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pdfOMB #: 0925-0593
OMB Expiration Date: 8/31/2014
Interviewer Observation Questionnaire - Adult, Phase 2g
OMB Specification
Interviewer Observation Questionnaire - Adult
Event Category:
Event:
Administration:
Instrument Target:
Time-Based
Pre-Pregnancy, PV1, PV2, Birth, 3M, 6M, 9M,
12M, 18M, 24M, 30M, 36M, 42M, 48M, 54M,
60M
Pre-Pregnancy, PV1, PV2, Birth, 3M, 6M, 9M,
12M, 18M, 24M, 30M, 36M, 42M, 48M, 54M,
60M
Pre-Pregnant Woman;
Biological Mother;
Pregnant Woman;
Primary Caregiver
Instrument Respondent:
Data Collector
Domain:
Questionnaire
Document Category:
Observation
Method:
Data Collector Administered
Mode (for this instrument*):
OMB Approved Modes:
In-Person, CAI;
Phone, CAI
In-Person, CAI;
Phone, CAI;
Web-Based, CAI
Estimated Administration Time:
0 minutes
Multiple Child/Sibling Consideration:
Per Event
Special Considerations:
N/A
Version:
1.0
MDES Release:
4.0
*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for
administration in this/these mode(s) only.
This page intentionally left blank.
QUE Interviewer Observation Questionnaire - Adult, MDES 4.0, V1.0
OMB Specification
ii
Interviewer Observation Questionnaire - Adult
TABLE OF CONTENTS
GENERAL PROGRAMMER INSTRUCTIONS: .......................................................................... 1
INTERVIEWER OBSERVATIONS – ADULT .............................................................................. 3
INTERVIEWER OBSERVATIONS - INTERVIEW ...................................................................... 6
QUE Interviewer Observation Questionnaire - Adult, MDES 4.0, V1.0
OMB Specification
iii
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QUE Interviewer Observation Questionnaire - Adult, MDES 4.0, V1.0
OMB Specification
iv
Interviewer Observation Questionnaire - Adult
GENERAL PROGRAMMER INSTRUCTIONS:
WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES
AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED
THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:
DATA ELEMENT FIELDS
MAXIMUM
CHARACTE
RS
PERMITTED
DATA TYPE
PROGRAMMER INSTRUCTIONS
100
CHARACTER
UNIT AND PHONE FIELDS
10
CHARACTER
_OTH AND COMMENT FIELDS
255
CHARACTER
•
Limit text to 255 characters
FIRST NAME AND LAST NAME
30
CHARACTER
•
Limit text to 30 characters
ALL ID FIELDS
36
CHARACTER
ZIP CODE
5
CHARACTER
ZIP CODE LAST FOUR
4
CHARACTER
CITY
50
CHARACTER
ADDRESS AND EMAIL FIELDS
NUMERIC
DOB AND ALL OTHER DATE
FIELDS (E.G., DT, DATE, ETC.)
CHARACTER
10
TIME VARIABLES
TWO-DIGIT
HOUR AND
TWO-DIGIT
MINUTE,
AM/PM
DESIGNATI
ON
NUMBER OF HOURS PER DAY
TWO-DIGIT
HOUR
NUMBER OF DAYS PER WEEK
ONE-DIGIT
NUMERIC
NUMERIC
NUMERIC
QUE Interviewer Observation Questionnaire - Adult, MDES 4.0, V1.0
OMB Specification
• DISPLAY AS MM/DD/YYYY
• STORE AS YYYY-MM-DD
• HARD EDITS:
MM MUST EQUAL 01 TO 12
DD MUST EQUAL 01 TO 31
YYYY MUST BE BETWEEN 1900
AND CURRENT YEAR.
• HARD EDITS:
HOURS MUST BE BETWEEN 00 AND
12;
MINUTES MUST BE BETWEEN 00
AND 59
• HARD EDITS:
HOURS MUST BE BETWEEN 1 AND
24
• HARD EDITS:
DAYS PER WEEK MUST BE
BETWEEN 1 AND 7
1
Instrument Guidelines for Participant and Respondent IDs:
PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G.
THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).
POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE
PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE
COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD
AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER.
THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID
(RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT.
THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY
OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.
A REMINDER:
ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON,
PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES,
WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH
QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF
QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE
THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES
VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL
IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.
QUE Interviewer Observation Questionnaire - Adult, MDES 4.0, V1.0
OMB Specification
2
INTERVIEWER OBSERVATIONS – ADULT
(TIME_STAMP_IOP_ST).
PROGRAMMER INSTRUCTIONS
• INSERT DATE/TIME STAMP
• IF EVENT_TYPE = 11 (PRE-PREG), PRELOAD PARTICIPANT ID (P_ID) FOR PREPREGNANT WOMAN.
