4.3 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Pregnancy Visit 1 Questionnaire - Adult, Phase 2g

OMB Specification

Pregnancy Visit 1 Questionnaire - Adult

Event Category:	Trigger-Based
Event:	PV1
Administration:	N/A
Instrument Target:	Pregnant Woman
Instrument Respondent:	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:	19 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.

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Pregnancy Visit 1 Questionnaire - Adult

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

CURRENT PREGNANCY INFORMATION 3

MEDICAL HISTORY 15

HEALTH INSURANCE 22

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS 25

REACTIONS TO RACE 41

COMMUTING 44

PREGNANCY HEALTH CARE LOG INTRODUCTION 47

IMMIGRATION STATUS 48

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Pregnancy Visit 1 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 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	CHARACTER
ZIP CODE LAST FOUR	4	CHARACTER
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
NUMBER OF HOURS PER DAY	TWO-DIGIT HOUR	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 1 AND 24
NUMBER OF DAYS PER WEEK	ONE-DIGIT	NUMERIC	HARD EDITS: DAYS PER WEEK MUST BE BETWEEN 1 AND 7

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.

CURRENT PREGNANCY INFORMATION

(TIME_STAMP_CPI_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PARTICIPANT ID (P_ID​) FOR PREGNANT WOMAN.

• THROUGHOUT ENTIRE INSTRUMENT, IF PROGRAMMER INSTRUCTIONS INDICATE TO "DISPLAY SOFT EDIT," DISPLAY "THIS VALUE IS OUTSIDE THE EXPECTED RANGE. PROBE AND CORRECT OR CONFIRM ANSWER BEFORE PROCEEDING TO THE NEXT QUESTION" UNLESS OTHERWISE SPECIFIED IN PROGRAMMER INSTRUCTIONS. 

CPI01000. In the next set of questions, I’ll ask about you, your health, and your health history.

INTERVIEWER INSTRUCTIONS

• MODIFY TRANSITIONAL STATEMENTS AS NEEDED TO MAKE APPROPRIATE FOR CURRENT INTERVIEW.

CPI02000/(PREGNANT). The first questions ask about how your pregnancy is progressing. Are you still pregnant?

Label	Code	Go To
YES	1	CPI05000
NO	2
REFUSED	-1	IS12000
DON'T KNOW	-2	IS12000

SOURCE

Pregnancy Risk Assessment Monitoring System (modified)

Current: National Children’s Study, Vanguard Phase (LI Non & Preg, PV2)

CPI03000.  I’m so sorry for your loss. I know this can be a difficult time.

INTERVIEWER INSTRUCTIONS

• USE SOCIAL CUES AND PROFESSIONAL JUDGMENT IN RESPONSE.

• IF ROC HAS PREGNANCY LOSS INFORMATION TO DISSEMINATE, OFFER TO PARTICIPANT.

CPI04000/(LOSS_INFO_2). DID PARTICIPANT REQUEST ADDITIONAL INFORMATION ON COPING WITH PREGNANCY LOSS?

Label	Code	Go To
YES	1	IS11000
NO	2	IS11000

CPI05000. What is your current due date?

INTERVIEWER INSTRUCTIONS

• IF SOFT EDIT MESSAGE DISPLAYED, ASK QUESTION AGAIN

SOURCE

Pregnancy, Infection, and Nutrition Study

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

(DUE_DATE_MM) MONTH

|___|___|

  M   M

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(DUE_DATE_DD) DAY

|___|___|

D      D

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(DUE_DATE_YYYY) YEAR:

|___|___|___|___|

  Y      Y     Y    Y

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

PROGRAMMER INSTRUCTIONS

• PERFORM A SOFT EDIT CHECK OF REPORTED DUE DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:

• SET DUE_DATE_MM, DUE_DATE_DD, DUE_DATE_YYYY = YYYY-MM-DD AS REPORTED.

• IF DATE IS MORE THAN 9 MONTHS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 9 MONTHS FROM TODAY. RE-ENTER DATE.”

• IF DATE IS MORE THAN 1 MONTH BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT OCCURRED MORE THAN A MONTH BEFORE TODAY. RE-ENTER DATE.”

• IF DUE_DATE_MM, DUE_DATE_DD, AND DUE_DATE_YYYY ≠ -1 OR -2, GO TO KNOW_DATE

CPI06000/(KNOW_DATE). How did you find out your due date? Did you...

Label	Code	Go To
Figure it out yourself	1	HOME_TEST
Have an ultrasound to figure it out	2	HOME_TEST
Have a doctor or other provider tell you without an ultrasound	3	HOME_TEST
REFUSED	-1	HOME_TEST
DON'T KNOW	-2	HOME_TEST

SOURCE

Pregnancy, Infection, and Nutrition Study

Current: National Children’s Study, Vanguard Phase (LI Non & Preg)

CPI07000. What was the first day of your last menstrual period?

INTERVIEWER INSTRUCTIONS

• ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR

SOURCE

National Health and Nutrition Examination Survey 2000

Current: National Children’s Study, Vanguard Phase (LI Non & Preg, PV2)

(DATE_PERIOD_MM) MONTH:

|___|___|

Label	Code	Go To
REFUSED	-1	HOME_TEST
DON'T KNOW	-2	HOME_TEST

(DATE_PERIOD_DD) DAY:

|___|___|

D      D

DATA COLLECTOR INSTRUCTIONS

• CODE DAY AS "15" IF PARTICIPANT IS UNSURE/UNABLE TO ESTIMATE DAY.

Label	Code	Go To
REFUSED	-1	HOME_TEST

(DATE_PERIOD_YYYY)  

YEAR:

|___|___|___|___|

  Y      Y     Y    Y

Label	Code	Go To
REFUSED	-1	HOME_TEST
DON'T KNOW	-2	HOME_TEST

PROGRAMMER INSTRUCTIONS

• CHECK REPORTED MENSTRUAL DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:

• IF DATE IS MORE THAN 10 MONTHS BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 10 MONTHS BEFORE TODAY. CONFIRM DATE.”

• IF DATE IS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT HAS NOT OCCURRED YET. RE-ENTER DATE.”

