[SKIP]
No.......................................................................................................................... 3
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH13. Is there a place [CHILD] usually goes when (he/she) is sick or you need advice about
(his/her) health?
CODE ONE ONLY
Yes ........................................................................................................................ 1
CH14
No.......................................................................................................................... 2
CH15
Yes, more than one place ................................................................................... 3
CH14
DON’T KNOW ....................................................................................................... d
CH14
REFUSED ............................................................................................................. r
CH14
CH13= NE2
CH14. Is it a doctor’s office, emergency room, hospital outpatient department, clinic, or some
other place?
CODE ONE ONLY
DOCTOR’S OFFICE ............................................................................................. 1
[SKIP]
HOSPITAL EMERGENCY ROOM ........................................................................ 2
[SKIP]
HOSPITAL OUTPATIENT DEPARTMENT........................................................... 3
[SKIP]
CLINIC OR HEALTH CENTER ............................................................................. 4
[SKIP]
SCHOOL (NURSE’S OFFICE, ATHLETIC TRAINER’S OFFICE, ETC) .............. 5
FRIEND/RELATIVE .............................................................................................. 6
MEXICO/OTHER LOCATIONS OUT OF US ........................................................ 7
DOES NOT GO TO ONE PLACE MOST OFTEN ................................................ 8
OTHER (SPECIFY) ............................................................................................... 99
[SKIP]
___________________________________________________ (STRING 200)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What other place?
ALL
CH15. Overall, would you say [CHILD]'s health is…
CODE ONE ONLY
Excellent, ............................................................................................................. 1
[SKIP]
Very good, ............................................................................................................ 2
[SKIP]
Good, .................................................................................................................... 3
[SKIP]
Fair, or .................................................................................................................. 4
[SKIP]
Poor? .................................................................................................................... 5
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH16. Has a doctor, nurse, or other medical professional told you that [CHILD] has
developmental delays?
PROBE:
INTERVIEWER:
ALL
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
CH17. During the past 12 months, did [CHILD] need a referral to see any doctors or receive any
services?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
CH17=1
CH18. Was getting referrals…
CODE ONE ONLY
A big problem, ..................................................................................................... 1
A small problem, or ............................................................................................. 2
Not a problem? .................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
CH19. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and
others who specialize in one area of health care. During the past 12 months, did [CHILD]
see a specialist?
YES ....................................................................................................................... 1
CH23
NO ......................................................................................................................... 0
CH22
DON’T KNOW ....................................................................................................... d
CH22
REFUSED ............................................................................................................. r
CH22
CH19 NE1
CH20. During the past 12 months, did you or a doctor think that [CHILD] needed to see a
specialist?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
CH19=1 OR CH20= 1
CH21. During the past 12 months, how much of a problem, if any, was it to get the care from the
specialists that [CHILD] needed? Would you say it was…
CODE ONE ONLY
A big problem, ..................................................................................................... 1
A small problem, or ............................................................................................. 2
Not a problem? .................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
CH22. Does anyone help you arrange or coordinate [CHILD]’s care among the different doctors
or services that (he/she) uses?
PROBE:
By “arrange or coordinate,” I mean: Is there anyone who helps you make sure
that [CHILD] gets all the health care and services (he/she) needs, that health
care providers share information, and that these services fit together and are
paid for in a way that works for you?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
CH12=2
CH23. During the past 12 months, have you felt that you could have used extra help arranging or
coordinating [CHILD]’s care among the different health care providers or services?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
CH12=2
CH24. During the past 12 months, how often did you get as much help as you wanted with
arranging or coordinating [CHILD]’s care? Would you say…
CODE ONE ONLY
Never, ................................................................................................................... 1
[SKIP]
Sometimes, or ..................................................................................................... 2
[SKIP]
Usually? ............................................................................................................... 3
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH25. Overall, how satisfied are you with communication among [CHILD]’s doctors and other
health care providers? Would you say…
CODE ONE ONLY
Very satisfied, ...................................................................................................... 1
[SKIP]
Somewhat satisfied, ............................................................................................ 2
[SKIP]
Somewhat dissatisfied, or .................................................................................. 3
[SKIP]
Very dissatisfied? ............................................................................................... 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH26. During the past 12 months, how often did [CHILD]’s doctors and other health care
providers spend enough time with (him/her)? Would you say…
CODE ONE ONLY
Never, ................................................................................................................... 1
[SKIP]
Sometimes, .......................................................................................................... 2
[SKIP]
Usually, or ............................................................................................................ 3
[SKIP]
Always? ................................................................................................................ 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH27. During the past 12 months, how often did [CHILD]’s doctors and other health care
providers listen carefully to you? Would you say…
CODE ONE ONLY
Never, ................................................................................................................... 1
[SKIP]
Sometimes, .......................................................................................................... 2
[SKIP]
Usually, or ............................................................................................................ 3
[SKIP]
Always? ................................................................................................................ 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH28. When [CHILD] is seen by doctors or other health care providers, how often are they
sensitive to your family’s values and customs? Would you say…
CODE ONE ONLY
ALL
Never, ................................................................................................................... 1
[SKIP]
Sometimes, .......................................................................................................... 2
[SKIP]
Usually, or ............................................................................................................ 3
[SKIP]
Always? ................................................................................................................ 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
CH29. Information about a child’s health or health care can include things such as causes of any
health problems, how to care for a child now, and what changes to expect in the future.
During the past 12 months, how often did you get the specific information you needed
from [CHILD]’s doctors and other health care providers? Would you say…
CODE ONE ONLY
Never, ................................................................................................................... 1
[SKIP]
Sometimes, .......................................................................................................... 2
[SKIP]
Usually, or ............................................................................................................ 3
[SKIP]
Always? ................................................................................................................ 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH30. During the past 12 months, how often did [CHILD]’s doctors or other health care providers
help you feel like a partner in (his/her) care? Would you say…
CODE ONE ONLY
Never, ................................................................................................................... 1
[SKIP]
Sometimes, .......................................................................................................... 2
[SKIP]
Usually, or ............................................................................................................ 3
[SKIP]
Always? ................................................................................................................ 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
PRIMARY LANGUAGE ISN’T ENGLISH
CH31. An interpreter is someone who repeats what one person says in a language used by
another person. During the past 12 months, did you need an interpreter to speak with
[CHILD]’s doctors or other health care providers?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
CH31=1
CH32. When you needed an interpreter, how often were you able to get someone other than a
family member to help you speak with [CHILD]’s doctors or other health care providers?
Would you say…
CODE ONE ONLY
Never, ................................................................................................................... 1
[SKIP]
Sometimes, .......................................................................................................... 2
[SKIP]
Usually, or ............................................................................................................ 3
[SKIP]
Always? ................................................................................................................ 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH33. Has [CHILD] made any emergency room visits since (he/she) was born?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH34. Not including when [CHILD] was born, how many different times has (he/she) stayed in a
hospital for at least one night?
| | |
(0-50)
|
| TIMES
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question
HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question
CH34 GTE 1
CH35. Altogether, since (he/she) was born, how many nights did [CHILD] stay in a hospital?
| | |
(0-50)
|
| NIGHTS
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question
HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question
CH34 GTE 1
If CH35=1, ‘Was this hospitalization’ ; if CH35 GT 1, ‘Were any of these hospitalizations’
CH36. (Was this hospitalization/ Were any of these hospitalizations) because of an accident or
injury? For example, burns, falls, poisoning or choking?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
CH34 NE 1 AND CH36=1
NUMBER FROM CH35
CH37. How many of the [CH35] hospitalizations were because of an accident or injury?
| | | |
(0-CH38)
| HOSPITALIZATIONS
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question
HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question
ALL
INSERT FILL CONDITION OR DELETE ROW
CH38. Does [CHILD] have any chronic condition for which (he/she) is seen regularly by a doctor?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
CH38=1
CH39. What is the problem or condition?
___________________________________________________ (STRING 200)
PROBLEM OR CONDITION
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH40. Sometimes people have difficulties in getting medical care when they need it. In the past
12 months, have you delayed or gone without health care for [CHILD]?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
CH41. During the past 12 months, was there any time when [CHILD] needed prescription
medications?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
CH41=1
CH42. Did [CHILD] receive all prescription medications (he/she) needed?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
CH42=0
CH43. Why did [CHILD] not get the prescription medications (he/she) needed?
CODE ALL THAT APPLY
COST TOO MUCH................................................................................................ 1
[SKIP]
HEALTH PLAN PROBLEM ................................................................................... 2
[SKIP]
NOT AVAILABLE IN AREA/TRANSPORT PROBLEM ......................................... 3
[SKIP]
OTHER (SPECIFY) ............................................................................................... 99
[SKIP]
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What other reason?
ALL
FILL MEDICAID NAMES
CH44. Does [CHILD] have any kind of health care coverage, including health insurance, prepaid
plans such as HMOS, or government plans such as Medicaid?
PROBE:
Medicaid refers to a medical assistance program that provides health care
coverage to low-income and disabled persons. The Medicaid program is a joint
federal-state program that is administered by the states.
HMO is Health Maintenance Organization.
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
FILL CHIP NAMES
CH45. Is [CHILD] insured by Medicaid or the State Children’s Health Insurance Program or SCHIP? In this state, the program is sometimes called [FILL MEDICAID NAME, S-CHIP
NAME].
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH46. Have you ever received help in applying for health insurance for [CHILD]?