• IF EVENT_TYPE = 13 OR 15, PRELOAD PARTICIPANT ID (P_ID) FOR PREGNANT
WOMAN.
• IF EVENT_TYPE = 18 (BIRTH), 24 (6-MONTH), 27 (12-MONTH), 31 (24-MONTH), 37
(36-MONTH), 40 (48-MONTH), OR 42 (60-MONTH), PRELOAD PARTICIPANT ID
(P_ID) FOR ADULT CAREGIVER.
• PRELOAD C_FNAME FROM INSTRUMENT_ID = XX (PARTICIPANT VERIFICATION,
SCHEDULING, AND TRACING).
• IF C_FNAME ≠ -1 OR -2, DISPLAY CHILD'S NAME THROUGHOUT INSTRUMENT.
• IF C_FNAME = -1 OR -2, DISPLAY "THE CHILD".
• PRELOAD STAFF_ID.
• IF INS_MODE = 1 (CAPI), GO TO UNDER_INFLUENCE.
• IF INS_MODE = 2 (CATI), GO TO VIOLENCE
IOP01000/(UNDER_INFLUENCE). DID THE ADULT APPEAR TO BE UNDER THE
INFLUENCE OF DRUGS OR ALCOHOL?
Label
YES
NO
NOT APPLICABLE/DID NOT
OBSERVE THE
PARTICIPANT
Code
1
2
-7
Go To
SOURCE
New
IOP02000/(DEPRESSED). DID THE ADULT SEEM UNHAPPY, SAD, OR DEPRESSED?
Label
YES
NO
NOT APPLICABLE/DID NOT
OBSERVE THE
PARTICIPANT
Code
1
2
-7
Go To
SOURCE
Iowa Child and Family Household Health Survey (modified)
IOP03000/(TENSE). DID THE ADULT SEEM NERVOUS, HIGH-STRUNG, OR TENSE?
QUE Interviewer Observation Questionnaire - Adult, MDES 4.0, V1.0
OMB Specification
3
Label
YES
NO
NOT APPLICABLE/DID NOT
OBSERVE THE
PARTICIPANT
Code
1
2
-7
Go To
SOURCE
Iowa Child and Family Household Health Survey (modified)
IOP04000/(CONCERNED). DID THE ADULT SEEM CONCERNED ABOUT OTHER PEOPLE
PRESENT AT THE INTERVIEW?
Label
YES
NO
NOT APPLICABLE/DID NOT
OBSERVE THE
PARTICIPANT
Code
1
2
-7
Go To
TRAUMA
TRAUMA
SOURCE
Iowa Child and Family Household Health Survey (modified)
IOP05000/(PEOPLE). WHAT OTHER PEOPLE DID THE ADULT SEEM UNHAPPY ABOUT
BEING PRESENT AT THE INTERVIEW?
INTERVIEWER INSTRUCTIONS
• SELECT ALL THAT APPLY.
Label
OTHER NCS STAFF
SPOUSE/PARTNER
OTHER ADULTS (NON-NCS
STAFF)
CHILDREN
OTHER
Code
1
2
3
Go To
4
-5
SOURCE
New
PROGRAMMER INSTRUCTIONS
• IF PEOPLE = -5, OR ANY COMBINATION OF 1 - 4 AND -5, GO TO PEOPLE_OTH.
• OTHERWISE, GO TO TRAUMA.
IOP06000/(PEOPLE_OTH). SPECIFY: ________________________________
SOURCE
New
QUE Interviewer Observation Questionnaire - Adult, MDES 4.0, V1.0
OMB Specification
4
IOP07000/(TRAUMA). DID THE ADULT HAVE ANY SIGNS OF PHYSICAL INJURY OR
TRAUMA?
Label
YES
NO
NOT APPLICABLE/DID NOT
OBSERVE PARTICIPANT
Code
1
2
-7
Go To
SOURCE
California Health Interview Survey (modified)
IOP08000/(VIOLENCE). DID THE ADULT MENTION ANYTHING ABOUT CURRENT OR
PAST INTIMATE PARTNER VIOLENCE? VIOLENCE COULD INCLUDE HITTING,
SLAPPING, PUSHING, KICKING, OR PHYSICALLY HURTING THE ADULT.
Label
YES
NO
Code
1
2
Go To
TIME_STAMP_IOP_ET
SOURCE
California Health Interview Survey (modified)
IOP09000/(VIOLENCE_DETAIL). YOU INDICATED THAT THE ADULT MENTIONED
CURRENT OR PAST INTIMATE PARTNER VIOLENCE. TO THE BEST OF YOUR ABILITY,
PLEASE WRITE DOWN WHAT THE ADULT TOLD YOU.
SPECIFY: _______________________________________________________
SOURCE
New
INTERVIEWER INSTRUCTIONS
• NOTE THAT THERE IS A SIZE LIMIT OF 255 CHARACTERS FOR YOUR
DESCRIPTION.