• IF DATE IS NONMISSING, NO MORE THAN 10 MONTHS BEFORE CURRENT DATE, AND NO LATER THAN CURRENT DATE, CALCULATE DUE DATE FROM THE FIRST DATE OF LAST MENSTRUAL PERIOD AND SET DUE_DATE_MM, DUE_DATE_DD, AND DUE_DATE_YYYY = DATE_PERIOD_MM, DATE_PERIOD_DD, AND ​DATE_PERIOD_YYYY + 280 DAYS.

CPI08000/(KNEW_DATE). DID PARTICIPANT GIVE DATE?

Label	Code	Go To
PARTICIPANT GAVE COMPLETE DATE	1
INTERVIEWER ENTERED 15 FOR DAY	2

CPI09000/(HOME_TEST). Did you use a home pregnancy test to help find out you were pregnant?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Vanguard Phase (LI Non- and Preg, PV2)

CPI10000/(MULTIPLE_GESTATION). Are you pregnant with a single baby (singleton), twins, or triplets or other multiple births?

Label	Code	Go To
SINGLETON	1
TWINS	2
TRIPLETS OR HIGHER	3
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Legacy Phase (T1 Mother)

PROGRAMMER INSTRUCTIONS

• IF MULTIPLE_GESTATION =2 OR 3, DISPLAY “babies” AS APPROPRIATE THROUGHOUT THE REST OF THE INSTRUMENT.

• OTHERWISE, DISPLAY “baby.”

CPI11000/(BIRTH_PLAN). Where do you plan to deliver your {baby/babies}?

Label	Code	Go To
In a hospital	1
A birthing center	2
At home	3	PN_VITAMIN
Some other place	4
REFUSED	-1	PN_VITAMIN
DON'T KNOW	-2	PN_VITAMIN

SOURCE

National Children’s Study, Legacy Phase (T1 Mother)

CPI12000. What is the name and address of the place where you are planning to deliver your {baby/babies}?

SOURCE

National Children’s Study, Legacy Phase (T1 Mother)

Current: National Children’s Study, Vanguard Phase (LI Non & Preg, PV2)

(BIRTH_PLACE) _____________________________________________________

NAME OF BIRTH HOSPITAL/BIRTHING CENTER

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(B_ADDRESS_1) _____________________________________________________

STREET ADDRESS

Label	Code	Go To
REFUSED	-1	B_CITY
DON'T KNOW	-2	B_CITY

PROGRAMMER INSTRUCTIONS

• IF B_ADDRESS_1 = -1, SET B_ADDRESS_2 = -1

• IF B_ADDRESS_1 = -2, SET B_ADDRESS_2 = -2

(B_ADDRESS_2) _____________________________________________________

STREET ADDRESS

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(B_CITY) _____________________________________________________

CITY

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(B_STATE) |___|___|                           

STATE

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(B_ZIPCODE) |___|___|___|___|___|

ZIP CODE

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

CPI13000/(PN_VITAMIN). In the month before you became pregnant, did you regularly take multivitamins, prenatal vitamins, folate, or folic acid?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Pregnancy Risk Assessment Monitoring System (modified)

Current: National Children’s Study, Vanguard Phase (LI Non & Preg)

CPI14000/(PREG_VITAMIN). Since you've become pregnant, have you regularly taken multivitamins, prenatal vitamins, folate, or folic acid?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Pregnancy Risk Assessment Monitoring System (modified)

Current: National Children’s Study, Vanguard Phase (LI Non & Preg)

CPI15000. What was the date of your most recent doctor’s visit or checkup since you’ve become pregnant?

INTERVIEWER INSTRUCTIONS

• ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR

SOURCE

National Children’s Study, Legacy Phase (T1 Mother, T3 Prior)

Current: National Children’s Study, Vanguard Phase (LI Non & Preg, PV2)

(DATE_VISIT_MM) |___|___|

M   M

Label	Code	Go To
HAVE NOT HAD A VISIT	-7	CPI16000
REFUSED	-1	CPI16000
DON'T KNOW	-2	CPI16000

(DATE_VISIT_DD) DAY:

|___|___|

D      D

Label	Code	Go To
REFUSED	-1	CPI16000
DON'T KNOW	-2

(DATE_VISIT_YYYY) YEAR:

|___|___|___|___|

  Y      Y     Y    Y

Label	Code	Go To
REFUSED	-1	CPI16000
DON'T KNOW	-2	CPI16000

CPI16000. {At this visit or at}/{At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?

PROGRAMMER INSTRUCTIONS

• IF DATE_VISIT_MM ≠ -1, -2 OR -7, AND IF DATE_VISIT_YYYY ≠ -1 OR -2, DISPLAY "At this visit or at”.

• OTHERWISE, DISPLAY “At”.

SOURCE

National Health and Nutrition Examination Survey (modified)

CPI17000/(DIABETES_1). Diabetes?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at}/{At}  any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

CPI18000/(HIGHBP_PREG). High blood pressure?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at}/{At}  any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

CPI19000/(URINE). Protein in your urine?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at}/{At}  any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

CPI20000/(PREECLAMP). Preeclampsia or toxemia?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at}/{At}  any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

CPI21000/(EARLY_LABOR). Early or premature labor?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at}/{At}  any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

CPI22000/(ANEMIA). Anemia or low blood count?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at}/{At}  any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

CPI23000/(NAUSEA). Severe nausea or vomiting, also called hyperemesis?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at}/{At}  any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

CPI24000/(KIDNEY). Bladder or kidney infection?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at}/{At}  any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

CPI25000/(RH_DISEASE). Rh disease or isoimmunization?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at}/{At}  any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

CPI26000/(GROUP_B). Infection with bacteria called Group B strep?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at}/{At}  any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

CPI27000/(HERPES). Infection with a Herpes virus?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at}/{At}  any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

Current: National Children’s Study, Vanguard Phase (LI Non & Preg, PV2)

CPI28000/(VAGINOSIS). Infection of the vagina with bacteria, also called bacterial vaginosis?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at}/{At}  any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

CPI29000/(OTH_CONDITION). Any other serious condition?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at}/{At}  any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2	TIME_STAMP_CPI_ET
REFUSED	-1	TIME_STAMP_CPI_ET
DON'T KNOW	-2	TIME_STAMP_CPI_ET

SOURCE

National Health and Nutrition Examination Survey (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

CPI30000/(CONDITION_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

(TIME_STAMP_CPI_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

MEDICAL HISTORY

(TIME_STAMP_MH_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

MH01000. These next questions are about your health when you are not pregnant.