YES ....................................................................................................................... 1
CH52
NO ......................................................................................................................... 0
CH51
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
CH46=0
CH47. Have you ever wanted or needed help in applying for health insurance for [CHILD]?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
CH46 NE 0
CH48. Are you currently receiving help in applying for health insurance for [CHILD]?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
CH49. The next questions are about [CHILD]’s dental health. Does [CHILD] have any teeth yet?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH50. Do you clean [CHILD]'s teeth or gums every day, either by wiping with a clean, damp cloth
or with a small, soft toothbrush?
ALL
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
CH51. During the past 12 months, did [CHILD] see a dentist for any kind of dental care, including
check-ups, dental cleanings, x-rays, or filling cavities? Include visits to dental hygienists
and all types of dental specialists.
YES ....................................................................................................................... 1
CH56
NO ......................................................................................................................... 0
CH57
DON’T KNOW ....................................................................................................... d
CH58
REFUSED ............................................................................................................. r
CH58
CH51=1
CH52. During the past 12 months, how many times did [CHILD] see a dentist for preventive dental
care, such as check-ups and dental cleanings?
| | |
(1-20)
|
| TIMES
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question
HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question
CH50=0 OR CH51=0
CH53. What is the main reason your child has not visited a dentist in the past year?
CODE ONE ONLY
NO REASON TO GO/NO PROBLEMS ................................................................ 1
[SKIP]
NOT OLD ENOUGH ............................................................................................. 2
[SKIP]
COULD NOT AFFORD IT/TOO EXPENSIVE/NO INSURANCE .......................... 3
[SKIP]
FEAR, DISLIKES GOING ..................................................................................... 4
[SKIP]
DO NOT HAVE/KNOW A DENTIST ..................................................................... 5
[SKIP]
CANNOT GET TO THE OFFICE/CLINIC ............................................................. 6
[SKIP]
NO DENTIST AVAILABLE/NO APPOINTMENTS AVAILABLE ........................... 7
[SKIP]
DIDN’T KNOW WHERE TO GO ........................................................................... 8
[SKIP]
HOURS NOT CONVENIENT ................................................................................ 9
[SKIP]
DIDN’T KNOW WHERE TO GO ........................................................................... 10
[SKIP]
SPEAK A DIFFERENT LANGUAGE .................................................................... 11
[SKIP]
OTHER (SPECIFY) ............................................................................................... 99
[SKIP]
___________________________________________________ (STRING 200)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What other reason?
ALL
CH54. How old was [CHILD] in months when (he/she) started to…
PROGRAMMER:
RANGE FOR GRID IS NUMBER RANGE
MONTHS (116)
a. Sit alone, steady, without support?
|
|
|
|
|
b. Crawl on hands and knees?
|
|
|
|
|
c.
|
|
|
|
|
|
|
|
|
|
Pull (him/her)self to a standing position?
d. First walk while holding on to something, such as furniture?
ALL
CH55. Where does [CHILD] sleep?
PROBE:
If respondent says “in a crib,” probe for location.
CODE ONE ONLY
INFANT CRIB IN A SEPARATE ROOM, .............................................................. 1
[SKIP]
INFANT CRIB IN PARENTS' ROOM .................................................................... 2
[SKIP]
IN PARENTS' BED ............................................................................................... 3
[SKIP]
INFANT CRIB IN A ROOM WITH SIBLING .......................................................... 4
[SKIP]
OTHER (SPECIFY) ............................................................................................... 99
[SKIP]
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
IF OTHER SPECIFY (99): Where does [CHILD] sleep?
ALL
CH56. In what position does [CHILD] sleep most of the time? Is it…
CODE ONE ONLY
On (his/her) belly, ................................................................................................ 1
[SKIP]
On (his/her side), or ............................................................................................ 2
[SKIP]
On (his/her) back? ............................................................................................... 3
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH57. How much time does your child spend in sleep during the night, that is, between 7 in the
evening and 7 in the morning?
PROGRAMMER:
|
|
|
| HOURS (0-12)
|
|
|
| MINUTES (0-60)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
CH58. How much time does your child spend in sleep during the day, that is, between 7 in the
morning and 7 in the evening?
PROGRAMMER:
|
|
|
| HOURS (0-12)
|
|
|
| MINUTES (0-60)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
CH59. How many times on average does your child wake at night?
| | |
(0-20)
|
| TIMES
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question
HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question
CH59 GT 0
CH60. How much time does your child spend in wakefulness during the night between the hours
or 10 pm and 6 am?
PROGRAMMER:
|
|
|
| HOURS (0-12)
|
|
|
| MINUTES (0-60)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
CH61. How long does it take to put your child to sleep in the evening?
PROGRAMMER:
|
|
|
| HOURS (0-12)
|
|
|
| MINUTES (0-60)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
CH62. How does your child usually fall asleep? Is it while…
CODE ONE ONLY
Feeding, ............................................................................................................... 1
[SKIP]
Being rocked, ...................................................................................................... 2
[SKIP]
Being held, ........................................................................................................... 3
[SKIP]
In bed alone, or .................................................................................................... 4
[SKIP]
In bed near a parent? .......................................................................................... 5
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
IF OTHER SPECIFY (99): Insert Other specify statement/question
ALL
CH63. At what time does your baby usually fall asleep for the night?
|
|
| HOURS (1-12)
|
|
| MINUTES (0-60)
AM ......................................................................................................................... 1
[SKIP]
PM ......................................................................................................................... 2
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SOFT CHECK: IF CONDITION (e.g. 1:00AM – 5:00AM); Soft check statement/question
HARD CHECK: IF CONDITION (e.g. 1:00AM – 5:00AM); Hard check statement/question
ALL
CH64. Do you consider your child's sleeping to be problematic? Would you say…
CODE ONE ONLY
A very serious problem, ..................................................................................... 1
[SKIP]
A small problem, or ............................................................................................. 2
[SKIP]
Not a problem at all? ........................................................................................... 3
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH65. Have you ever heard or read about what can happen if a baby is shaken?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH66. Next, I’m going to read you a series of topics. For each, please tell me whether anyone has
discussed these topics with you. Please count only discussions, not reading materials or
videos.
YES
NO
a. How you and your family can be exposed to lead in your environment?
1
0
b. What steps you can take to prevent you and your family from being
exposed to lead?
1
0
1
0
c.
How eating fish containing high levels of mercury could affect your
baby?
ALL
CH67. Do you have a car seat that you can use for your baby?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH68. When [CHILD] rides in a car, truck, or van, how often does (he/she) ride in a car seat?
Would you say…
SELECT CODING TYPE
Always, ................................................................................................................. 1
[SKIP]
Often, .................................................................................................................... 2
[SKIP]
Sometimes, .......................................................................................................... 3
[SKIP]
Rarely, or .............................................................................................................. 4
[SKIP]
Never? .................................................................................................................. 5
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
CH69. Brief Infant Toddler Social and Emotional Assessment (BITSEA), 42 items
P. PARENTING
ALL
P1.
Did you ever breastfeed or pump breast milk to feed [CHILD] after delivery?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
P1=1
P2.
Are you currently breastfeeding or feeding pumped milk to [CHILD]?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
P1=1
P3.
How many weeks or months did you breastfeed or pump milk to feed [CHILD]?
|
|
| WEEKS
(----------; CANNOT BE GT AGE OF BABY)
|
|
| MONTHS
(------------; CANNOT BE GT AGE OF BABY)
IF LESS THAN ONE WEEK, CODE 1
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
PREGNANT AT BASELINE
P4.
How old was [CHILD] the first time (he/she) ate or drank anything other than breast milk or
formula?
|
|
| WEEKS
(1-26 WEEKS)
|
|
| MONTHS (1-6 MONTHS)
BABY WAS LESS THAN ONE WEEK OLD ......................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
P5.
How old was [CHILD] the first time (he/she) ate food (such as baby cereal, baby food or
any other food)?
|
|
| WEEKS
(1-26 WEEKS)
|
|
| MONTHS (1-6 MONTHS)
BABY WAS LESS THAN ONE WEEK OLD ......................................................... 0
NEVER .................................................................................................................. 1
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
P1=0
P6.
What were your reasons for not breastfeeding [CHILD]?
CODE ALL THAT APPLY
MY BABY HAD DIFFICULTY LATCHING OR NURSING .................................... 1
MY NIPPLES WERE SORE, CRACKED, OR BLEEDING ................................... 2
IT WAS TOO HARD, PAINFUL OR TOO TIME-CONSUMING ............................ 3
MY BABY WAS SICK AND I WAS NOT ABLE TO BREASTFEED...................... 4
I WAS SICK OR ON MEDICINE .......................................................................... 5
I HAD OTHER CHILDREN TO TAKE CARE OF .................................................. 6
I HAD TOO MANY OTHER HOUSEHOLD DUTIES ............................................ 7
I DIDN’T LIKE BREASTFEEDING ........................................................................ 8
I DIDN’T WANT TO .............................................................................................. 9
I WAS EMBARRASSED TO BREASTFEED ........................................................ 10
I GOT SICK AND WAS NOT ABLE TO BREASTFEED ....................................... 11
MY BABY WAS JAUNDICED (YELLOWING OF THE SKIN OR WHITES OF
THE EYES) ........................................................................................................... 12
OTHER (SPECIFY) ............................................................................................... 99
___________________________________________________ (STRING 200)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
P2=0
P7.
What were your reasons for stopping breastfeeding?