(TIME_STAMP_IOP_ET).
PROGRAMMER INSTRUCTIONS
• INSERT DATE/TIME STAMP
QUE Interviewer Observation Questionnaire - Adult, MDES 4.0, V1.0
OMB Specification
5
INTERVIEWER OBSERVATIONS - INTERVIEW
(TIME_STAMP_IOI_ST).
PROGRAMMER INSTRUCTIONS
• INSERT DATE/TIME STAMP
• PRELOAD THE TARGET RESPONDENT FOR THE INSTRUMENT(S) COMPLETED
DURING THE VISIT.
IOI01000/(PROXY). WAS THIS INTERVIEW
RESPONDENT OR SOMEONE ELSE?
Label
INTENDED RESPONDENT
SOMEONE ELSE
COMPLETED
Code
1
2
WITH
THE
INTENDED
Go To
SOURCE
New
PROGRAMMER INSTRUCTIONS
• IF PROXY = 1 AND
o INS_MODE = 1 (CAPI), GO TO INT_PART_HOME.
o INS_MODE = 2 (CATI), GO TO INT_MODE.
IOI02000/(PR_REL_CHILD). WHAT IS THE
RESPONDENT TO {C_FNAME/THE CHILD}?
Label
BIOLOGICAL MOTHER
BIOLOGICAL FATHER
GRANDPARENT
OTHER RELATIVE
NEIGHBOR
CAREGIVER
TEACHER
PRIMARY CHILD CARE
PROVIDER
OTHER CHILD CARE
PROVIDER
AUNT
UNCLE
COUSIN
OTHER NON-RELATIVE
ADOPTIVE MOTHER
ADOPTIVE FATHER
SOCIAL MOTHER
SOCIAL FATHER
STEP MOTHER
STEP FATHER
RELATIONSHIP
OF
THE
Code
2
4
10
11
13
15
16
17
Go To
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
18
PR_REL_RESP
19
20
21
22
23
24
25
26
27
28
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
QUE Interviewer Observation Questionnaire - Adult, MDES 4.0, V1.0
OMB Specification
INTERVIEW
6
Label
STEP BROTHER
STEP SISTER
ADOPTIVE BROTHER
ADOPTIVE SISTER
GRANDMOTHER
GRANDFATHER
OTHER
Code
29
30
31
32
33
34
-5
Go To
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
PR_REL_RESP
SOURCE
New
IOI03000/(PR_REL_CHILD_OTH). SPECIFY: ____________________________________
SOURCE
New
IOI04000/(PR_REL_RESP). WHAT IS THE RELATIONSHIP
RESPONDENT TO THE INTENDED RESPONDENT?
Label
MOTHER
FATHER
SPOUSE
DOMESTIC PARTNER
OTHER ADULT RELATIVE
OTHER ADULT NONRELATIVE
OTHER
Code
1
2
3
4
5
6
OF
THE
INTERVIEW
Go To
-5
SOURCE
New
PROGRAMMER INSTRUCTIONS
• IF PR_REL_RESP = ANY VALUE 1 THROUGH 6, GO TO PROGRAMMER
INSTRUCTIONS AFTER PR_REL_RESP_OTH.
IOI05000/(PR_REL_RESP_OTH). SPECIFY: _____________________________________
SOURCE
New
PROGRAMMER INSTRUCTIONS
• IF INS_MODE = 1 (CAPI), GO TO INT_PART_HOME.
• IF INS_MODE = 2 (CATI), GO TO INT_MODE.
IOI06000/(INT_PART_HOME). DID YOU CONDUCT THIS INTERVIEW AT THE ADULT'S
HOME-EITHER INSIDE OR OUTSIDE?
QUE Interviewer Observation Questionnaire - Adult, MDES 4.0, V1.0
OMB Specification
7
Label
YES
NO
Code
1
2
Go To
INT_MODE
SOURCE
National Survey on Drug Use and Health
IOI07000/(INT_WHERE). WHERE DID YOU CONDUCT THIS INTERVIEW?
Label
ADULT’S WORKPLACE
AT HOME OF ADULT’S
FRIEND OR RELATIVE
IN SOME TYPE OF
COMMON AREA, SUCH AS
A LOBBY, HALLWAY,
STAIRWELL, OR LAUNDRY
ROOM
AT A CLINIC
IN A MOBILE VAN
OTHER
Code
1
2
Go To
INT_MODE
INT_MODE
3
INT_MODE
4
5
-5
INT_MODE
INT_MODE
SOURCE
National Survey on Drug Use and Health
IOI08000/(INT_WHERE_OTH). SPECIFY _____________________________________
SOURCE
National Survey on Drug Use and Health
IOI09000/(INT_MODE). IN WHAT MODE WAS THIS INTERVIEW COMPLETED?
