Form 2.1 Survey

Continuation of National Children's Study Vanguard (Pilot) Study Data Collection: Study Visits through 60-Months and Sibling Birth Enrollment

PrePregnancyQuestionnaireHousehold

Pre-Pregnancy Interview

OMB: 0925-0593

Document [docx]
Download: docx | pdf

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Pre-Pregnancy Questionnaire - Household, Phase 2g

OMB Specification


Pre-Pregnancy Questionnaire - Household


Event Category:

Trigger-Based

Event:

Pre-Pregnancy

Administration:

N/A

Instrument Target:

Pre-Pregnant Woman's Residence

Instrument Respondent:

Pre-Pregnant Woman

Domain:

Questionnaire

Document Category:

Questionnaire

Method:

Data Collector Administered

Mode (for this instrument*):

In-Person, CAI;
Phone, CAI

OMB Approved Modes:

In-Person, CAI;
Phone, CAI;
Web-Based, CAI

Estimated Administration Time:

6 minutes

Multiple Child/Sibling Consideration:

Per Event

Special Considerations:

N/A

Version:

1.0

MDES Release:

MDES 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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Pre-Pregnancy Questionnaire - Household



TABLE OF CONTENTS





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Pre-Pregnancy 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 CHARACTERS PERMITTED

DATA TYPE

PROGRAMMER INSTRUCTIONS

ADDRESS AND EMAIL FIELDS

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

NUMERIC


ZIP CODE LAST FOUR

4

NUMERIC


CITY

50

CHARACTER


DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)

10

NUMERIC


CHARACTER



  • 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.

TIME VARIABLES

TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION

NUMERIC

  • HARD EDITS:

HOURS MUST BE BETWEEN 00 AND 12;

MINUTES MUST BE BETWEEN 00 AND 59


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.





HOUSING CHARACTERISTICS


(TIME_STAMP_HC_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP

  • PRELOAD PRE-PREGNANT WOMAN'S HOUSEHOLD ID (HH_ID) AND RESPONDENT ID (R_P_ID) FOR ADULT.

  • PRELOAD OWN_HOME FROM PREGNANCY SCREENER (INSTRUMENT_ID = XX) IF AVAILABLE.


HC01000. Now I’d like to find out more about your home and the area in which you live.


PROGRAMMER INSTRUCTIONS

  • IF OWN_HOME COLLECTED IN PREGNANCY SCREENER (INSTRUMENT_ID = XX), GO TO RECENT_MOVE

  • OTHERWISE, GO TO OWN_HOME


HC02000/(RECENT_MOVE). Have you moved or changed your housing situation since we contacted you last?


Label

Code

Go To

YES

1


NO

2

AGE_HOME

REFUSED

-1

AGE_HOME

DON'T KNOW

-2

AGE_HOME


SOURCE

National Children’s Study, Vanguard Phase


HC03000/(OWN_HOME). Is your home…


Label

Code

Go To

Owned or being bought by you or someone in your household

1

AGE_HOME

Rented by you or someone in your household

2

AGE_HOME

Occupied without payment of rent

3

AGE_HOME

SOME OTHER ARRANGEMENT

-5


REFUSED

-1

AGE_HOME

DON'T KNOW

-2

AGE_HOME


SOURCE

National Children’s Study, Vanguard Phase


HC04000/(OWN_HOME_OTH). SPECIFY: _____________________________


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children’s Study, Vanguard Phase


HC05000/(AGE_HOME). Which of these categories best describes when your home or building was built?


INTERVIEWER INSTRUCTIONS

  • IF USING SHOW CARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

  • IF NOT USING SHOW CARDS, READ RESPONSE OPTIONS.


Label

Code

Go To

2001 OR LATER

1


1981 TO 2000

2


1961 TO 1980

3


1941 TO 1960

4


1940 OR BEFORE

5


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Survey of Lead and Allergens in Housing (modified)


HC06000. How long have you lived in this home?