CODE ALL THAT APPLY
MY BABY HAD DIFFICULTY LATCHING OR NURSING .................................... 1
BREAST MILK ALONE DID NOT SATISFY MY BABY ........................................ 2
I THOUGHT MY BABY WAS NOT GAINING ENOUGH WEIGHT ....................... 3
MY NIPPLES WERE SORE, CRACKED, OR BLEEDING ................................... 4
IT WAS TOO HARD, PAINFUL OR TOO TIME CONSUMING ........................... 5
I THOUGHT I WAS NOT PRODUCING ENOUGH MILK ..................................... 6
MY BABY WAS SICK AND WAS NOT ABLE TO BREASTFEED........................ 7
I WAS SICK OR ON MEDICINE .......................................................................... 8
I HAD OTHER CHILDREN TO TAKE CARE OF ................................................ 9
I HAD TOO MANY OTHER HOUSEHOLD DUTIES ............................................ 10
I DIDN’T LIKE BREASTFEEDING ........................................................................ 11
I TRIED BUT IT WAS TOO HARD ........................................................................ 12
I DIDN’T WANT TO ............................................................................................... 12
I WAS EMBARRASSED TO BREASTFEED ........................................................ 13
I FELT IT WAS THE RIGHT TIME TO STOP BREASTFEEDING ....................... 14
I GOT SICK AND WAS NOT ABLE TO BREASTFEED ....................................... 15
I WENT BACK TO WORK OR SCHOOL .............................................................. 16
MY EMPLOYER DOES NOT SUPPORT BREASTFEEDING .............................. 17
I WANTED MY BODY BACK TO MYSELF........................................................... 18
I WENT BACK TO WORK OR SCHOOL .............................................................. 19
MY BABY WAS JAUNDICED (YELLOWING OF THE SKIN OR WHITES OF
THE EYES) ........................................................................................................... 20
OTHER (SPECIFY) ............................................................................................... 99
___________________________________________________ (STRING 200)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
P8.
What kind of milk did [CHILD] usually drink during the past 7 days?
CODE ONE ONLY
WHOLE MILK ........................................................................................................ 1
2% MILK ............................................................................................................... 2
SKIM MILK ............................................................................................................ 3
LOW FAT OR 1% MILK ....................................................................................... 4
SOY MILK ............................................................................................................ 5
BOTH REGULAR COW’S MILK AND SOY MILK ................................................ 6
OTHER (SPECIFY) ............................................................................................... 99
___________________________________________________ (STRING (NUM))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What kind of milk did [CHILD] drink?
ALL
P9.
During the past 7 days, how many times did [CHILD] drink 100% fruit juice? Was it..
CODE ONE ONLY
FOUR OR MORE TIMES A DAY .......................................................................... 1
TWO OR THREE TIMES A DAY .......................................................................... 2
ONCE A DAY ........................................................................................................ 3
ALMOST EVERY DAY .......................................................................................... 4
1 TO 3 TIMES DURING THE PAST 7 DAYS ....................................................... 5
MY CHILD DOES NOT DRINK JUICE ................................................................. 6
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
P10.
During the past 7 days, how many times did [CHILD] drink 100% fruit drinks that are not
100% fruit (for example, Kool Aid, Sunny Delight, Hi-C, Fruitopia, or Fruitworks), sports
drinks (for example, Gatorade), or soda pop (for example, Coke, Pepsi or Mountain Dew)?
CODE ONE ONLY
FOUR OR MORE TIMES A DAY .......................................................................... 1
TWO OR THREE TIMES A DAY .......................................................................... 2
ONCE A DAY ........................................................................................................ 3
ALMOST EVERY DAY .......................................................................................... 4
1 TO 3 TIMES DURING THE PAST 7 DAYS ....................................................... 5
HE/SHE DID NOT DRINK THESE BEVERAGES ................................................ 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
P11.
How many times do you offer a new food before you decide [CHILD] does not like it?
CODE ONE ONLY
ONCE ................................................................................................................... 1
TWICE.................................................................................................................. 2
THREE TO FIVE TIMES ................................................................................... 3
SIX TO TEN TIMES ........................................................................................... 4
MORE THAN TEN TIMES ................................................................................ 5
CHILD LIKES EVERYTHING ................................................................................ 6
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
P12.
Do you consider [CHILD]…
CODE ONE ONLY
A very picky eater, .............................................................................................. 1
A somewhat picky eater, or ............................................................................... 2
Not a picky eater ................................................................................................. 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
P13.
During the past 7 days, how many times did [CHILD] eat a meal or snack from a fast food
restaurant with no wait service such as McDonald's, Pizza Hut, Burger King, Kentucky
Fried Chicken, Taco Bell, Wendy's and so on? Consider eating in, carry out, and delivery
of meals to your residence.
CODE ONE ONLY
Four or more times a day, .................................................................................. 1
Two or three times a day, ................................................................................... 2
Once a day, .......................................................................................................... 3
Almost every day, or ........................................................................................... 4
1 to 3 times during the past 7 days ................................................................... 5
HE/SHE DID NOT EAT FAST FOOD ................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
P14.
During the past 7 days, how many times did [CHILD] eat candy (including Fruit Roll-Ups
and similar items), ice cream, cookies, cakes, brownies, or other sweets?
CODE ONE ONLY
FOUR OR MORE TIMES A DAY .......................................................................... 1
TWO OR THREE TIMES A DAY .......................................................................... 2
ONCE A DAY ........................................................................................................ 3
ALMOST EVERY DAY .......................................................................................... 4
1 TO 3 TIMES DURING THE PAST 7 DAYS ....................................................... 5
HE/SHE DID NOT EAT CANDY ........................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
P15.
During the past 7 day, how many times did [CHILD] eat potato chips, corn chips such as
Fritos or Doritos, Cheetos, pretzels, popcorn, crackers or other salty snack foods? Was
it…
CODE ONE ONLY
FOUR OR MORE TIMES A DAY .......................................................................... 1
TWO OR THREE TIMES A DAY .......................................................................... 2
ONCE A DAY ........................................................................................................ 3
ALMOST EVERY DAY .......................................................................................... 4
1 TO 3 TIMES DURING THE PAST 7 DAYS ....................................................... 5
HE/SHE DID NOT EAT SALTY SNACK FOODS ................................................. 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
P16.
Parent Stress Index- Short Form (PSI-SF), 10 items
RESPONDENTS WHO LIVE WITH BIO DAD
FILL NAME OF CHILD’S BIO DAD from Preload or household roster.
P17.
Since [CHILD] was born, how many months have you lived in the same household as [BIO
DAD]?
| | | | | DESCRIPTION
(NUMBER RANGE)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
P18.
In the past 3 months, how often did [BIO DAD] buy things for [CHILD], such as food,
diapers, clothes, or toys, or give you money to buy things for [CHILD]? Would you
say…Every day or almost every day, a few times a week, a few times a month, less than a
few times a month, or never?
CODE ONE ONLY
Every day or almost every day, ......................................................................... 1
A few times a week, ............................................................................................ 2
A few times a month, .......................................................................................... 3
Less often than a few times a month ................................................................ 4
Never .................................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
P19.
During the past 3 months, how often has [BIO DAD] helped you in other ways, such as
caring for [CHILD], helping around the house or with chores, or providing transportation to
places you needed to go? Would you say…
CODE ONE ONLY
Every day or almost every day, ......................................................................... 1
A few times a week, ............................................................................................ 2
A few times a month, .......................................................................................... 3
Less often than a few times a month ................................................................ 4
Never .................................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
BIO DAD NOT LIVING IN HOUSEHOLD
P20.
In the past 3 months, about how often has [CHILD] seen (his/her) [BIO DAD]? Would you
say…
CODE ONE ONLY
Every day or almost every day, ......................................................................... 1
A few times a week, ............................................................................................ 2
A few times a month, .......................................................................................... 3
Less often than a few times a month ................................................................ 4
Never .................................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
FILL CHILD’S AGE
P21.
Conflict Tactics Scale- Parent Child Version (CTS-PC), 13 items
ALL
FILL LOCAL NAME OF CHILD PROTECTIVE SERVICES FROM PRELOAD
P22.
Since [CHILD] was born, has Child Protective Services or [LOCAL NAME OF CHILD
PROTECTIVE SERVICES] contacted you about [CHILD].
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
PH. PARENT HEALTH AND WELL-BEING
ALL
PH1.
In general, would you say your health is…
CODE ONE ONLY
Excellent, ............................................................................................................. 1
Very good, ........................................................................................................... 2
Good, .................................................................................................................... 3
Fair, or .................................................................................................................. 4
Poor? .................................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
PH2.
How tall are you without shoes?
PROBE:
You may answer in feet and inches or meters and centimeters.
INTERVIEWER: TO RESPOND IN FEET AND INCHES, ENTER 1. TO RESPOND IN METERS
AND CENTIMETERS, ENTER 2.
|
| FEET (3 – 6)
|
|
| INCHES (0 – 11) ALLOW DECIMAL
|
|
| METERS (0-2)
|
|
| CENTIMETERS (0-211)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
PH3.
How much do you weigh without shoes? Your best estimate is fine.
|
|
|
| POUNDS (085 – 500)
|
|
|
| KILOS (038 – 227)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
PH4.
The following questions are about activities you might do during a typical day. Does your
health now limit you in these activities? If so, are you limited a lot, or limited a little?
CODE ONE PER ROW
Yes, limited a lot
Yes, limited a little
No, not limited
at all
a. Moderate activities, such as moving a
table, pushing a vacuum cleaner,
bowling, or playing golf?Question a
1
2
3
b. Climbing several flights of stairs?
1
2
3
ALL
PH5.
During the past 4 weeks, how much of the time has your physical or emotional health
interfered with your social activities (like visiting friends, relatives, etc.)?