Label
COMPUTER-ASSISTED
INTERVIEWING (CAI)
PAPER DATA COLLECTION
FORM
BOTH CAI AND PAPER
FORM
OTHER
Code
1
Go To
INT_METHOD
2
INT_METHOD
3
INT_METHOD
-5
SOURCE
New
IOI10000/(INT_MODE_OTH).
SPECIFY: _______________________________________________
SOURCE
New
QUE Interviewer Observation Questionnaire - Adult, MDES 4.0, V1.0
OMB Specification
8
IOI10100/(INT_METHOD). WAS THE INTERVIEW SELF-ADMINISTERED, INTERVIEWERADMINISTERED, OR BOTH (I.E., SOME PARTS WERE INTERVIEWER-ADMINISTERED,
SOME PARTS WERE SELF-ADMINISTERED)?
Label
SELF-ADMINISTERED
INTERVIEWERADMINISTERED
BOTH
Code
1
2
Go To
3
SOURCE
New
IOI11000/(PART_UND). HOW WOULD YOU ESTIMATE THE ADULT'S UNDERSTANDING
OF THE INTERVIEW?
Label
NO DIFFICULTY – NO
LANGUAGE OR READING
PROBLEM
JUST A LITTLE
DIFFICULTY—ALMOST NO
LANGUAGE OR READING
PROBLEM
A FAIR AMOUNT OF
DIFFICULTY—SOME
LANGUAGE OR READING
PROBLEM
A LOT OF DIFFICULTY—
CONSIDERABLE
LANGUAGE OR READING
PROBLEM
Code
1
Go To
2
3
4
SOURCE
National Survey on Drug Use and Health
IOI12000/(PART_COOP).
INTERVIEW?
Label
VERY COOPERATIVE
FAIRLY COOPERATIVE
NOT VERY COOPERATIVE
OPENLY HOSTILE
HOW
COOPERATIVE
WAS
Code
1
2
3
4
THE
ADULT
DURING
THE
Go To
SOURCE
National Survey on Drug Use and Health (modified)
QUE Interviewer Observation Questionnaire - Adult, MDES 4.0, V1.0
OMB Specification
9
IOI13000/(INT_PRIVATE). ON A SCALE FROM 1 THROUGH 4, HOW PRIVATE WAS THE
INTERVIEW? (DO NOT COUNT YOURSELF OR OTHER NCS STAFF AS ANOTHER
PERSON IN THE ROOM.)
Label
COMPLETELY PRIVATE –
NO ONE WAS IN THE ROOM
OR COULD OVERHEAR
ANY PART
MINOR DISTRACTIONS –
PERSONS IN THE ROOM
OR LISTENING ABOUT 1/3
OF THE TIME
SERIOUS INTERRUPTIONS
OF PRIVACY MORE THAN
HALF THE TIME
CONSTANT PRESENCE OF
OTHER PERSON(S)
Code
1
Go To
2
3
4
SOURCE
National Survey on Drug Use and Health
IOI14000/(INT_LANG). WHAT LANGUAGE WAS USED TO CONDUCT THIS INTERVIEW?
Label
ENGLISH
SPANISH
ARABIC
CHINESE
FRENCH
FRENCH CREOLE
GERMAN
ITALIAN
KOREAN
POLISH
RUSSIAN
TAGALOG
VIETNAMESE
URDU
PUNJABI
BENGALI
FARSI
JAPANESE
MANDARIN
PORTUGUESE
TAIWANESE
TURKISH
OTHER
Code
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
-5
QUE Interviewer Observation Questionnaire - Adult, MDES 4.0, V1.0
OMB Specification
Go To
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
INT_COMMENT
10
SOURCE
National Children’s Study, Vanguard Phase
IOI15000/(INT_LANG_OTH). SPECIFY: ___________________________________________
SOURCE
National Children’s Study, Vanguard Phase
IOI16000/(INT_COMMENT). PLEASE NOTE ANYTHING ELSE YOU THINK WOULD BE
HELPFUL FOR THE INTERPRETATION AND UNDERSTANDING OF THIS INTERVIEW.
COMMENT: ___________________________________________
SOURCE
National Survey on Drug Use and Health
PROGRAMMER INSTRUCTIONS
• ALLOW 255 CHARATERS.
(TIME_STAMP_IOI_ET).