SOURCE

National Survey of Lead and Allergens in Housing


(LENGTH_RESIDE) |___|___|

NUMBER


Label

Code

Go To

REFUSED

-1

HC07000

DON'T KNOW

-2

HC07000


(LENGTH_RESIDE_UNIT)


Label

Code

Go To

WEEKS

1


MONTHS

2


YEARS

3


REFUSED

-1


DON'T KNOW

-2



HC07000. Now I’m going to ask about how your home is heated and cooled.


HC08000/(MAIN_HEAT). Which of these types of heat sources best describes the main heating fuel source for your home?


INTERVIEWER INSTRUCTIONS

  • IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

  • IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.


Label

Code

Go To

ELECTRIC

1

HEAT2

GAS – PROPANE OR LP

2

HEAT2

OIL

3

HEAT2

WOOD

4

HEAT2

KEROSENE OR DIESEL

5

HEAT2

COAL OR COKE

6

HEAT2

SOLAR ENERGY

7

HEAT2

HEAT PUMP

8

HEAT2

NO HEATING SOURCE

9

COOLING

OTHER

-5


REFUSED

-1

COOLING

DON'T KNOW

-2

COOLING


SOURCE

American Healthy Homes Survey


HC09000/(MAIN_HEAT_OTH). SPECIFY: _____________________________


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

American Healthy Homes Survey


HC10000/(HEAT2). Are there any other types of heat you use regularly during the heating season to heat your home?


INTERVIEWER INSTRUCTIONS

  • IF USING SHOW CARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

  • IF NOT USING SHOW CARDS, READ RESPONSE OPTIONS.

  • PROBE FOR ANY OTHER RESPONSES: Do you have any space heaters, or any secondary method for heating your home?

  • SELECT ALL THAT APPLY


Label

Code

Go To

ELECTRIC

1


GAS – PROPANE OR LP

2


OIL

3


WOOD

4


KEROSENE OR DIESEL

5


COAL OR COKE

6


SOLAR ENERGY

7


HEAT PUMP

8


NO OTHER HEATING SOURCE

9


OTHER

-5


REFUSED

-1


DON'T KNOW

-2



SOURCE

American Healthy Homes Survey


PROGRAMMER INSTRUCTIONS

  • IF HEAT2 = ANY COMBINATION OF VALUES 1 – 8, THEN GO TO COOLING.

  • IF HEAT2 = -5, OR ANY COMBINATION OF VALUES 1 – 8 AND -5, GO TO HEAT2_OTH. 

  • IF HEAT2 = 9, -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO COOLING.


HC11000/(HEAT2_OTH). SPECIFY: _____________________________


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

American Healthy Homes Survey


HC12000/(COOLING). Does your home have any type of cooling or air conditioning besides fans?


Label

Code

Go To

YES

1


NO

2

HC15000

REFUSED

-1

HC15000

DON'T KNOW

-2

HC15000


SOURCE

National Children’s Study, Vanguard Phase


HC13000/(COOL). Not including fans, which of the following kinds of cooling systems do you regularly use?


INTERVIEWER INSTRUCTIONS

  • PROBE FOR ANY OTHER RESPONSES

  • SELECT ALL THAT APPLY


Label

Code

Go To

Window or wall air conditioners

1


Central air conditioning

2


Evaporative cooler, also called swamp cooler

3


NO COOLING OR AIR CONDITIONING REGULARLY USED

-7


Some other cooling system

-5


REFUSED

-1


DON'T KNOW

-2



SOURCE

American Healthy Homes Survey


PROGRAMMER INSTRUCTIONS

  • IF COOL = ANY COMBINATION OF VALUES 1 - 3, GO TO HC15000.

  • IF COOL = -5, OR ANY COMBINATION OF VALUES 1 – 3 AND -5, GO TO COOL_OTH. 

  • IF COOL = 4, -7, -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO HC15000.


HC14000/(COOL_OTH). SPECIFY: _____________________________


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

American Healthy Homes Survey


HC15000. Water damage is a common problem that occurs inside of many homes.  Water damage includes water stains on the ceiling or walls, rotting wood, and flaking sheetrock or plaster. This damage may be from broken pipes, a leaky roof, or floods.