CODE ONE ONLY
All of the time ...................................................................................................... 1
Most of the time ................................................................................................... 2
A little of the time ................................................................................................ 3
None of the time .................................................................................................. 4
Never .................................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
INSERT CONDITIONAL FILL ONLY IF R IS FEMALE
PH6.
Is there a place you go for general health care, if you are sick or need advice about your
health (- that is, any care except prenatal care or family planning)?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
PH6=1
PH7.
What kind of place do you go/ did you go?
CODE ONE ONLY
THE SAME PLACE I RECEIVE GENERAL HEALTH CARE ............................... 1
[SKIP]
CLINIC................................................................................................................... 2
[SKIP]
HEALTH CENTER ................................................................................................ 3
[SKIP]
DOCTOR’S OFFICE ............................................................................................. 4
[SKIP]
OTHER (SPECIFY) ............................................................................................... 99
[SKIP]
___________________________________________________ (STRING (NUM))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What kind of place?
PH6=0
PH8.
What is the main reason you don’t have a usual place to go for your general health care?
CODE ONE ONLY
NO INSURANCE/CAN’T AFFORD ....................................................................... 1
[SKIP]
TRANSPORTATION ............................................................................................. 2
[SKIP]
DIDN’T NEED ....................................................................................................... 3
[SKIP]
OTHER (SPECIFY) ............................................................................................... 99
[SKIP]
___________________________________________________ (STRING (NUM))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What is the main reason?
ALL
PH9.
Has a doctor ever told you that you have asthma?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
PH9=1
PH10. During the past 12 months, have you had an episode of asthma or an asthma attack?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
PH11. Has a doctor ever told you that you have high blood pressure?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
HIGH NORMAL/BORDERLINE/PRE-HYPERTENSION ..................................... 2
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
PH12. Since [CHILD] was born, did a doctor, nurse, or other health care worker tell you that you
had diabetes or high blood sugar?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
PH13. During the past 12 months, did you get a flu shot or the nasal flu vaccine, called Flumist?
PROBE: “A flu shot is usually given in the Fall and protects against influenza for the flu
season.”
CODE ALL THAT APPLY
FLU SHOT ........................................................................................................... 1
NASAL FLUMIST .................................................................................................. 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
PH14. Have you been vaccinated with Tdap (Pertussis or Whooping cough vaccine)?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
PH15. Since [CHILD] was born, have you had any medical problem that caused you to go to the
hospital and stay overnight?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
PH16. Sometimes people have difficulties in getting medical care when they need it. During the
past 12 months, was there any time when you needed medical care or surgery, but did not
get it?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
PH17. In the past 12 months, was there any time when you needed prescription medicines but
could not get them?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
PH17=0
PH18. Why did you not get medical care or prescription medications you needed?
CODE ALL THAT APPLY
COST TOO MUCH................................................................................................ 1
[SKIP]
HEALTH PLAN PROBLEM ................................................................................... 2
[SKIP]
NOT AVAILABLE IN AREA/TRANSPORT PROBLEM ......................................... 3
[SKIP]
NOT CONVENIENT TIMES .................................................................................. 4
[SKIP]
DOCTOR DID NOT KNOW HOW TO TREAT OR PROVIDE CARE ................... 5
[SKIP]
Other Specify Response option ............................................................................ 99
[SKIP]
___________________________________________________ (STRING (NUM))
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
IF OTHER SPECIFY (99): What was the reason?
ALL
FILL STATE HEALTH INSURANCE PROGRAM
PH19. The next questions are about health insurance, including health insurance obtained
through employment or purchased directly as well as government programs like [NAME
OF STATE HEALTH INSURANCE PROGRAM], Medicare and Medicaid that provide medical
care or help pay medical bills.Are you covered by health insurance or some other kind of
health care plan?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
PH20. What kind of health insurance or health care coverage do you have? Include those that
pay for only one type of service (nursing home care, accidents, or dental care). Exclude
private plans that only provide extra cash while hospitalized. If you have more than one
kind of health insurance, tell me about all the plans that you have.
PROBE:
IF R GIVES A NAME OF A HEALTH INSURANCE PLAN, LIKE “BLUE
CROSS/BLUE SHIELD,” ASK: Is that private insurance paid for by you or an
employer, or is it paid for by the state or federal government, like Medicaid or
[STATE SPECIFIC MEDICAID NAME]?
IF R TELLS YOU ABOUT CHILD’S INSURANCE, DO NOT RECORD HERE. THAT
GETS CODED IN A SUBSEQUENT QUESTION.
CODE ALL THAT APPLY
PRIVATE HEALTH INSURANCE ......................................................................... 1
MEDICARE ........................................................................................................... 2
MEDIGAP .............................................................................................................. 3
MEDICAID ............................................................................................................. 4
SCHIP (CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM) ....................... 5
MILITARY HEALTH CARE (TRICARE/VA/CHAMP-VA) ...................................... 6
INDIAN HEALTH SERVICE .................................................................................. 7
STATE-SPONSORED HEALTH PLAN ................................................................. 8
SINGLE SERVICE PLAN (E.G., DENTAL, VISION, PRESCRIPTIONS) ............. 9
NO COVERAGE OF ANY TYPE .......................................................................... 10
OTHER (SPECIFY) ............................................................................................... 99
___________________________________________________ (STRING (NUM))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What other insurance?
ALL
PH21. During the past year, have you ever received help in applying for health insurance for
yourself?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
PH21=0,D,R
PH22. During the past year, did you ever want or need help in applying for health insurance for
yourself?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
PH21=1
PH23. Are you currently receiving help in applying for health insurance for yourself?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
FEMALE RESPONDENTS
PH24. Is there a place you go, or have gone, for family planning or birth control?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
PH24=1
PH25.
What kind of place do you go or did you go?
CODE ONE ONLY
THE SAME PLACE I RECEIVE GENERAL HEALTH CARE ............................... 1
[SKIP]
CLINIC................................................................................................................... 2
[SKIP]
HEALTH CENTER ................................................................................................ 3
[SKIP]
DOCTOR’S OFFICE ............................................................................................. 4
[SKIP]
OTHER (SPECIFY) ............................................................................................... 99
[SKIP]
___________________________________________________ (STRING (NUM))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What kind of place?
P24=1
P26.
Since [CHILD] was born, how often have you seen someone for family planning or birth
control?
CODE ONE ONLY
1-2 TIMES ............................................................................................................. 1
[SKIP]
3-6 TIMES ............................................................................................................. 2
[SKIP]
7-12 TIMES ........................................................................................................... 3
[SKIP]
13 TIMES OR MORE ............................................................................................ 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
PH24=0
PH27. What is the main reason you don’t/didn’t have a usual place to go for family planning?
CODE ONE ONLY
NO INSURANCE/CAN’T AFFORD ....................................................................... 1
[SKIP]
TRANSPORTATION ............................................................................................. 2
[SKIP]
DIDN’T NEED ....................................................................................................... 3
[SKIP]
OTHER (SPECIFY) ............................................................................................... 99
[SKIP]
___________________________________________________ (STRING (NUM))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What is the main reason?
FEMALE RESPONDENTS
PH28. Are you currently pregnant?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
PH28=1
PH29. How many weeks or months pregnant were you when you had your first visit for prenatal
care? Do not count a visit that was only for a pregnancy test or only for WIC (the Special
Supplemental Nutrition Program for Women, Infants, and Children).
PROBE:
You may answer in weeks, months, or trimesters.
INTERVIEWER: TO RESPOND IN WEEKS, ENTER 1. TO RESPOND IN MONTHS, ENTER 2.
TO RESPOND IN TRIMESTERS, ENTER 3.
|
|
| WEEKS (0 – 44)
|
|
| MONTHS (0 – 12)
|
|
| TRIMESTERS (1-3)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
R IS BIO MOM OR BIO DAD
PH30. Since [CHILD] was born, have you used any form of birth control? By birth control, I mean
methods such the following: Withdrawal/pulling out, Natural family planning/ safe
period/calendar/rhythm, Jelly/cream alone, Foam, Suppository/insert, Contraceptive
Sponge, Condom/rubber, IUD, coil, loop, Diaphragm, Pill, Depo-Provera shots, Norplant,
Abstinence, Operation/Female sterilization/tubes tied, Operation/Male
sterilization/vasectomy
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
PH30=1
PH31. Which method have you used most of the time?
CODE ONE ONLY
WITHDRAWAL/PULLING OUT ............................................................................ 1
[SKIP]
NATURAL FAMILY PLANNING/ SAFE PERIOD/CALENDAR/RHYTHM ............ 2
[SKIP]
JELLY/CREAM ALONE ........................................................................................ 3
[SKIP]
FOAM .................................................................................................................... 4
[SKIP]
SUPPOSITORY/INSERT ...................................................................................... 5
[SKIP]
CONTRACEPTIVE SPONGE ............................................................................... 6
[SKIP]
CONDOM/RUBBER .............................................................................................. 7
[SKIP]
IUD ........................................................................................................................ 8
[SKIP]
COIL ...................................................................................................................... 9
[SKIP]
LOOP .................................................................................................................... 10
[SKIP]
DIAPHRAGM ........................................................................................................ 11
[SKIP]
PILL ....................................................................................................................... 12
[SKIP]
DEPO-PROVERA SHOTS .................................................................................... 13
[SKIP]
NORPLANT ........................................................................................................... 14
[SKIP]
ABSTINENCE ....................................................................................................... 15
[SKIP]
OPERATION/FEMALE STERILIZATION/TUBES TIED ....................................... 16
[SKIP]
OPERATION/MALE STERILIZATION/VASECTOMY .......................................... 17
[SKIP]
OTHER (SPECIFY) ............................................................................................... 99
[SKIP]
___________________________________________________ (STRING (NUM))
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
IF OTHER SPECIFY (99): What form of birth control have you used?