PROGRAMMER INSTRUCTIONS
• INSERT DATE/TIME STAMP
QUE Interviewer Observation Questionnaire - Adult, MDES 4.0, V1.0
OMB Specification
11
OMB #: 0925-0593
OMB Expiration Date: 8/31/2014
Interviewer Observation Questionnaire - Child, Phase 2g
OMB Specification
Interviewer Observation Questionnaire - Child
Event Category:
Time-Based
Event:
Birth, 3M, 6M, 9M, 12M, 18M, 24M, 30M, 36M,
42M, 48M, 54M, 60M
Administration:
N/A
Instrument Target:
Child
Instrument Respondent:
Data Collector
Domain:
Questionnaire
Document Category:
Observation
Method:
Data Collector Administered
Mode (for this instrument*):
OMB Approved Modes:
In-Person, CAI;
Phone, CAI
In-Person, CAI;
Phone, CAI;
Web-Based, CAI
Estimated Administration Time:
0 minutes
Multiple Child/Sibling Consideration:
Per Event
Special Considerations:
N/A
Version:
1.0
MDES Release:
4.0
*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for
administration in this/these mode(s) only.
This page intentionally left blank.
QUE Interviewer Observation Questionnaire - Child, MDES 4.0, V1.0
OMB Specification
ii
Interviewer Observation Questionnaire - Child
TABLE OF CONTENTS
GENERAL PROGRAMMER INSTRUCTIONS: .......................................................................... 1
INTERVIEWER OBSERVATIONS – CHILD............................................................................... 3
QUE Interviewer Observation Questionnaire - Child, MDES 4.0, V1.0
OMB Specification
iii
This page intentionally left blank.
QUE Interviewer Observation Questionnaire - Child, MDES 4.0, V1.0
OMB Specification
iv
Interviewer Observation Questionnaire - Child
GENERAL PROGRAMMER INSTRUCTIONS:
WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES
AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED
THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:
DATA ELEMENT FIELDS
MAXIMUM
CHARACTE
RS
PERMITTED
DATA TYPE
PROGRAMMER INSTRUCTIONS
100
CHARACTER
UNIT AND PHONE FIELDS
10
CHARACTER
_OTH AND COMMENT FIELDS
255
CHARACTER
•
Limit text to 255 characters
FIRST NAME AND LAST NAME
30
CHARACTER
•
Limit text to 30 characters
ALL ID FIELDS
36
CHARACTER
ZIP CODE
5
CHARACTER
ZIP CODE LAST FOUR
4
CHARACTER
CITY
50
CHARACTER
ADDRESS AND EMAIL FIELDS
NUMERIC
DOB AND ALL OTHER DATE
FIELDS (E.G., DT, DATE, ETC.)
CHARACTER
10
TIME VARIABLES
TWO-DIGIT
HOUR AND
TWO-DIGIT
MINUTE,
AM/PM
DESIGNATI
ON
NUMBER OF HOURS PER DAY
TWO-DIGIT
HOUR
NUMBER OF DAYS PER WEEK
ONE-DIGIT
NUMERIC
NUMERIC
NUMERIC
QUE Interviewer Observation Questionnaire - Child, MDES 4.0, V1.0
OMB Specification
• DISPLAY AS MM/DD/YYYY
• STORE AS YYYY-MM-DD
• HARD EDITS:
MM MUST EQUAL 01 TO 12
DD MUST EQUAL 01 TO 31
YYYY MUST BE BETWEEN 1900
AND CURRENT YEAR.
• HARD EDITS:
HOURS MUST BE BETWEEN 00 AND
12;
MINUTES MUST BE BETWEEN 00
AND 59
• HARD EDITS:
HOURS MUST BE BETWEEN 1 AND
24
• HARD EDITS:
DAYS PER WEEK MUST BE
BETWEEN 1 AND 7
1
Instrument Guidelines for Participant and Respondent IDs:
PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G.
THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).
POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE
PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE
COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD
AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER.
THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID
(RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT.
THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY
OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.
A REMINDER:
ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON,
PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES,
WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH
QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF
QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE
THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES
VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL
IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.
QUE Interviewer Observation Questionnaire - Child, MDES 4.0, V1.0
OMB Specification
2
INTERVIEWER OBSERVATIONS – CHILD
(TIME_STAMP_IOC_ST).
PROGRAMMER INSTRUCTIONS
• INSERT DATE/TIME STAMP
• PRELOAD PARTICIPANT ID (P_ID) FOR CHILD
• PRELOAD C_FNAME FROM INSTRUMENT_ID = XX (PARTICIPANT VERIFICATION,
SCHEDULING, AND TRACING QUESTIONNAIRE).
• IF C_FNAME ≠ -1 OR -2, DISPLAY CHILD'S FIRST NAME IN "C_FNAME"
THROUGHOUT INSTRUMENT.
• OTHERWISE, IF C_FNAME = -1 OR -2, DISPLAY "THE CHILD" THROUGHOUT
INSTRUMENT.
• PRELOAD STAFF_ID.
IOC01000/(SEE_CHILD). DID YOU SEE {C_FNAME/THE CHILD} DURING YOUR STUDY
VISIT?