MH02000/(HEALTH). Would you say your health in general is . . .

Label	Code	Go To
Excellent	1
Very good	2
Good	3
Fair	4
Poor	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

PROGRAMMER INSTRUCTIONS

• IF FIRST PREGNANCY VISIT 1 INTERVIEW, GO TO MH03000.

• IF SUBSEQUENT PREGANCY VISIT 1 INTERVIEW, GO TO ​WEIGHT.

MH03000. How tall are you without shoes?

SOURCE

Behavioral Risk Factor Surveillance System

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

(HEIGHT_FT) |___|                           

FEET

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(HT_INCH) |___|___|

INCHES

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

PROGRAMMER INSTRUCTIONS

• DISPLAY A SOFT EDIT IF HEIGHT_FT > 7 OR < 4

• IF HEIGHT_FT ≠ -1 OR -2, DISPLAY A SOFT EDIT IF HT_INCH > 12.

• IF HEIGHT_FT ≠ -1 OR -2, DISPLAY A HARD EDIT IF HT_INCH > 84 OR < 48.

MH04000/(WEIGHT). What was your weight just before you became pregnant?

|___|___|___|

POUNDS

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

PROGRAMMER INSTRUCTIONS

• DISPLAY A SOFT EDIT IF WEIGHT < 90 OR > 400

MH05000. The next questions are about medical conditions or health problems you might have now or may have had {in the past/{since {DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW}}/{since {DATE OF MOST RECENT SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW}}.

PROGRAMMER INSTRUCTIONS

• IF FIRST PREGNANCY VISIT 1 INTERVIEW (I.E., NO PREGNANCY VISIT 1 INTERVIEWS SET TO COMPLETE), DISPLAY “in the past.”

• IF ONE PREVIOUS PREGNANCY VISIT 1 INTERVIEW SET TO COMPLETE, DISPLAY “since” AND DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW.

• IF TWO OR MORE PREVIOUS PREGNANCY VISIT 1 INTERVIEWS SET TO COMPLETE, DISPLAY “since” AND DATE OF MOST RECENT PREGNANCY VISIT 1 INTERVIEW.

• DISPLAY DATE AS MM/DD/YYYY.

 

• FOR  ASTHMA, HIGHBP_NOTPREG, DIABETES_NOTPREG, DIABETES_3 AND THYROID_1:

• IF FIRST PREGNANCY VISIT 1 INTERVIEW (I.E., NO PREGNANCY VISIT 1 INTERVIEWS SET TO COMPLETE), DISPLAY “ever”.

• IF ONE PREVIOUS PREGNANCY VISIT 1 INTERVIEW SET TO COMPLETE, DISPLAY “since” AND PRELOAD AND DISPLAY DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW.

• IF TWO OR MORE PREVIOUS PREGNANCY VISIT 1 INTERVIEWS SET TO COMPLETE, DISPLAY “since” AND PRELOAD AND DISPLAY DATE OF MOST RECENT PREGNANCY VISIT 1 INTERVIEW.

• DISPLAY DATE AS MM/DD/YYYY.

SOURCE

National Health and Nutrition Examination Survey 2004 (modified)

MH06000/(ASTHMA). Have you {ever} been told by a doctor or other health care provider that you had asthma {since {DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW}}/{since {DATE OF MOST RECENT SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW}}?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey 2004 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

MH07000/(HIGHBP_NOTPREG). Have you {ever} been told by a doctor or other health care provider that you had

 

Hypertension or high blood pressure when you’re not pregnant {since {DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW}}/{since {DATE OF MOST RECENT SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW}}?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey 2004 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

MH08000/(DIABETES_NOTPREG). Have you {ever} been told by a doctor or other health care provider that you had

 

High blood sugar or diabetes when you’re not pregnant {since {DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW}}/{since {DATE OF MOST RECENT SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW}}?

Label	Code	Go To
YES	1
NO	2	THYROID_1
REFUSED	-1	THYROID_1
DON'T KNOW	-2	THYROID_1

SOURCE

National Health and Nutrition Examination Survey 2004 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

MH09000/(DIABETES_2). Have you taken any medicine or received other medical treatment for diabetes in the past 12 months?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey 2004 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

MH10000/(DIABETES_3). Have you {ever} taken insulin {since {DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW}}/{since {DATE OF MOST RECENT SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW}}?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey 2004 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

MH11000/(THYROID_1). Have you {ever} been told by a doctor or other health care provider that you had hypothyroidism, that is, an under-active thyroid {since {DATE OF FIRST PREGNANCY VISIT 1 INTERVIEW}}/{since {DATE OF MOST RECENT SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW}}?

Label	Code	Go To
YES	1
NO	2	DIFF_HEAR
REFUSED	-1	DIFF_HEAR
DON'T KNOW	-2	DIFF_HEAR

SOURCE

National Health and Nutrition Examination Survey 2004 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

MH12000/(THYROID_2). Have you taken any medicine or received other medical treatment for a thyroid problem in the past 12 months?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey 2004 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

MH13000/(DIFF_HEAR). Are you deaf or do you have serious difficulty hearing?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act.

MH14000/(DIFF_SEE). Are you blind or do you have serious difficulty seeing, even when wearing glasses?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act.

MH15000/(DIFF_CONCENTRATE). Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DPN'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act.

MH16000/(DIFF_WALK). Do you have serious difficulty walking or climbing stairs?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act.

MH17000/(DIFF_DRESS). Do you have difficulty dressing or bathing?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act.

MH18000/(DIFF_ERRAND). Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act.

MH19000. This next question is about where you go for routine health care.

MH20000/(HLTH_CARE). What kind of place do you usually go to when you need routine or preventive care, such as a physical examination or check-up?