R IS BIO MOM OR BIO DAD
PH32. Which of these methods, if any, will you use most of the time?
CODE ONE ONLY
NO BIRTH CONTROL .......................................................................................... 0
[SKIP]
WITHDRAWAL/PULLING OUT ............................................................................ 1
[SKIP]
NATURAL FAMILY PLANNING/ SAFE PERIOD/CALENDAR/RHYTHM ............ 2
[SKIP]
JELLY/CREAM ALONE ........................................................................................ 3
[SKIP]
FOAM .................................................................................................................... 4
[SKIP]
SUPPOSITORY/INSERT ...................................................................................... 5
[SKIP]
CONTRACEPTIVE SPONGE ............................................................................... 6
[SKIP]
CONDOM/RUBBER .............................................................................................. 7
[SKIP]
IUD ........................................................................................................................ 8
[SKIP]
COIL ...................................................................................................................... 9
[SKIP]
LOOP .................................................................................................................... 10
[SKIP]
DIAPHRAGM ........................................................................................................ 11
[SKIP]
PILL ....................................................................................................................... 12
[SKIP]
DEPO-PROVERA SHOTS .................................................................................... 13
[SKIP]
NORPLANT ........................................................................................................... 14
[SKIP]
ABSTINENCE ....................................................................................................... 15
[SKIP]
OPERATION/FEMALE STERILIZATION/TUBES TIED ....................................... 16
[SKIP]
OPERATION/MALE STERILIZATION/VASECTOMY .......................................... 17
[SKIP]
OTHER (SPECIFY) ............................................................................................... 99
[SKIP]
___________________________________________________ (STRING (NUM))
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
IF OTHER SPECIFY (99): What form of birth control will you use?
PH30=0 AND PH32=0
INSERT CONDITIONAL FILL
PH33. What is the main reason you are not (using birth control now/planning to use birth
control)?
CODE ONE ONLY
NO SEX ................................................................................................................. 1
[SKIP]
WANTS PREGNANCY ......................................................................................... 2
[SKIP]
DOESN’T WANT TO ............................................................................................. 3
[SKIP]
DOESN’T THINK ABOUT IT ................................................................................. 4
[SKIP]
CURRENTLY PREGNANT ................................................................................... 5
[SKIP]
OTHER (SPECIFY) ............................................................................................... 99
[SKIP]
___________________________________________________ (STRING (NUM))
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
IF OTHER SPECIFY (99): What is the reason?
R IS BIO MOM
PH34. How many live births have you had?
| | | DESCRIPTION
(NUMBER RANGE)
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
R IS BIO MOM
PH35. How many more children would you like to have?
| | | DESCRIPTION
(NUMBER RANGE)
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
R IS BIO MOM AND PH28=0
PH36. How old would you like [CHILD] to be when you have your next child?
| | | DESCRIPTION
(NUMBER RANGE)
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
PH37. How many cigarettes or packs do you currently smoke on an average day?
INTERVIEWER:
ENTER “0” IF RESPONDENT DID NOT SMOKE.
ENTER “1” IF RESPONDENT SMOKED LESS THAN 1 CIGARETTE A DAY.
PROBE:
|
|
A pack has 20 cigarettes.
| NUMBER (1-60) AND CODE
CIGARETTES ....................................................................................................... 1
PACKS .................................................................................................................. 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
PH38. Which of the following statements best describes the rules about smoking inside your
home now?
CODE ONE ONLY
No one is allowed to smoke anywhere inside my home .............................. 1
[SKIP]
Smoking is allowed in some rooms or at some times .................................. 2
[SKIP]
Smoking is permitted anywhere inside my home? ...................................... 3
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
PH39. The next questions are about drinking alcoholic beverages. By a “drink” we mean a can or
bottle of beer, a wine cooler or glass of wine, a shot of liquor, or a mixed drink.
During the 3 months, how many alcoholic drinks did you have in an average week?
NOTE: A HELP SCREEN IS AVAILABLE WITH EQUIVALENCES
CODE ONE ONLY
DIDN’T DRINK THEN ........................................................................................... 0
LESS THAN 1 DRINK ........................................................................................... 1
1 TO 3 DRINKS ..................................................................................................... 2
4 TO 6 DRINKS ..................................................................................................... 3
7 TO 13 DRINKS ................................................................................................... 4
14 TO 19 DRINKS ................................................................................................. 5
20 OR MORE DRINKS ......................................................................................... 6
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
PH39 NE 0
PH40. How many times did you drink 4 alcoholic drinks or more in one sitting? Would you say…
PROBE:
A sitting is a two hour time span.
CODE ONE ONLY
6 or more times, .................................................................................................. 4
4 to 5 times, ......................................................................................................... 3
2 to 3 times, ......................................................................................................... 2
1 time, or .............................................................................................................. 1
Never? .................................................................................................................. 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
PH41. The next questions are about drug use on your own. By “on your own” we mean either
without a doctor’s prescription, in larger amounts than prescribed, or for a longer period
than prescribed. Did you use any of the following drugs on your own in the month before
you got pregnant? [READ LIST, CODE ONE FOR EACH]
CODE ONE PER ROW
YES
NO
DON’T
KNOW
REFUSED
1
0
d
r
1
0
d
r
Amphetamines(uppers, ice, speed, crystal meth,
crank)? ....................................................................
1
0
d
r
d. Cocaine (rock, coke, crack) or heroin (smack,
horse)? ....................................................................
1
0
d
r
e. Tranquilizers (downers, ludes) or hallucinogens
(LSD/acid, PCP/angel dust, ecstasy)? ...................
1
0
d
r
1
0
d
r
a. Prescription drugs? .................................................
(IF YES) What kinds? ENTER MEDICINE
NAMES: (STRING 50)
b. Marijuana (pot, bud) or Hashish (Hash)? ...............
c.
f.
Sniffing gasoline, glue, hairspray, or other
aerosols? ................................................................
ALL
PH42. During the past year, have you received help or treatment for alcohol or substance abuse
problems?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
PH42=1
PH43. I’m going to read a list of places where people may go to receive help or treatment for
alcohol or substance abuse problems. For each one, please tell me whether you used the
service, or if you needed or wanted the service during the past year.
CODE ONE PER ROW
YES,
NEEDE
D OR
WANTE
D
NO
DON’T
KNOW
REFUSE
D
a. Doctor or other health care professional ................ 1
2
0
d
r
b. A hospital or other inpatient program ..................... 1
2
0
d
r
A social worker, counselor, or other mental
1
health professional .................................................
2
0
d
r
d. Anyone else, including a support group,
1
priest, minister, rabbi, or spiritualist ........................
2
0
d
r
YES,
received
c.
IF PH43A=1 AND/OR PH43B=1 AND/OR PH43C=1 AND/OR PH43D=1
ASK FOR EACH YES (1) RESPONSE IN PH43
PH44. In the last 12 months, how many times have you used [SERVICE FROM PH43] for alcohol
or substance abuse treatment?
CODE ONE ONLY
1-2 TIMES ............................................................................................................. 1
[SKIP]
3-6 TIMES ............................................................................................................. 2
[SKIP]
7-12 TIMES ........................................................................................................... 3
[SKIP]
13 TIMES OR MORE ............................................................................................ 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
PH45. During the past year, have you received mental health help or treatment?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
PH45=1
PH46. I’m going to read a list of places where people may go to receive mental health help or
treatment. For each one, please tell me whether you used the service, or if you needed or
wanted the service during the past year.
CODE ONE PER ROW
YES,
needed
or
wanted
NO
DON’T
KNOW
REFUSE
D
a. Doctor or other health care professional ................ 1
2
0
d
r
b. A hospital or other inpatient program ..................... 1
2
0
d
r
c.
A social worker, counselor, or other mental
1
health professional .................................................
2
0
d
r
d. Anyone else, including a support group,
1
priest, minister, rabbi, or spiritualist ........................
2
0
d
r
YES,
received
IF PH46A=1 AND/OR PH46B=1 AND/OR PH46C=1 AND/OR PH46D=1
ASK FOR EACH YES (1) RESPONSE IN PH46
PH47. In the last 12 months, how many times have you used [SERVICE FROM PH46] for mental
health help or treatment?
CODE ONE ONLY
1-2 TIMES ............................................................................................................. 1
[SKIP]
3-6 TIMES ............................................................................................................. 2
[SKIP]
7-12 TIMES ........................................................................................................... 3
[SKIP]
13 TIMES OR MORE ............................................................................................ 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
PH48. Center for Epidemiologic Studies Depression Scale (CES-D), 10 items
ALL
PH49. Generalized Anxiety Scale (GAD-7), 7 items
IF PH49A = 1 OR PH49B=1 OR PH49C=1 OR PH49D=1 OR PH49E=1 OR PH49F=1 OR PH49G=1
PH50. How difficult have these feelings made it for you to do your work, take care of things at
home, or get along with other people? Would you say…
CODE ONE ONLY
Not difficult at all, ................................................................................................ 1
[SKIP]
Somewhat difficult, ............................................................................................. 2
[SKIP]
Very difficult, or ................................................................................................... 3
[SKIP]
Extremely difficult ............................................................................................... 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
PH51. Pearlin Mastery Scale, 7 items
PV. INTIMATE PARTNER VIOLENCE
RESPONDENTS WHO HAVE A SPOUSE OR PARTNER
FILL GENDER OF SPOUSE/PARTNER
PV1.