Label
YES
NO
Code
1
2
Go To
CHILD_VIOLENCE
SOURCE
New
IOC02000/(CHILD_ELIG). IS {C_FNAME/THE CHILD} 2 YEARS OF AGE OR OLDER?
Label
YES
NO
Code
1
2
Go To
SOURCE
New
PROGRAMMER INSTRUCTIONS
• IF CHILD_ELIG = 2 AND
o IF INS_MODE = 1 (CAPI), GO TO CHILD_TRAUMA.
o IF INS_MODE = 2 (CATI), GO TO CHILD_VIOLENCE.
• IF CHILD_ELIG = 1 AND
o IF INS_MODE = 1, GO TO INTERACT.
o IF INS_MODE = 2, GO TO CHILD_VIOLENCE.
IOC03000/(INTERACT). DID YOU SEE {C_FNAME/THE CHILD} INTERACT WITH OTHER
CHILDREN DURING YOUR VISIT?
Label
YES
Code
1
QUE Interviewer Observation Questionnaire - Child, MDES 4.0, V1.0
OMB Specification
Go To
3
Label
NO
Code
2
Go To
CHILD_SAD
SOURCE
New
IOC04000/(GET_ALONG). DID THE CHILD GET ALONG WITH OTHER CHILDREN,
INCLUDING BROTHERS AND SISTERS?
Label
YES
NO
Code
1
2
Go To
SOURCE
New
IOC05000/(CHILD_SAD). DID THE CHILD SEEM UNHAPPY, SAD, OR DEPRESSED?
Label
YES
NO
Code
1
2
Go To
SOURCE
Iowa Child and Family Household Health Survey (modified)
IOC05100/(CHILD_NERVOUS). DID THE CHILD SEEM NERVOUS, HIGH-STRUNG, OR
TENSE?
Label
YES
NO
Code
1
2
Go To
SOURCE
Iowa Child and Family Household Health Survey (modified)
IOC06000/(CHILD_TRAUMA). DID THE CHILD HAVE ANY SIGNS OF PHYSICAL TRAUMA?
Label
YES
NO
Code
1
2
Go To
SOURCE
New
IOC07000/(CHILD_VIOLENCE). DID THE ADULT CAREGIVER MENTION ANYTHING
ABOUT CURRENT OR PAST VIOLENCE TOWARDS THE CHILD? VIOLENCE COULD
INCLUDE HITTING, SLAPPING, PUSHING, KICKING, OR PHYSICALLY HURTING.
Label
Code
QUE Interviewer Observation Questionnaire - Child, MDES 4.0, V1.0
OMB Specification
Go To
4
Label
YES
NO
Code
1
2
Go To
TIME_STAMP_IOC_ET
SOURCE
California Child Abuse Detection Guidance document (modified)
IOC08000/(CHILD_VIOLENCE_DETAIL). YOU INDICATED THAT THE ADULT CAREGIVER
MENTIONED CURRENT OR PAST VIOLENCE TOWARDS THE CHILD. TO THE BEST OF
YOUR ABILITY, PLEASE WRITE DOWN WHAT THE ADULT CAREGIVER TOLD YOU.
SPECIFY: _______________________________________________________
SOURCE
New
(TIME_STAMP_IOC_ET).
PROGRAMMER INSTRUCTIONS
• INSERT DATE/TIME STAMP
QUE Interviewer Observation Questionnaire - Child, MDES 4.0, V1.0
OMB Specification
5
OMB #: 0925-0593
OMB Expiration Date: 8/31/2014
Interviewer Observation Questionnaire - Household, Phase 2g
OMB Specification
Interviewer Observation Questionnaire - Household
Event Category:
Event:
Administration:
Instrument Target:
Time-Based
Pre-Pregnancy, PV1, PV2, Birth, 3M, 6M, 9M,
12M, 18M, 24M, 30M, 36M, 42M, 48M, 54M,
60M
Pre-Pregnancy, PV1, PV2, Birth, 3M, 6M, 9M,
12M, 18M, 24M, 30M, 36M, 42M, 48M, 54M,
60M
Pre-Pregnant Woman's Residence;
Pregnant Woman's Residence;
Child’s Primary Residence
Instrument Respondent:
Data Collector
Domain:
Questionnaire
Document Category:
Observation
Method:
Data Collector Administered
Mode (for this instrument*):
OMB Approved Modes:
In-Person, CAI;
Phone, CAI
In-Person, CAI;
Phone, CAI;
Web-Based, CAI
Estimated Administration Time:
0 minutes
Multiple Child/Sibling Consideration:
Per Event
Special Considerations:
In-Person events only
Version:
1.0
MDES Release:
4.0
*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for
administration in this/these mode(s) only.