HC16000/(WATER). In the past 12 months, have you seen any water damage inside your home?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

American Healthy Homes Survey (modified)


HC17000/(MOLD). In the past 12 months, have you seen any mold or mildew on walls or other surfaces other than the shower or bathtub, inside your home?


Label

Code

Go To

YES

1


NO

2

HC20000

REFUSED

-1

HC20000

DON'T KNOW

-2

HC20000


SOURCE

American Healthy Homes Survey (modified)


HC18000/(ROOM_MOLD). In which rooms have you seen the mold or mildew?


INTERVIEWER INSTRUCTIONS

  • PROBE FOR ANY OTHER RESPONSES: Any other rooms?

  • SELECT ALL THAT APPLY


Label

Code

Go To

KITCHEN

1


LIVING ROOM

2


HALL OR LANDING

3


PARTICIPANT’S BEDROOM

4


OTHER BEDROOM

5


BATHROOM/TOILET

6


BASEMENT

7


OTHER

-5


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children’s Study, Vanguard Phase


PROGRAMMER INSTRUCTIONS

  • IF ROOM_MOLD = ANY COMBINATION OF VALUES 1 – 7, GO TO HC20000.

  • IF ROOM_MOLD = -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, GO TO ROOM_MOLD_OTH. 

  • IF ROOM_MOLD = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO HC20000.


HC19000/(ROOM_MOLD_OTH). SPECIFY: _____________________________


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children’s Study, Vanguard Phase


HC20000. The next few questions ask about any recent additions or renovations to your home. 


HC21000/(RENOVATE). In the past 12 months, have any additions or renovations been done to your home? Include only major projects that made your home larger or involved construction. Do not count smaller projects such as painting or wallpapering, carpeting, or refinishing floors."


Label

Code

Go To

YES

1


NO

2

DECORATE

REFUSED

-1

DECORATE

DON'T KNOW

-2

DECORATE


SOURCE

American Housing Survey


HC22000/(RENOVATE_ROOM). Which rooms were renovated?


INTERVIEWER INSTRUCTIONS

  • PROBE: Any others?

  • SELECT ALL THAT APPLY


Label

Code

Go To

KITCHEN

1


LIVING ROOM

2


HALL OR LANDING

3


PARTICIPANT’S BEDROOM

4


OTHER BEDROOM

5


BATHROOM/TOILET

6


BASEMENT

7


OTHER

-5


REFUSED

-1


DON'T KNOW

-2



SOURCE

American Housing Survey


PROGRAMMER INSTRUCTIONS

  • IF RENOVATE_ROOM = ANY COMBINATION OF VALUES 1 – 7, THEN GO TO DECORATE.

  • IF RENOVATE_ROOM = -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, GO TO RENOVATE_ROOM_OTH. 

  • IF RENOVATE_ROOM = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO DECORATE.


HC23000/(RENOVATE_ROOM_OTH). SPECIFY: _____________________________


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

American Housing Survey


HC24000/(DECORATE). In the past 12 months, were any smaller projects done in your home, such as painting, wallpapering, refinishing floors, or installing new carpet?


Label

Code

Go To

YES

1


NO

2

HC27000

REFUSED

-1

HC27000

DON'T KNOW

-2

HC27000


SOURCE

Avon Longitudinal Study of Parents and Children


HC25000/(DECORATE_ROOM). In which rooms were these smaller projects done?


INTERVIEWER INSTRUCTIONS

  • PROBE: Any others?

  • SELECT ALL THAT APPLY.


Label

Code

Go To

KITCHEN

1


LIVING ROOM

2


HALL OR LANDING

3


PARTICIPANT’S BEDROOM

4


OTHER BEDROOM

5


BATHROOM/TOILET

6


BASEMENT

7


OTHER

-5


REFUSED

-1


DON'T KNOW

-2



SOURCE

Avon Longitudinal Study of Parents and Children


PROGRAMMER INSTRUCTIONS

  • IF DECORATE_ROOM = ANY COMBINATION OF VALUES 1 – 7, THEN GO TO HC27000.