Women's Experience and Battery Scale (WEB), 6 items
RESPONDENTS WHO HAVE A SPOUSE OR PARTNER
PV2.
In Conflict Tactics Scale (CTS) taken from the Supporting Healthy Marriage Survey, 9 items
C. CRIME
ALL
C1.
Have you been arrested within the past year?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
FS. FAMILY SELF-SUFFICIENCY
ALL
FS1.
Next, I'd like to ask you to tell me a little bit about the education you've received as well as
your education-related activities. What is the highest grade or year of school that you have
completed?
PROBE:
IF GED: Before you received your GED, what was the highest grade or year of
school you completed?
CODE ONE ONLY
HIGHEST GRADE/YEAR IN SCHOOL SPECIFY GRADE .................................. 1
|
|
| GRADE (1 – 11)
HIGH SCHOOL DIPLOMA .................................................................................... 2
ASSOCIATE DEGREE ......................................................................................... 3
BA/BS DEGREE ................................................................................................... 4
MA/MASTERS ...................................................................................................... 5
PHD/DOCTORATE ............................................................................................... 6
SOME COLLEGE BUT NO DEGREE COMPLETION .......................................... 7
NO REGULAR/FORMAL SCHOOL EDUCATION ................................................ 0
OTHER (SPECIFY) ............................................................................................... 99
___________________________________________________ (STRING (NUM))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): Please specify your highest level of education completed (STRING 99)
ALL
FS2.
Are you currently taking any education or training classes? This could include (IF F1 LT 5:
high school, ABE, GED,) ESL or college courses, or any job skills training.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
F2=1
FS3
FS3.
What type of degree are you working towards?
CODE ONE ONLY
HS DIPLOMA/GED ............................................................................................... 1
[SKIP]
2-YEAR DEGREE ................................................................................................. 2
[SKIP]
4-YEAR DEGREE ................................................................................................. 3
[SKIP]
GRADUATE DEGREE .......................................................................................... 4
[SKIP]
OTHER (SPECIFY) ............................................................................................... 99
[SKIP]
___________________________________________________ (STRING 99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What other degree?
FS2=0, d, r
FS4.
Do you plan on pursuing additional education in the future?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
FS4=1
FS5.
ALL
What type of degree would you pursue?
___________________________________________________ (STRING 200)
DESCRIPTION
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
FS6.
How many months were you employed (did you work for pay) during the past year
(including your current job)?
| | |
(0-12)
|
| MONTHS
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question
HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question
ALL
FS7.
Are you currently working for pay?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
FS7=1
FS8.
How many jobs do you currently have?
| | |
(0-10)
|
| JOBS
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question
HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question
FS8 GT 1
FS9.
JOB
At which job do you work the most hours?
PROBE:
The name of the employer is fine.
___________________________________________________ (STRING 99)
DESCRIPTION
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
FS7=1
FS10. Would you describe this job as…
Var
SELECT CODING TYPE
Full time (30 or more hours per week), ............................................................. 1
[SKIP]
Part-time with hours most weeks, ..................................................................... 2
[SKIP]
Seasonal work, .................................................................................................... 3
[SKIP]
Temporary work through a temp agency, ........................................................ 4
[SKIP]
Day labor, ............................................................................................................ 5
[SKIP]
Odd jobs, or ........................................................................................................ 6
[SKIP]
Something else? ................................................................................................. 99
[SKIP]
___________________________________________________ (STRING 99)
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
IF OTHER SPECIFY (99): What other type of job is it?
FS7=1
Fill JOB from FS9
FS11. Including overtime, how many hours per week do you usually work at [JOB]?
| | |
(0-80)
|
| HOURS
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question
HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question
FS7=1
Fill JOB from FS9
FS12. At [JOB], what is your wage, before taxes? Please include tips, commissions, and regular
overtime pay.
PROBE:
Please do not include earnings from anyone else in your household.
PROGRAMMER: ALLOW DECIMAL
$|
|,|
|
|
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
FS12 CONTAINS NUMBER
FS13. Is that…
SELECT CODING TYPE
Per hour, .............................................................................................................. 1
[SKIP]
Per week, .............................................................................................................. 2
[SKIP]
Per every 2 weeks, .............................................................................................. 3
[SKIP]
Twice a month, .................................................................................................... 4
[SKIP]
Once a month, ..................................................................................................... 5
[SKIP]
Per day or per piece, or ...................................................................................... 5
[SKIP]
Some other way? ................................................................................................ 99
[SKIP]
___________________________________________________ (STRING 99)
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
IF OTHER SPECIFY (99): Please specify how you are paid.
FS13= 5 OR 99
FS14. What would you estimate you make in a week?
| | |
(0-5000)
|
| DOLLARS
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question
HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question
FS7 NE 0
FILL PREVIOUS MONTH AND YEAR OF PREVIOUS MONTH
FS15. Last month, that is (MONTH/YEAR), what were your approximate total earnings from your
work, including tips and overtime pay? When answering, please include income from all
jobs you held last month. Please do not include earnings from anyone else in your
household. Was it…
CODE ONE ONLY
Less than $500, ................................................................................................... 1
$500 to $999, ........................................................................................................ 2
$1,000 to $1,499, .................................................................................................. 3
$1,500 to $1,999, .................................................................................................. 4
$2,000 to $2,500 ................................................................................................... 5
$2,500 to $2,999, .................................................................................................. 6
$3,000 to $3,499, or ............................................................................................. 7
$3,5000 or over? .................................................................................................. 8
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
FS16. Some earnings and income come from other sources, like unemployment insurance or
help from family and friends. Thinking about these other sources of income, what is the
total amount of additional income that you received (that is, in addition to earnings) and
the total amount of any income or earnings any other adult members of your household
received last month? Was it…
PROBE:
Your best estimate is fine.
CODE ONE ONLY
Less than $1,000, ................................................................................................ 1
$1,000 or more, but less than $2,000, ............................................................... 2
$2,000 or more but less than $3,000, ................................................................ 3
$3,000 or more but less than $4,000, ................................................................ 4
$4,000 or more but less than 5,000, or .............................................................. 5
More than $5,000? ............................................................................................... 6
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
Fill Local TANF from preload
FS17. Now please tell me whether you, or other members of your household have received
income or benefits from these sources in the past month. This includes anyone who you
support and/or supports you and lives in your household. Did you or any other members
of your household receive income from this source in the past month?
CODE ONE PER ROW
YES
NO
DON’T
KNOW
REFUSED
a. Cash welfare which is also known as TANF, or [Local name
of TANF] ........................................................................................
1
0
d
r
b. Food stamp or Supplemental Nutrition Assistance Program
(SNAP) benefits............................................................................
1
0
d
r
Disability insurance such as Supplemental Security Income
(SSI) or Social Security Disability Insurance (SSDI) ................
1
0
d
r
d. Benefits from WIC (the Special Supplemental Nutrition
Program for Women, Infants, and Children) .............................
1
0
d
r
c.
ALL
FS18. During the past year, have you ever received help in applying for public benefits, including
TANF, SNAP, or WIC?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
FS18=1
FS19. Who provided you with that help?
INTERVIEWER: PROBE FOR TYPE OF PERSON, IF JUST A NAME IS GIVEN
___________________________________________________ (STRING 99)
Person
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
FS18=1
FS20. Are you currently receiving help in applying for public benefits, including TANF, SNAP, or
WIC?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
FS18=0,d,r
FS21. During the past year, did you ever want or need help in applying for public benefits,
including TANF, SNAP, or WIC?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
FILL CURRENT MONTH AND PREVIOUS YEAR. IF R IS ONLY ADULT IN HOUSEHOLD, FILL “I.”
ELSE, “WE”
FS22. I am going to read you several statements that people have made about their food
situation. For these statements please tell me whether the statement was often true,
sometimes true, or never true for your household in the last 12 months, that is since
(DISPLAY CURRENT MONTH AND LAST YEAR).
Within the past 12 months (I/we) worried whether our food would run out before (I/we) got
money to buy more. Was this . . .
CODE ONE ONLY
Often true, ............................................................................................................ 1
Sometimes true, or .............................................................................................. 2
Never true? .......................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
IF R IS ONLY ADULT IN HOUSEHOLD, FILL “I.” ELSE, “WE”
FS23. Within the past 12 months the food that (I/we) bought just didn’t last and we didn’t have
money to get more. Was this . . .
CODE ONE ONLY
Often true, ............................................................................................................ 1
Sometimes true, or .............................................................................................. 2
Never true? .......................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
IF R IS ONLY ADULT IN HOUSEHOLD, FILL “I.” ELSE, “WE”
FS24. (I/We) couldn’t afford to eat balanced meals Was this . . .
CODE ONE ONLY
Often true, ............................................................................................................ 1
Sometimes true, or .............................................................................................. 2
Never true? .......................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
FILL CURRENT MONTH AND PREVIOUS YEAR. IF R IS ONLY ADULT IN HOUSEHOLD, FILL “YOU.”
ELSE, “OTHER ADULTS IN YOUR HOUSEHOLD”
FS25. In the last 12 months, that is, since (DISPLAY CURRENT MONTH AND LAST YEAR), did
(you/other adults in your household) ever cut the size of your meals or skip meals because
there wasn't enough money for food?