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QUE Interviewer Observation Questionnaire - Household, MDES 4.0, V1.0
OMB Specification
ii
Interviewer Observation Questionnaire - Household
TABLE OF CONTENTS
GENERAL PROGRAMMER INSTRUCTIONS: .......................................................................... 1
INTERVIEWER OBSERVATIONS – HOME (INTERIOR) .......................................................... 3
QUE Interviewer Observation Questionnaire - Household, MDES 4.0, V1.0
OMB Specification
iii
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QUE Interviewer Observation Questionnaire - Household, MDES 4.0, V1.0
OMB Specification
iv
Interviewer Observation Questionnaire - Household
GENERAL PROGRAMMER INSTRUCTIONS:
WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES
AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED
THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:
DATA ELEMENT FIELDS
MAXIMUM
CHARACTE
RS
PERMITTED
DATA TYPE
PROGRAMMER INSTRUCTIONS
100
CHARACTER
UNIT AND PHONE FIELDS
10
CHARACTER
_OTH AND COMMENT FIELDS
255
CHARACTER
•
Limit text to 255 characters
FIRST NAME AND LAST NAME
30
CHARACTER
•
Limit text to 30 characters
ALL ID FIELDS
36
CHARACTER
ZIP CODE
5
CHARACTER
ZIP CODE LAST FOUR
4
CHARACTER
CITY
50
CHARACTER
ADDRESS AND EMAIL FIELDS
NUMERIC
DOB AND ALL OTHER DATE
FIELDS (E.G., DT, DATE, ETC.)
CHARACTER
10
TIME VARIABLES
TWO-DIGIT
HOUR AND
TWO-DIGIT
MINUTE,
AM/PM
DESIGNATI
ON
NUMBER OF HOURS PER DAY
TWO-DIGIT
HOUR
NUMBER OF DAYS PER WEEK
ONE-DIGIT
NUMERIC
NUMERIC
NUMERIC
QUE Interviewer Observation Questionnaire - Household, MDES 4.0, V1.0
OMB Specification
• DISPLAY AS MM/DD/YYYY
• STORE AS YYYY-MM-DD
• HARD EDITS:
MM MUST EQUAL 01 TO 12
DD MUST EQUAL 01 TO 31
YYYY MUST BE BETWEEN 1900
AND CURRENT YEAR.
• HARD EDITS:
HOURS MUST BE BETWEEN 00 AND
12;
MINUTES MUST BE BETWEEN 00
AND 59
• HARD EDITS:
HOURS MUST BE BETWEEN 1 AND
24
• HARD EDITS:
DAYS PER WEEK MUST BE
BETWEEN 1 AND 7
1
Instrument Guidelines for Participant and Respondent IDs:
PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G.
THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).
POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE
PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE
COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD
AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER.
THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID
(RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT.
THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY
OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.
A REMINDER:
ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON,
PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES,
WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH
QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF
QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE
THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES
VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL
IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.
QUE Interviewer Observation Questionnaire - Household, MDES 4.0, V1.0
OMB Specification
2
INTERVIEWER OBSERVATIONS – HOME (INTERIOR)
(TIME_STAMP_IOH_ST).
PROGRAMMER INSTRUCTIONS
• INSERT DATE/TIME STAMP
• PRELOAD DWELLING_UNIT_ID FOR THE DWELLING UNIT FROM THE
PARTICIPANT VERIFICATION, SCHEDULING, AND TRACING QUESTIONNAIRE
(INSTRUMENT_ID = XX)
• PRELOAD STAFF_ID.
• PRELOAD INS_MODE.
• IF INS_MODE = 1 (CAPI), GO TO GO_INSIDE_HOME.
• IF INS_MODE = 2 (CATI), GO TO TIME_STAMP_IOH_ET.
INTERVIEWER INSTRUCTIONS
• YOU SHOULD NOW ANSWER THE HOUSEHOLD OBSERVATION
MODULE. PLEASE ANSWER THESE QUESTIONS THE BEST YOU CAN. YOU
SHOULD ANSWER BASED ON WHAT YOU KNOW OR HAVE SEEN SO FAR. DO
NOT EXPLORE THE HOME MORE THAN YOU ALREADY HAVE IN ORDER TO
ANSWER THESE QUESTIONS.
IOH01000/(GO_INSIDE_HOME). DID YOU GO INSIDE THE PARTICIPANT'S HOME?
Label
YES
NO
Code
1
2
Go To
TIME_STAMP_IOH_ET
SOURCE
New
IOH02000/(HOME_HAZARDS). WAS THE HOUSE OR APARTMENT FREE OF
POTENTIALLY DANGEROUS STRUCTURAL OR HEALTH HAZARDS (EXPOSED OUTLETS,
BROKEN WINDOWS, WINDOWS WITHOUT SCREENS OR GUARDS, LEAKING RADIATOR,
POTS HANGING OVER THE EDGE OF THE STOVE)?