Label	Code	Go To
Clinic or health center	1
Doctor's office or health maintenance organization (HMO)	2
Hospital emergency room	3
Hospital outpatient department	4
Some other place	5
DOESN'T GO TO ONE PLACE MOST OFTEN	6
DOESN'T GET PREVENTIVE CARE ANYWHERE	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health Interview Survey

Legacy: National Children’s Study, Legacy Phase (T1 Mother, T3 Prior)

Current: National Children’s Study, Vanguard Phase (Pre-Preg, LI Non & Preg)

(TIME_STAMP_MH_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

HEALTH INSURANCE

(TIME_STAMP_HI_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

HI01000. Now I’m going to switch to another subject and ask about health insurance.

HI02000/(INSURE). Are you currently covered by any kind of health insurance or some other kind of health care plan?

Label	Code	Go To
YES	1
NO	2	TIME_STAMP_HI_ET
REFUSED	-1	TIME_STAMP_HI_ET
DON'T KNOW	-2	TIME_STAMP_HI_ET

SOURCE

American Community Survey 2006 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

HI03000. Now I’ll read a list of different types of insurance. Please tell me which types you currently have. Do you currently have…

SOURCE

American Community Survey 2006 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

HI04000/(INS_EMPLOY). Insurance through an employer or union either through yourself or another family member?

INTERVIEWER INSTRUCTIONS

•  RE-READ INTRODUCTORY STATEMENT “Do you currently have…” AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey 2006 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

HI05000/(INS_MEDICAID). Medicaid or any government-assistance plan for those with low incomes or a disability?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT “Do you currently have…” AS NEEDED.

• PROVIDE EXAMPLES OF LOCAL MEDICAID PROGRAMS.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey 2006 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

HI06000/(INS_TRICARE). TRICARE, VA, or other military health care?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT “Do you currently have…” AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey 2006 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

HI07000/(INS_IHS). Indian Health Service?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT “Do you currently have…” AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey 2006 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

HI08000/(INS_MEDICARE). Medicare, for people with certain disabilities?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT “Do you currently have…” AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey 2006 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

HI09000/(INS_OTH). Any other type of health insurance or health coverage plan?

INTERVIEWER INSTRUCTIONS

•  RE-READ INTRODUCTORY STATEMENT “Do you currently have…” AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey 2006 (modified)

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

(TIME_STAMP_HI_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS

(TIME_STAMP_HCA_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

HCA01000. Now, I’d like to ask some questions about your schooling and employment.

HCA02000/(EDUC). What is the highest degree or level of school that you have completed?

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
LESS THAN A HIGH SCHOOL DIPLOMA OR GED	1
HIGH SCHOOL DIPLOMA OR GED	2
SOME COLLEGE BUT NO DEGREE	3
ASSOCIATE DEGREE	4
BACHELOR'S DEGREE (FOR EXAMPLE, BA, BS)	5
POST-GRADUATE DEGREE (FOR EXAMPLE, MASTER'S OR DOCTORAL)	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

Census

Legacy:  National Children’s Study, Legacy Phase (P1, T1 Mother, T1 Father, 6M)

HCA03000/(WORK_CURRENTLY). Are you currently employed?

Label	Code	Go To
YES	1
NO	2	ENGLISH_WELL
REFUSED	-1	ENGLISH_WELL
DON'T KNOW	-2	ENGLISH_WELL

SOURCE

Pregnancy, Infection, and Nutrition Study

HCA04000/(HOURS). Approximately how many hours each week are you working?

 

|___|___|___|

NUMBER OF HOURS

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Pregnancy, Infection, and Nutrition Study (modified)

Legacy: National Children’s Study, Legacy Phase (6M)

PROGRAMMER INSTRUCTIONS

• DISPLAY A SOFT EDIT IF RESPONSE > 60.

HCA05000/(SHIFT_WORK). Do you currently work a shift that starts after 2 pm?

Label	Code	Go To
YES	1
NO	2
SOMETIMES	3
REFUSED	-1
DON'T KNOW	-2

SOURCE

Avon Longitudinal Study of Parents and Children (modified)

Legacy: National Children’s Study, Legacy Phase (P1, T1 Mother)

HCA06000/(WORK_NAME). What is the name of the place where you work?

_____________________________________

INTERVIEWER INSTRUCTIONS

• IF PARTICIPANT REPORTS HAVING MULTIPLE JOBS, ASK PARTICIPANT TO RESPOND IN RELATION TO THE PLACE THEY WORK MOST OFTEN

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Evaluation of the Community Health Marriage Incentive and National Longitudinal Survey of Youth (modified)

Current: National Children’s Study, vanguard Phase (PV2, Birth EHPBHIPBS, Birth LI, Core, 24M)

HCA07000. What is the address where you work? 

INTERVIEWER INSTRUCTIONS

• PROBE AND ENTER AS MUCH INFORMATION AS PARTICIPANT KNOWS.

• IF PARTICIPANT REPORTS HAVING MULTIPLE JOBS, ASK PARTICIPANT TO RESPOND IN RELATION TO THE PLACE THEY WORK MOST OFTEN

SOURCE

Evaluation of the Community Health Marriage Incentive and National Longitudinal Survey of Youth (modified)

Current: National Children’s Study, vanguard Phase (PV2, Birth EHPBHIPBS, Birth LI, Core, 24M)

(WORK_ADDRESS_1) __________________________________________________

ADDRESS 1 - STREET/PO BOX

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(WORK_ADDRESS_2) __________________________________________________

ADDRESS 2

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(WORK_UNIT) __________________________________________________

UNIT

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(WORK_CITY) __________________________________________________

CITY

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(WORK_STATE) |___|___|                       

STATE

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(WORK_ZIP) |___|___|___|___|___| 

ZIP CODE     

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(WORK_ZIP4)  - |___|___|___|___|

    ZIP+4

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

HCA08000/(ENGLISH_WELL). How well do you speak English? Would you say…

Label	Code	Go To
Very well	1
Well	2
Not well	3
Not at all	0
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act.

HCA09000. These next questions are about the language that will be spoken to your {baby/babies}.

HCA10000/(HH_NONENGLISH_NEW). Do you speak a language other than English at home?

Label	Code	Go To
YES	1
NO	2	MARISTAT
REFUSED	-1	MARISTAT
DON'T KNOW	-2	MARISTAT

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act.

HCA11000/(OTHER_LANG). What is this language?