YES ....................................................................................................................... 1
FS26
NO ......................................................................................................................... 0
FS27
DON’T KNOW ....................................................................................................... d
FS27
REFUSED ............................................................................................................. r
FS27
FS25=1
INSERT FILL CONDITION OR DELETE ROW
FS26. How often did this happen?
CODE ONE ONLY
Almost every month,........................................................................................... 1
[SKIP]
Some months but not every month, or ............................................................. 2
[SKIP]
In only 1 or 2 months? ........................................................................................ 3
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
FS27. In the last 12 months, did you ever eat less than you felt you should because there wasn't
enough money for food?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
FS28. In the last 12 months, were you ever hungry but didn't eat because there wasn’t enough
money for food?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SS. SOCIAL SERVICES
ALL
SS1.
Now let’s talk about any care [CHILD] receives from someone not related to (him/her),
either in your home or someone else’s. This includes home child care providers or
neighbors, but not day care centers or preschools. Is [CHILD] now receiving care in your
home or another home on a regular basis at least once a week from someone who is not
related to (him/her)?
YES ....................................................................................................................... 1
SS2
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SS1=1
SS2.
Is this care provided in your own home or in another home?
SELECT CODING TYPE
OWN HOME .......................................................................................................... 1
[SKIP]
ANOTHER HOME ................................................................................................. 2
[SKIP]
BOTH/VARIES ...................................................................................................... 3
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS1=1
SS3.
How many hours each week does [CHILD] receive care from someone not related to him or
her?
PROBE:
| | |
(0-100)
Your best estimate is fine.
|
| HOURS
DON’T KNOW ....................................................................................................... d
[SKIP]
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question
HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question
ALL
SS4.
Is [CHILD] now attending a day care center or preschool program?
YES ....................................................................................................................... 1
SS5
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SS4=1
SS5.
How many hours each week does [CHILD] attend a day care center or preschool program?
PROBE:
| | |
(0-100)
Your best estimate is fine.
|
| HOURS
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question
HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question
ALL
SS6.
[SKIP]
In the past year, has [CHILD] used or received Early Intervention services?
PROBE:
Early Intervention provides services for children with disabilities or delays.
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS6=1
SS7.
How many times did [CHILD] use or receive Early Intervention services? Would you say…
CODE ONE ONLY
1-2 times, .............................................................................................................. 1
[SKIP]
3-6 times, .............................................................................................................. 2
[SKIP]
7-12 times, or ....................................................................................................... 3
[SKIP]
13 times or more? ............................................................................................... 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS6 NE 1
SS8.
In the past year, did you want or need Early Intervention services for [CHILD]?
INTERVIEWER: IF R RESPONDS “YES,” PROBE FOR WANTED OR NEEDED
CODE ONE ONLY
WANTED ............................................................................................................... 1
[SKIP]
NEEDED ............................................................................................................... 2
[SKIP]
NO/DIDN’T NEED ................................................................................................ 3
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS1=1 OR SS6=1
IF SS1=1 AND SS6 NE1, “CHILD CARE PROVIDERS”; IF SS1=1 AND SS6 =1, “CHILD CARE
PROVIDERS OR EARLY INTERVENTION PROGRAM”; IF SS1 NE 1 AND SS6=1, “EARLY
INTERVENTION PROGRAM”
SS9.
Do [CHILD]’s doctors or other health care providers need to communicate with (his/her)
(child care providers or early intervention program)?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS9=1
SS10. Overall, how satisfied are you with that communication? Would you say…
CODE ONE ONLY
Very satisfied, ...................................................................................................... 1
[SKIP]
Somewhat satisfied, ............................................................................................ 2
[SKIP]
Somewhat dissatisfied, or .................................................................................. 3
[SKIP]
Very dissatisfied? ............................................................................................... 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
SS11. In the past year, have you or [CHILD] used or received services from a women’s shelter?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS11=1
SS12. How many times did you visit a women’s shelter? Would you say…
CODE ONE ONLY
1-2 times, .............................................................................................................. 1
[SKIP]
3-6 times, .............................................................................................................. 2
[SKIP]
7-12 times, or ....................................................................................................... 3
[SKIP]
13 times or more? ............................................................................................... 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS11 NE 1
SS13. In the past year, did you want or need services from a women’s shelter?
INTERVIEWER: IF R RESPONDS “YES,” PROBE FOR WANTED OR NEEDED
CODE ONE ONLY
WANTED ............................................................................................................... 1
[SKIP]
NEEDED ............................................................................................................... 2
[SKIP]
NO/DIDN’T NEED ................................................................................................ 3
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
SS14. In the past year, have you or [CHILD] used or received services for domestic violence
counseling or anger management?
YES ....................................................................................................................... 1
[SKIP]
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS14=1
SS15. How many times did you or [CHILD] use or receive services for domestic violence
counseling or anger management? Would you say…
CODE ONE ONLY
1-2 times, .............................................................................................................. 1
[SKIP]
3-6 times, .............................................................................................................. 2
[SKIP]
7-12 times, or ....................................................................................................... 3
[SKIP]
13 times or more? ............................................................................................... 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS14 NE 1
SS16. In the past year, did you want or need services for domestic violence counseling or anger
management?
INTERVIEWER: IF R RESPONDS “YES,” PROBE FOR WANTED OR NEEDED
CODE ONE ONLY
WANTED ............................................................................................................... 1
[SKIP]
NEEDED ............................................................................................................... 2
[SKIP]
NO/DIDN’T NEED ................................................................................................ 3
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
ALL
SS17. In the past year, have you or [CHILD] received transportation to needed services?
YES ....................................................................................................................... 1
SS16
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS17=1
SS18. How many times did you or [CHILD] receive transportation to needed services? Would you
say…
CODE ONE ONLY
1-2 times, .............................................................................................................. 1
[SKIP]
3-6 times, .............................................................................................................. 2
[SKIP]
7-12 times, or ....................................................................................................... 3
[SKIP]
13 times or more? ............................................................................................... 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS17 NE 1
SS19. In the past year, did you want or need transportation to needed services?
INTERVIEWER: IF R RESPONDS “YES,” PROBE FOR WANTED OR NEEDED
CODE ONE ONLY
WANTED ............................................................................................................... 1
[SKIP]
NEEDED ............................................................................................................... 2
[SKIP]
NO/DIDN’T NEED ................................................................................................ 3
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS19=1
SS20. What services did you want or need transportation for?
INTERVIEWER:
CODE ALL THAT APPLY
PRENATAL CARE ................................................................................................ 1
[SKIP]
MATERNAL PREVENTIVE CARE ........................................................................ 2
[SKIP]
FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE ............................. 3
[SKIP]
SUBSTANCE USE (ALCOHOL AND OTHER DRUGS) TREATMENT ............... 4
[SKIP]
MENTAL HEALTH TREATMENT ......................................................................... 5
[SKIP]
DOMESTIC VIOLENCE SHELTER ...................................................................... 6
[SKIP]
DOMESTIC VIOLENCE COUNSELING/ANGER MANAGEMENT ...................... 7
[SKIP]
ADULT EDUCATION SERVICES (INCLUDING GED AND ESL) ........................ 8
[SKIP]
JOB TRAINING AND EMPLOYMENT .................................................................. 9
[SKIP]
PEDIATRIC PRIMARY CARE .............................................................................. 10
[SKIP]
CHILDCARE ......................................................................................................... 11
[SKIP]
EARLY INTERVENTION SERVICES ................................................................... 12
[SKIP]
OTHER (SPECIFY) ............................................................................................... 99
[SKIP]
___________________________________________________ (STRING (NUM))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What other services?
CONTROL GROUP
SS21. In the past year, have you participated in a home visiting program or parenting program
for parents of infants?
YES ....................................................................................................................... 1
SS19
NO ......................................................................................................................... 0
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS21=1
SS22. What was the name of the program?
___________________________________________________ (STRING 200)
Program
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS21=1
SS23. How many times did you receive home visits from a home visiting program and/or
participate in a parenting program? Would you say…
CODE ONE ONLY
1-2 times, .............................................................................................................. 1
[SKIP]
3-6 times, .............................................................................................................. 2
[SKIP]
7-12 times, or ....................................................................................................... 3
[SKIP]
13 times or more? ............................................................................................... 4
[SKIP]
DON’T KNOW ....................................................................................................... d
[SKIP]
REFUSED ............................................................................................................. r
[SKIP]
SS21=1
SS24. Did a home visitor help you receive any of the following services?
PROBE:
INTERVIEWER:
Yes
No
DK
R
a. Prenatal Care
1
0
d
r
b. Maternal Preventive Care
1
0
d
r
Family Planning and Reproductive
Health Care
1
0
d
r
d. Substance Use (Alcohol and other
drugs) Treatment
1
0
d
r
e. Mental Health Treatment
1
0
d
r
f.
1
0
d
r
g. Domestic Violence Counseling/Anger
Management
1
0
d
r
h. Adult Education Services (including
GED and ESL)
1
0
d
r
i.
Job Training and Employment
1
0
d
r
j.
Pediatric Primary Care
1
0
d
r
k.
Childcare
1
0
d
r
c.
Domestic Violence Shelter
ALL
H1a.
We are almost done with the survey. Thank you very much for answering my questions. I
just have a few more. First, what is your e-mail address? This will be kept private and only
used as a way of contacting you when we need to talk to you again for the follow-up
survey.
___________________________________________________
___________________________________________________ (STRING (50))
E-MAIL ADDRESS
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SAMPLE LOAD DID NOT INCLUDE RESPONDENT’S PHONE NUMBER OR IF THERE IS A
BREAKOFF
H1b.
What is your telephone number?