Label
YES
NO
Code
1
2
Go To
SOURCE
Home Observation for Measurement of the Environment
IOH03000/(HOME_CLEAN). WERE ALL VISIBLE ROOMS
REASONABLY CLEAN AND MINIMALLY CLUTTERED?
Label
YES
Code
1
QUE Interviewer Observation Questionnaire - Household, MDES 4.0, V1.0
OMB Specification
OF
THE
HOME
ARE
Go To
3
Label
NO
Code
2
Go To
SOURCE
Home Observation for Measurement of the Environment/The National Survey of Child
and Adolescent Well-being
IOH04000/(FLOOR_SPACE). IN TERMS OF AVAILABLE FLOOR SPACE, WERE THE
ROOMS OVERCROWDED WITH FURNITURE?
Label
YES
NO
Code
1
2
Go To
SOURCE
Home Observation for Measurement of the Environment
IOH05000/(DARK_INSIDE). WAS THE INTERIOR OF THE HOME DARK?
Label
YES
NO
Code
1
2
Go To
SOURCE
Home Observation for Measurement of the Environment/The National Survey of Child
and Adolescent Well-Being (modified)
IOH06000/(NOISE_INSIDE). WAS THE HOUSE OR APARTMENT OVERLY NOISY DUE TO
NOISE INSIDE THE HOUSE (E.G., TELEVISION, LOUD VOICES, RADIO)?
Label
YES
NO
Code
1
2
Go To
SOURCE
Home Observation for Measurement of the Environment (modified)
IOH07000/(NOISE_OUTSIDE). WAS THE HOUSE OR APARTMENT OVERLY NOISY DUE
TO NOISE OUTSIDE THE HOUSE (E.G., TELEVISION, LOUD VOICES, RADIO)?
Label
YES
NO
Code
1
2
Go To
SOURCE
Home Observation for Measurement of the Environment (modified)
QUE Interviewer Observation Questionnaire - Household, MDES 4.0, V1.0
OMB Specification
4
IOH08000/(SIGNS_DRUG_ALCOHOL). WERE THERE OBVIOUS SIGNS OF RECENT
ALCOHOL OR NON-PRESCRIPTION DRUG CONSUMPTION IN THE HOME (E.G., DRUG
PARAPHERNALIA, BEER CANS, LIQUOR BOTTLES)?
Label
YES
NO
Code
1
2
Go To
SOURCE
Home Observation for Measurement of the Environment
IOH09000/(SIGNS_SMOKE_INSIDE). WAS THERE EVIDENCE OF SMOKING INSIDE THE
HOME, SUCH AS ASH TRAYS, TOBACCO PRODUCTS, LIGHTERS, OR ODORS?
Label
YES
NO
Code
1
2
Go To
SOURCE
Children’s Health After the Storm
IOH10000/(SIGNS_RODENT_INSIDE). WAS THERE EVIDENCE OF RODENT DROPPINGS,
TRAPS, OR POISONS INSIDE THE HOME?
Label
YES
NO
Code
1
2
Go To
SOURCE
Children’s Health After the Storm
IOH11000/(FOOD_REMAINS). WAS THERE EVIDENCE OF FOOD REMAINS INSIDE THE
HOME (THAT IS, FOOD THAT HAS NOT BEEN DISPOSED OF PROPERLY)?
Label
YES
NO
Code
1
2
Go To
SOURCE
Children’s Health After the Storm (modified)
IOH12000/(VISIBLE_MOLD). WAS THERE MOLD VISIBLE ON WALLS, CARPET, OR OTHER
SURFACES INSIDE THE HOME?
Label
YES
NO
Code
1
2
Go To
SOURCE
QUE Interviewer Observation Questionnaire - Household, MDES 4.0, V1.0
OMB Specification
5
SOURCE
Children’s Health After the Storm
IOH13000/(SMELL_MOLD). DID THE HOME HAVE A MOLDY SMELL?
Label
YES
NO
Code
1
2
Go To
SOURCE
Children’s Health After the Storm
IOH14000/(WATER_DAMAGE). DID THE HOME HAVE ANY VISIBLE WATER DAMAGE?
Label
YES
NO
Code
1
2
Go To
SOURCE
Children’s Health After the Storm
IOH15000/(INSIDE_TEMP). HOW WOULD YOU DESCRIBE THE TEMPERATURE IN THE
HOME?
Label
TOO HOT FOR THE
SEASON
ABOUT RIGHT FOR THE
SEASON
TOO COLD FOR THE
SEASON
Code
1
Go To
2
3
SOURCE
New
(TIME_STAMP_IOH_ET).
PROGRAMMER INSTRUCTIONS
• INSERT DATE/TIME STAMP
QUE Interviewer Observation Questionnaire - Household, MDES 4.0, V1.0
OMB Specification
6
| File Type | application/pdf |
| File Modified | 2013-12-09 |
| File Created | 2013-12-09 |