Label	Code	Go To
Spanish	1	HH_PRIMARY_LANG
Other	-5
REFUSED	-1	MARISTAT
DON'T KNOW	-2	MARISTAT

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act.

HCA12000/(OTHER_LANG_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act.

HCA13000/(HH_PRIMARY_LANG). What is the primary language spoken in your home?

Label	Code	Go To
ENGLISH	1	MARISTAT
SPANISH	2	MARISTAT
ARABIC	3	MARISTAT
CHINESE	4	MARISTAT
FRENCH	5	MARISTAT
FRENCH CREOLE	6	MARISTAT
GERMAN	7	MARISTAT
ITALIAN	8	MARISTAT
KOREAN	9	MARISTAT
POLISH	10	MARISTAT
RUSSIAN	11	MARISTAT
TAGALOG	12	MARISTAT
VIETNAMESE	13	MARISTAT
URDU	14	MARISTAT
PUNJABI	15	MARISTAT
BENGALI	16	MARISTAT
FARSI	17	MARISTAT
SIGN LANGUAGE	18	MARISTAT
CANNOT CHOOSE	19	MARISTAT
OTHER	-5
REFUSED	-1	MARISTAT
DON'T KNOW	-2	MARISTAT

SOURCE

Early Childhood Longitudinal Study, Birth Cohort

National Children’s Study, Legacy Phase (6M)

HCA14000/(HH_PRIMARY_LANG_OTH). SPECIFY: ____________________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort

Legacy: National Children’s Study, Legacy Phase (6M)

HCA15000/(MARISTAT). I’d like to ask about your marital status. Are you:

INTERVIEWER INSTRUCTIONS

• PROBE FOR CURRENT MARITAL STATUS

Label	Code	Go To
Married	1
Not married but living together with a partner	2
Never been married	3	HCA17000
Divorced	4	HCA17000
Separated	5	HCA17000
Widowed	6	HCA17000
REFUSED	-1	HCA17000
DON'T KNOW	-2	HCA17000

SOURCE

National Survey for Family Growth

Legacy: National Children’s Study, Legacy Phase (P1, T1 Mother)

HCA16000/(SP_EDUC). What is the highest degree or level of school that your spouse or partner has completed?

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
LESS THAN A HIGH SCHOOL DIPLOMA OR GED	1
HIGH SCHOOL DIPLOMA OR GED	2
SOME COLLEGE BUT NO DEGREE	3
ASSOCIATE DEGREE	4
BACHELOR'S DEGREE (FOR EXAMPLE, BA, BS)	5
POST GRADUATE DEGREE (FOR EXAMPLE, MASTERS OR DOCTORAL)	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

Census (modified)

Current: National Children’s Study, vanguard Phase (Pre-Preg)

HCA17000. Next, I’d like to ask some questions about {your/you and your spouse or partner’s} race and ethnicity.

PROGRAMMER INSTRUCTIONS

• IF MARISTAT ≠ 1 OR 2, DISPLAY “your” AND GO TO ETHNIC_ORIGIN.

• IF MARISTAT  = 1 OR 2, DISPLAY “you and your spouse or partner’s” AND GO TO SP_ETHNIC_1.

HCA18000/(SP_ETHNIC_1). Is your spouse or partner of Hispanic, Latino/a, or Spanish origin?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• PRELOAD MODE

• IF SP_ETHNIC_1 = 1, GO TO SP_ETHNIC_2.

• IF SP_ETHNIC_1 ≠ 1, AND

• IF MODE = CAPI, GO TO SP_RACE_NEW.

• IF MODE = CATI, GO TO SP_RACE_1.

HCA19000/(SP_ETHNIC_2). Is your spouse or partner one or more of the following?

INTERVIEWER INSTRUCTIONS

• SELECT ALL THAT APPLY.

• PROBE: Anything else?

Label	Code	Go To
Mexican, Mexican American, Chicano/a	1
Puerto Rican	2
Cuban	3
Another Hispanic, Latino/a, Spanish origin	4
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF SP_ETHNIC_2 = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PROGRAMMER INSTRUCTIONS FOLLOWING SP_ETHNIC_2_OTH

• IF SP_ETHNIC_2 = -5 OR ANY COMBINATION OF 1 THROUGH 4 AND -5, GO TO SP_ETHNIC_2_OTH.

• IF SP_ETHNIC_2 = ANY COMBINATION OF 1 THROUGH 4, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING SP_ETHNIC_2_OTH.

HCA20000/(SP_ETHNIC_2_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF MODE = CAPI, GO TO SP_RACE_NEW.

• OTHERWISE, IF MODE = CATI, GO TO SP_RACE_1.

HCA21000/(SP_RACE_NEW). What is your spouse or partner’s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

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

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• PROBE FOR ANY OTHER RESPONSES

• ONLY USE “SOME OTHER RACE” IF VOLUNTEERED.

• SELECT ALL THAT APPLY.

Label	Code	Go To
WHITE	1
BLACK OR AFRICAN AMERICAN	2
AMERICAN INDIAN OR ALASKA NATIVE	3
ASIAN INDIAN	4
CHINESE	5
FILIPINO	6
JAPANESE	7
KOREAN	8
VIETNAMESE	9
OTHER ASIAN	10
NATIVE HAWAIIAN	11
GUAMANIAN OR CHAMORRO	12
SAMOAN	13
OTHER PACIFIC ISLANDER	14
SOME OTHER RACE	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF SP_RACE_NEW =  -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO ETHNIC_ORIGIN.

• IF SP_RACE_NEW = -5, OR ANY COMBINATION OF 1 THROUGH 14 AND -5, GO TO SP_RACE_NEW_OTH.

• IF SP_RACE_NEW = ANY COMBINATION OF 1 THROUGH 14, GO TO ETHNIC_ORIGIN.

HCA22000/(SP_RACE_NEW_OTH). SPECIFY: ____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• GO TO ETHNIC_ORIGIN.

HCA23000/(SP_RACE_1). What is your spouse or partner’s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• ONLY USE  “SOME OTHER RACE” IF VOLUNTEERED.

• SELECT ALL THAT APPLY.

Label	Code	Go To
White	1
Black or African American	2
American Indian or Alaska native	3
Asian	4
Native Hawaiian or other Pacific Islander	5
SOME OTHER RACE	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF SP_RACE_1 =  -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO ETHNIC_ORIGIN.