INTERVIEWER:
|
|
|
|-|
(RANGE)
WE SHOULD COLLECT TWO NUMBERS IF POSSIBLE.
|
|
|-|
(RANGE)
|
|
|
|
(RANGE)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
CELL PHONE:
|
|
|
(RANGE)
|-|
|
|
|-|
(RANGE)
|
|
|
|
(RANGE)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
H2a.
Please tell me the names, addresses, telephone numbers, and e-mail addresses of three
people who do not live with you but who will know how to contact you roughly a year from
now. This will help us contact you if you move so we can still complete a follow up
interview with you.
What is the name of the first person who will know how we can reach you?
INTERVIEWER:
ENTER NAME OF PERSON
___________________________________________________ (STRING (50))
NAME
DON’T KNOW ....................................................................................................... d
CONCLUDE
REFUSED ............................................................................................................. r
CONCLUDE
H2 NE d, r
H2b.
How is this person related to you?
CODE ONE ONLY
BIOLOGICAL MOTHER ........................................................................................ 11
BIOLOGICAL FATHER ......................................................................................... 12
ADOPTIVE MOTHER ........................................................................................... 13
ADOPTIVE FATHER............................................................................................. 14
STEPMOTHER ..................................................................................................... 15
STEPFATHER ...................................................................................................... 16
GRANDMOTHER .................................................................................................. 17
GRANDFATHER ................................................................................................... 18
GREAT GRANDMOTHER .................................................................................... 19
GREAT GRANDFATHER ..................................................................................... 20
SISTER/STEPSISTER .......................................................................................... 21
BROTHER/STEPBROTHER ................................................................................ 22
OTHER RELATIVE OR IN-LAW (FEMALE) ......................................................... 23
OTHER RELATIVE OR IN-LAW (MALE) .............................................................. 24
FOSTER PARENT (FEMALE) .............................................................................. 25
FOSTER PARENT (MALE). .................................................................................. 26
OTHER NON-RELATIVE (FEMALE) .................................................................... 27
OTHER NON-RELATIVE (MALE) ......................................................................... 28
PARENT’S PARTNER (FEMALE) ........................................................................ 29
PARENT’S PARTNER (FEMALE) ........................................................................ 30
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER RELATIVE OR IN-LAW (FEMALE) (23): What is her relationship? (STRING (99))
IF OTHER RELATIVE OR IN-LAW (MALE) (24): What is his relationship? (STRING (99))
IF OTHER NON-RELATIVE (FEMALE) (27): What is her relationship? (STRING (99))
IF OTHER NON-RELATIVE (MALE) (28): What is his relationship? (STRING (99))
H2a NE d, r
H2c.
What is that person’s telephone number?
|
|
|
|-|
(RANGE)
|
|
|-|
(RANGE)
|
|
|
|
(RANGE)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
CELL PHONE:
|
|
|
(RANGE)
|-|
|
|
|-|
(RANGE)
|
|
|
|
(RANGE)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
H2a NE d, r
H2d.
Please give me their permanent address.
___________________________________________________
STREET 1
___________________________________________________
STREET 2
___________________________________________________
STREET 3
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
H2a NE d, r
H2e.
Please give me their e-mail address.
___________________________________________________ (STRING (50))
E-MAIL ADDRESS
INTERVIEWER: CODE E-MAIL ADDRESS TYPE
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
H3a NE d, r
H3a.
What is the name of a second person?
INTERVIEWER:
ENTER NAME OF PERSON
___________________________________________________ (STRING (50))
NAME
DON’T KNOW ....................................................................................................... d
CONCLUDE
REFUSED ............................................................................................................. r
CONCLUDE
H3a NE d, r
H3b.
How is this person related to you?
CODE ONE ONLY
BIOLOGICAL MOTHER ........................................................................................ 11
BIOLOGICAL FATHER ......................................................................................... 12
ADOPTIVE MOTHER ........................................................................................... 13
ADOPTIVE FATHER............................................................................................. 14
STEPMOTHER ..................................................................................................... 15
STEPFATHER ...................................................................................................... 16
GRANDMOTHER .................................................................................................. 17
GRANDFATHER ................................................................................................... 18
GREAT GRANDMOTHER .................................................................................... 19
GREAT GRANDFATHER ..................................................................................... 20
SISTER/STEPSISTER .......................................................................................... 21
BROTHER/STEPBROTHER ................................................................................ 22
OTHER RELATIVE OR IN-LAW (FEMALE) ......................................................... 23
OTHER RELATIVE OR IN-LAW (MALE) .............................................................. 24
FOSTER PARENT (FEMALE) .............................................................................. 25
FOSTER PARENT (MALE). .................................................................................. 26
OTHER NON-RELATIVE (FEMALE) .................................................................... 27
OTHER NON-RELATIVE (MALE) ......................................................................... 28
PARENT’S PARTNER (FEMALE) ........................................................................ 29
PARENT’S PARTNER (FEMALE) ........................................................................ 30
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER RELATIVE OR IN-LAW (FEMALE) (23): What is her relationship? (STRING (99))
IF OTHER RELATIVE OR IN-LAW (MALE) (24): What is his relationship? (STRING (99))
IF OTHER NON-RELATIVE (FEMALE) (27): What is her relationship? (STRING (99))
IF OTHER NON-RELATIVE (MALE) (28): What is his relationship? (STRING (99))
H3a NE d, r
H3c.
What is that person’s telephone number?
|
|
|
|-|
(RANGE)
|
|
|-|
(RANGE)
|
|
|
|
(RANGE)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
CELL PHONE:
|
|
|
(RANGE)
|-|
|
|
|-|
(RANGE)
|
|
|
|
(RANGE)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
H3a NE d, r
H3d.
Please give me their permanent address.
___________________________________________________
STREET 1
___________________________________________________
STREET 2
___________________________________________________
STREET 3
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
H3a NE d, r
H3e.
Please give me their e-mail address.
___________________________________________________ (STRING (50))
E-MAIL ADDRESS
INTERVIEWER: CODE E-MAIL ADDRESS TYPE
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
H4a NE d, r
H4a.
What is the name of a third person?
INTERVIEWER:
ENTER NAME OF PERSON
___________________________________________________ (STRING (50))
NAME
DON’T KNOW ....................................................................................................... d
CONCLUDE
REFUSED ............................................................................................................. r
CONCLUDE
H4a NE d, r
H4b.
How is this person related to you?
CODE ONE ONLY
BIOLOGICAL MOTHER ........................................................................................ 11
BIOLOGICAL FATHER ......................................................................................... 12
ADOPTIVE MOTHER ........................................................................................... 13
ADOPTIVE FATHER............................................................................................. 14
STEPMOTHER ..................................................................................................... 15
STEPFATHER ...................................................................................................... 16
GRANDMOTHER .................................................................................................. 17
GRANDFATHER ................................................................................................... 18
GREAT GRANDMOTHER .................................................................................... 19
GREAT GRANDFATHER ..................................................................................... 20
SISTER/STEPSISTER .......................................................................................... 21
BROTHER/STEPBROTHER ................................................................................ 22
OTHER RELATIVE OR IN-LAW (FEMALE) ......................................................... 23
OTHER RELATIVE OR IN-LAW (MALE) .............................................................. 24
FOSTER PARENT (FEMALE) .............................................................................. 25
FOSTER PARENT (MALE). .................................................................................. 26
OTHER NON-RELATIVE (FEMALE) .................................................................... 27
OTHER NON-RELATIVE (MALE) ......................................................................... 28
PARENT’S PARTNER (FEMALE) ........................................................................ 29
PARENT’S PARTNER (FEMALE) ........................................................................ 30
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER RELATIVE OR IN-LAW (FEMALE) (23): What is her relationship? (STRING (99))
IF OTHER RELATIVE OR IN-LAW (MALE) (24): What is his relationship? (STRING (99))
IF OTHER NON-RELATIVE (FEMALE) (27): What is her relationship? (STRING (99))
IF OTHER NON-RELATIVE (MALE) (28): What is his relationship? (STRING (99))
H4a NE d, r
H4c.
What is that person’s telephone number?
|
|
|
|-|
(RANGE)
|
|
|-|
(RANGE)
|
|
|
|
(RANGE)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
CELL PHONE:
|
|
|
(RANGE)
|-|
|
|
|-|
(RANGE)
|
|
|
|
(RANGE)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
H4a NE d, r
H4d.
Please give me their permanent address.
___________________________________________________
STREET 1
___________________________________________________
STREET 2
___________________________________________________
STREET 3
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
H4a NE d, r
H4e.
Please give me their e-mail address.
___________________________________________________ (STRING (50))
E-MAIL ADDRESS
INTERVIEWER: CODE E-MAIL ADDRESS TYPE
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
FOLLOW-UP VISIT NE COMPLETE
Appt.
Next, I’d like to make an appointment for our field interviewer to visit your home to do
some activities with you and [CHILD]. When would be a good time for that visit?
INTERVIEWER: MAKE APPOINTMENT
INSERT UNIVERSE
FILL ADDRESS FROM PRELOAD
Pmt.
I would like to confirm the name and address where we should send your thank-you gift
card. Is it…
INTERVIEWER:
READ ADDRESS TO RESPONDENT
___________________________________________________
STREET 1
___________________________________________________
STREET 2
___________________________________________________
STREET 3
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
Thank you.
Thank you for your cooperation. This completes the survey! Thank you again.
| File Type | application/pdf |
| File Title | Attachment A |
| Author | somersj |
| File Modified | 2012-12-05 |
| File Created | 2012-12-05 |