  • IF DECORATE_ROOM = -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, GO TO DECORATE_ROOM_OTH. 

  • IF DECORATE_ROOM = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO HC27000.


HC26000/(DECORATE_ROOM_OTH). SPECIFY: _____________________________


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

Avon Longitudinal Study of Parents and Children


HC27000. Now I’d like to ask about the water in your home.


HC28000/(WATER_DRINK). What water source in your home do you use most of the time for drinking?


Label

Code

Go To

Tap water

1

WATER_COOK

Filtered tap water

2

WATER_COOK

Bottled water

3

WATER_COOK

Some other source

-5


REFUSED

-1

WATER_COOK

DON'T KNOW

-2

WATER_COOK


SOURCE

National Human Exposure Assessment Survey


HC29000/(WATER_DRINK_OTH). SPECIFY: _____________________________


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

National Human Exposure Assessment Survey


HC30000/(WATER_COOK). What water source in your home is used most of the time for cooking?


Label

Code

Go To

Tap water

1

TIME_STAMP_HC_ET

Filtered tap water

2

TIME_STAMP_HC_ET

Bottled water

3


Some other source

-5

TIME_STAMP_HC_ET

REFUSED

-1

TIME_STAMP_HC_ET

DON'T KNOW

-2

TIME_STAMP_HC_ET


SOURCE

National Human Exposure Assessment Survey


HC31000/(WATER_COOK_OTH). SPECIFY: _____________________________


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

National Human Exposure Assessment Survey


(TIME_STAMP_HC_ET).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP



FAMILY INCOME


(TIME_STAMP_FI_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP


FI01000. Now I’m going to ask a few questions about your income.   Family income is important in analyzing the data we collect and is often used in scientific studies to compare groups of people who are similar.  Please remember that all the information you provide is confidential.

 

Please think about your total combined family income during {CURRENT YEAR – 1} for all members of the family.


PROGRAMMER INSTRUCTIONS

  • CALCULATE AND DISPLAY CURRENT YEAR MINUS 1.


FI02000/(HH_MEMBERS). How many household members are supported by your total combined family income?

 

|___|___|

NUMBER


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children’s Study, Vanguard Phase


PROGRAMMER INSTRUCTIONS

  • RESPONSE MUST BE > 0; INCLUDE A SOFT EDIT IF RESPONSE IS > 15

  • IF HH_MEMBERS = 1, -1, OR -2, GO TO INCOME

  • OTHERWISE, IF HH_MEMBERS > 1, GO TO NUM_CHILD.


FI03000 /(NUM_CHILD). How many of those people are children?  Please include anyone under 18 years or anyone older than 18 years and in high school.

 

|___|___|

NUMBER


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

Survey of Income and Program Participation


PROGRAMMER INSTRUCTIONS

  • INCLUDE HARD EDIT IF RESPONSE > HH_MEMBERS

  • INCLUDE SOFT EDIT IF RESPONSE > 10


FI01000/(INCOME). Of these income groups, which category best represents your total combined family income during the last calendar year?


INTERVIEWER INSTRUCTIONS

  • IF USING SHOW CARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

  • IF NOT USING SHOW CARDS, READ RESPONSE OPTIONS.


Label

Code

Go To

LESS THAN $4,999

1


$5,000-$9,999

2


$10,000-$19,999

3


$20,000-$29,999

4


$30,000-$39,999

5


$40,000-$49,999

6


$50,000-$74,999

7


$75,000-$99,999

8


$100,000-$199,999

9


$200,000 OR MORE

10


REFUSED

-1


DON'T KNOW

-2



SOURCE

Survey of Income and Program Participation (modified)


(TIME_STAMP_FI_ET).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP


Public reporting burden for this collection of information is estimated to average 6 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*).  Do not return the completed form to this address.

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