• IF SP_RACE_1 = -5, OR ANY COMBINATION OF 1 THROUGH 5 AND -5, GO TO SP_RACE_1_OTH.

• IF SP_RACE_1 = 4 OR ANY COMBINATION OF 4 AND 1, 2, 3, AND/OR 5, GO TO SP_RACE_2.

• IF SP_RACE_1 = 5 OR ANY COMBINATION OF 5 AND 1 THROUGH 3, GO TO SP_RACE_3.

• IF SP_RACE_1 = ANY COMBINATION OF 1 THROUGH 3, GO TO ETHNIC_ORIGIN.

HCA24000/(SP_RACE_1_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF SP_RACE_1 = 4 OR 4 AND ANY COMBINATION OF 1, 2, 3, 5, AND/OR -5 GO TO SP_RACE_2.

• IF SP_RACE_1 = 5 OR 5 AND ANY COMBINATION OF 1, 2, 3, AND/OR -5 GO TO SP_RACE_3.

• OTHERWISE, GO TO ETHNIC_ORIGIN.

HCA25000/(SP_RACE_2). What is your spouse or partner’s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY.

Label	Code	Go To
Asian Indian	1
Chinese	2
Filipino	3
Japanese	4
Korean	5
Vietnamese	6
Other Asian	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF SP_RACE_1 = 5 OR 5 AND ANY COMBINATION OF 1, 3, AND/OR -5 GO TO SP_RACE_3.

• ELSE GO TO ETHNIC_ORIGIN.

HCA26000/(SP_RACE_3). What is your spouse or partner’s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY.

Label	Code	Go To
Native Hawaiian	1
Guamanian or Chamorro	2
Samoan	3
Other Pacific Islander	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

HCA27000/(ETHNIC_ORIGIN). Are you of Hispanic, Latino/a or Spanish origin?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF ETHNIC_ORIGIN = 1, GO TO ​ETHNIC_ORIGIN_2.

• IF ETHNIC_ORIGIN  ≠ 1, AND

• IF MODE = CAPI, GO TO RACE_NEW.

• IF MODE = CATI, GO TO RACE_1.

HCA28000/(ETHNIC_ORIGIN_2). Are you one or more of the following?

INTERVIEWER INSTRUCTIONS

• SELECT ALL THAT APPLY.

• PROBE: Anything else?

Label	Code	Go To
Mexican, Mexican American, Chicano/a	1
Puerto Rican	2
Cuban	3
Another Hispanic, Latino/a, or Spanish origin	4
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF ETHNIC_ORIGIN_2 = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PROGRAMMER INSTRUCTIONS FOLLOWING ETHNIC_ORIGIN_2_OTH.

• IF ETHNIC_ORIGIN_2 = -5, OR ANY COMBINATION OF 1 THROUGH 4 AND -5, GO TO ETHNIC_ORIGIN_2_OTH.

• IF ETHNIC_ORIGIN_2 = ANY COMBINATION OF 1 THROUGH 4, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING ETHNIC_ORIGIN_2_OTH.

HCA29000/(ETHNIC_ORIGIN_2_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF MODE = CAPI, GO TO RACE_NEW.

• OTHERWISE, IF MODE = CATI, GO TO RACE_1.

HCA30000/(RACE_NEW). What is your race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

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

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• SELECT ALL THAT APPLY.

• CODE “SOME OTHER RACE” ONLY IF VOLUNTEERED.

• PROBE: Anything else?

Label	Code	Go To
WHITE	1
BLACK OR AFRICAN AMERICAN	2
AMERICAN INDIAN OR ALASKA NATIVE	3
ASIAN INDIAN	4
CHINESE	5
FILIPINO	6
JAPANESE	7
KOREAN	8
VIETNAMESE	9
OTHER ASIAN	10
NATIVE HAWAIIAN	11
GUAMANIAN OR CHAMORRO	12
SAMOAN	13
OTHER PACIFIC ISLANDER	14
SOME OTHER RACE	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF RACE_NEW =  -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PARTICIPANT_SEX.

• IF RACE_NEW = -5, OR ANY COMBINATION OF 1 THROUGH 14 AND -5, GO TO RACE_NEW_OTH.

• IF RACE_NEW = ANY COMBINATION OF 1 THROUGH 14, GO TO PARTICIPANT_SEX.

HCA31000/(RACE_NEW_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• GO TO PARTICIPANT_SEX.

HCA32000/(RACE_1). What is your race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• ONLY USE  “SOME OTHER RACE” IF VOLUNTEERED.

• SELECT ALL THAT APPLY.

Label	Code	Go To
White	1
Black or African American	2
American Indian or Alaska native	3
Asian	4
Native Hawaiian or other Pacific Islander	5
SOME OTHER RACE	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF RACE_1 = ANY COMBINATION OF 1 THROUGH 3, GO TO PARTICIPANT_SEX.

• IF RACE_1 = 4 OR ANY COMBINATION OF 4 AND 1, 2, 3, AND/OR 5, GO TO RACE_2.

• IF RACE_1 = 5 OR ANY COMBINATION OF 5 AND 1 THROUGH 3, GO TO RACE_3.

• IF RACE_1 = -5 OR ANY COMBINATION OF 1 THROUGH 5 AND -5, GO TO RACE_1_OTH.

• IF RACE_1 =  -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PARTICIPANT_SEX.

HCA33000/(RACE_1_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF RACE_1 = 4 OR 4 AND ANY COMBINATION OF 1, 2, 3, 5, AND/OR -5 GO TO RACE_2.

• IF RACE_1 = 5 OR 5 AND ANY COMBINATION OF 1, 2, 3, AND/OR -5 GO TO RACE_3.

• OTHERWISE, GO TO PARTICIPANT_SEX.

HCA34000/(RACE_2). What is your race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY

Label	Code	Go To
Asian Indian	1
Chinese	2
Filipino	3
Japanese	4
Korean	5
Vietnamese	6
Other Asian	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

PROGRAMMER INSTRUCTIONS

• IF RACE_1 = 5 OR 5 AND ANY COMBINATION OF 1, 2, 3, 4 AND/OR -5 GO TO RACE_3.

• OTHERWISE, GO TO PARTICIPANT_SEX.

HCA35000/(RACE_3). What is your race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY.

Label	Code	Go To
Native Hawaiian	1
Guamanian or Chamorro	2
Samoan	3
Other Pacific Islander	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act (modified)

HCA36000/(PARTICIPANT_SEX). WHAT IS THE SEX OF THE MOTHER?

INTERVIEWER INSTRUCTIONS

• DO NOT ADMINISTER TO PARTICIPANT.

Label	Code	Go To
MALE	1
FEMALE	2
REFUSED	-1
DON'T KNOW	-2

(TIME_STAMP_HCA_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

REACTIONS TO RACE

(TIME_STAMP_RTR_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

RTR01000. The next questions are about how other people identify your race and ethnicity and treat you.

RTR02000/(CLASSIFY_RACE). How do other people usually classify you in this country?

Label	Code	Go To
White	1
Black or African American	2
Hispanic or Latina	3
Asian	4
Native Hawaiian or Other Pacific Islander	5
American Indian or Alaska Native	6
SOME OTHER GROUP	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System (modified)

RTR03000/(CLASSIFY_RACE_OTH). SPECIFY: ________________________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System Questionnaire

RTR04000/(OTHERS_ETHNICITY). Do other people usually classify your race in this country as Hispanic or Latina?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System Questionnaire (modified)

RTR05000/(THINK_RACE). How often do you think about your race?

Label	Code	Go To
Never	1
Once a year	2
Once a month	3
Once a week	4
Once a day	5
Once an hour	6
Constantly	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System Questionnaire

RTR06000/(TREAT_OTHER_RACES). Within the past 12 months, do you feel you were treated worse than, the same as, or better than people of other races?

Label	Code	Go To
WORSE THAN PEOPLE OF OTHER RACES	1
THE SAME AS PEOPLE OF OTHER RACES	2
BETTER THAN PEOPLE OF OTHER RACES	3
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System Questionnaire

RTR07000/(HCARE_OTHER_RACES). Within the past 12 months, when seeking health care, do you feel your experiences were worse than, the same as, or better than for people of other races?

Label	Code	Go To
WORSE THAN FOR PEOPLE OF OTHER RACES	1
THE SAME AS FOR PEOPLE OF OTHER RACES	2
BETTER THAN FOR PEOPLE OF OTHER RACES	3
NO HEALTH CARE IN THE PAST 12 MONTHS	-7
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System Questionnaire

RTR08000/(PHYSCIAL_SX_30D). Within the past 30 days, have you experienced any physical symptoms as a result of how you were treated based on your race, for example, a headache, an upset stomach, tensing of your muscles, or a pounding heart?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System Questionnaire

RTR09000/(EMOT_SX_30D). Within the past 30 days, have you felt emotionally upset as a result of how you were treated based on your race, for example, angry, sad, or frustrated?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System Questionnaire

(TIME_STAMP_RTR_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

COMMUTING

(TIME_STAMP_COM_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

COM01000. Next, I’ll be asking about commuting and how you travel from place to place.

COM02000/(COMMUTE). Think of the longest regular commute that you take, to work, school, or other places. By regular commute, I mean some place that you travel to at least 3 days a week. Since you became pregnant, how do you normally get to your destination?

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY

Label	Code	Go To
CAR	1
BUS	2
TRAIN, SUBWAY, RAIL, OR LIGHT RAIL	3
WALK, BIKE (NON-MOTORIZED)	4
DOES NOT HAVE A REGULAR COMMUTE	-7
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Legacy Phase (T1 Mother)

PROGRAMMER INSTRUCTIONS

• IF COMMUTE =  -7, -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND  GO TO LOCAL_TRAV.

• IF COMMUTE = -5, OR ANY COMBINATION OF 1 THROUGH 4, AND -5, GO TO COMMUTE_OTH.

• IF COMMUTE = ANY COMBINATION OF 1 THROUGH 4, GO TO COMMUTE_TIME.

COM03000/(COMMUTE_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Legacy Phase (T1 Mother)

COM04000/(COMMUTE_TIME). About how many minutes is this commute, one way? Be sure to include any routine side trips you make on the way, such as stops at day care or school. {Include only the time spent driving or sitting inside the car, bus, train, subway, rail or light rail.}

 

|___|___|___|

NUMBER OF MINUTES

 

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Avon Longitudinal Study of Parents and Children

Legacy: National Children’s Study, Legacy Phase (T1 Mother)

PROGRAMMER INSTRUCTIONS

• IF COMMUTE = ANY COMBINATION INCLUDING 1, 2, AND/OR 3, DISPLAY BRACKETED TEXT. 

• OTHERWISE, DO NOT DISPLAY BRACKETED TEXT.

• DISPLAY SOFT EDIT IF RESPONSE > 60.

COM05000/(LOCAL_TRAV). Since you became pregnant, how do you normally get to other places, for example, shopping, doctor, visiting friends, or church?

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY.

Label	Code	Go To
CAR	1
BUS	2
TRAIN, SUBWAY, RAIL, OR LIGHT RAIL	3
WALK, BIKE (NON-MOTORIZED)	4
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Legacy Phase (T1 Mother)

PROGRAMMER INSTRUCTIONS

• IF LOCAL_TRAV = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND  GO TO COM07000.

• IF LOCAL_TRAV = -5 OR ANY COMBINATION OF 1 THROUGH 4, AND -5, GO TO LOCAL_TRAV_OTH.

• IF LOCAL_TRAV = ANY COMBINATION OF 1 THROUGH 4, GO TO COM07000.

COM06000/(LOCAL_TRAV_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Legacy Phase (T1 Mother)

COM07000. Next, I’d like to find out about how often you pump gasoline.

COM08000/(PUMP_GAS). Since you became pregnant, about how often have you pumped or poured gasoline into a car, truck, motorcycle, other motor vehicle, lawnmower, or other engine?

Label	Code	Go To
Every day	1
4-6 times per week	2
2-3 times per week	3
Once a week	4
One to three times a month	5
Less than once a month	6
Never	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Legacy Phase (T1 Mother)

(TIME_STAMP_COM_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PREGNANCY HEALTH CARE LOG INTRODUCTION

(TIME_STAMP_PHC_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PHC01000. In order to help you keep track of your doctor visits or other health care provider visits during your pregnancy, we are {giving/mailing} you a Pregnancy Health Care Log. {You may be familiar with this log and have used one in the past.}  At each Study visit or telephone interview, we will ask you about any health care visits you had since the last Study visit or telephone interview. This log will help you remember that information. The Pregnancy Health Care Log has a Health Care Provider Log section for writing down information about your health care providers' address and phone numbers, and there is also a Health Care Visits and Overnight Hospital Stays section for keeping track of information about your health care visits and any diagnoses, procedures, or treatments.

 

It will be very helpful if you use the log to write down information any time that you receive health care, so that you will be able to remember it accurately during your NCS Study visits or telephone interviews.

INTERVIEWER INSTRUCTIONS

• EXPLAIN PREGNANCY HEALTH CARE LOG.

PROGRAMMER INSTRUCTIONS

• IF MODE = CAPI, DISPLAY “giving.”

• OTHERWISE, IF MODE = CATI, DISPLAY “mailing.”

• IF SUBSEQUENT PREGNANCY VISIT 1 INTERVIEW (I.E., AT LEAST ONE PREVIOUS PREGNANCY VISIT 1 INTERVIEW SET TO COMPLETE), DISPLAY “ You may be familiar with this log and have used one in the past.”

(TIME_STAMP_PHC_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

IMMIGRATION STATUS

(TIME_STAMP_IS_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

IS01000. Next, we would like to ask you some questions about your country of birth and time in the U.S.

           

Please remember that all information you provide remains confidential. This information is important to collect since child health outcomes may be influenced by the birthplace of the child, parents or other family members. We are interested in learning what factors influence health among children of immigrants and children of parents born in the U.S. You do not need to answer any question that makes you uncomfortable.

IS02000. Where were you born? What city and state?

INTERVIEWER INSTRUCTIONS

• PROBE, “Was this in the United States?”

• VERIFY THE SPELLING OF THE CITY, STATE, AND COUNTRY.

SOURCE

Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006.

“The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

(BORN_CITY) ____________________________________                                                                                                      

CITY

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(BORN_STATE) ______________________________________________                                                                                                      

STATE/PROVINCE/TERRITORY

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(BORN_COUNTRY) __________________________________

COUNTRY

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

IS03000/(BORN_COUNTRY_INTERVIEW). WHERE WAS PARTICIPANT BORN?

INTERVIEWER INSTRUCTIONS

• US TERRITORIES INCLUDE PUERTO RICO, GUAM, AMERICAN SAMOA, AND MARSHALL ISLANDS.

Label	Code	Go To
BORN IN USA	1
BORN IN PUERTO RICO OR OTHER US TERRITORY	2
NOT BORN IN THE USA OR US TERRITORY	3
REFUSED	-1
DON'T KNOW	-2

PROGRAMMER INSTRUCTIONS

• IF BORN_COUNTRY_INTERVIEW = 1, SET US_CITIZEN = 1 AND GO TO IS12000.

• OTHERWISE, GO TO US_YEAR.

IS04000/(US_YEAR). In what year did you first come to the United States to live or work?  Please do not include short trips for shopping, vacation or family visits.

 

|___|___|___|___|

YEAR

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006.

“The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

PROGRAMMER INSTRUCTIONS

• DISPLAY HARD EDIT "YEAR CANNOT BE GREATER THAN CURRENT YEAR" IF RESPONSE > CURRENT YEAR.

• IF BORN_COUNTRY_INTERVIEW = 2, SET US_CITIZEN = 1 AND GO TO IS12000.

• OTHERWISE, GO TO US_CITIZEN.

IS05000/(US_CITIZEN). Are you a citizen of the United States?

Label	Code	Go To
YES	1
NO	2	GREEN_CARD
REFUSED	-1	GREEN_CARD
DON'T KNOW	-2	GREEN_CARD

SOURCE

Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006.

“The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

IS06000/(CITIZEN_HOW). How did you become a citizen of the United States?

Label	Code	Go To
Born abroad to American citizen parents	1	IS12000
Naturalization	2	IS12000
Through naturalization of one or both parents	3	IS12000
Through own spouse's military service	4	IS12000
Adopted by U.S. citizen parents	5	IS12000
REFUSED	-1	IS12000
DON'T KNOW	-2	IS12000

SOURCE

Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006.

“The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

IS07000/(GREEN_CARD). Do you currently have a permanent residence card or a green card?

Label	Code	Go To
YES	1	IS12000
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006.

“The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.” 

Social Science Research 35(4): 1000-1024

IS08000/(GRANT_ASYLUM). Have you been granted asylum, refugee status, or temporary protected immigrant status (TPS)?

Label	Code	Go To
YES	1	IS12000
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

 Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006.

“The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

IS09000/(HAVE_VISA). Do you have a tourist visa, a student visa, a work visa or permit, or another document which permits you to stay in the U.S. for a limited time?

Label	Code	Go To
YES	1
NO	2	IS12000
REFUSED	-1	IS12000
DON'T KNOW	-2	IS12000

SOURCE

 Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006.

“The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

IS10000/(VISA_VALID). Is the visa or document still valid or has it expired?

Label	Code	Go To
STILL VALID	1	IS12000
HAS EXPIRED	2	IS12000
REFUSED	-1	IS12000
DON'T KNOW	-2	IS12000

SOURCE

Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006.

“The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

IS11000. Again, I’d like to say how sorry I am for your loss. {We’ll send the information packet you requested as soon as possible.} Please accept our condolences. Thank you for your time.

INTERVIEWER INSTRUCTIONS

• DO NOT OFFER SAQS.

• END INTERVIEW

PROGRAMMER INSTRUCTIONS

• IF LOSS_INFO = 1, DISPLAY “We’ll send the information packet you requested as soon as possible.”

• GO TO TIME_STAMP_IS_ET.

IS12000. Thank you for participating in the National Children’s Study and for taking the time to complete this survey. This concludes the interview.

INTERVIEWER INSTRUCTIONS

• EXPLAIN SAQ AND RETURN PROCESS

• END INTERVIEW.

(TIME_STAMP_IS_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 19 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.