Form 5.1 Survey

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

PV2QuestionnaireAdult

Pregnancy Visit 2 Interview

OMB: 0925-0593

Document [docx]
Download: docx | pdf

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Pregnancy Visit 2 Interview - Adult, Phase 2g

OMB Specification


Pregnancy Visit 2 Questionnaire - Adult


Event Category:

Trigger-Based

Event:

PV2

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:

10 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 2 Questionnaire - Adult



TABLE OF CONTENTS





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Pregnancy Visit 2 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

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.





CURRENT PREGNANCY INFORMATION


(TIME_STAMP_CPI_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP

  • PRELOAD PARTICIPANT ID (P_ID) FOR PREGNANT WOMAN.

  • PRELOAD MULTIPLE_GESTATION FROM PREGNANCY VISIT 1 INTERVIEW.

  • IF MULTIPLE_GESTATION = 2 OR 3 IN PREGNANCY VISIT 1 INTERVIEW, DISPLAY 
    "babies" AS APPROPRIATE THROUGHOUT INSTRUMENT.

  • IF MULTIPLE_GESTATION = 1, -1, OR -2 IN PREGNANCY VISIT 1 INTERVIEW, DISPLAY "baby" APPROPRIATE THROUGHOUT THE INSTRUMENT.

  • PRELOAD F_F_NAME, F_L_NAME, CONTACT_F_LATER AND FATHER_KNOW_PREG FROM PREGNANCY VISIT 1 SAQ.


INTERVIEWER INSTRUCTIONS

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


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


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


Label

Code

Go To

YES

1

CPI05000

NO

2


REFUSED

-1

CS02000

DON'T KNOW

-2

CS02000


SOURCE

Pregnancy Risk Assessment Monitoring System (modified)


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). INTERVIEWER-ANSWERED QUESTION:   DID PARTICIPANT REQUEST ADDITIONAL INFORMATION ON COPING WITH PREGNANCY LOSS?


Label

Code

Go To

YES

1

CS01000

NO

2

CS01000


CPI05000. What is your current due date?


INTERVIEWER INSTRUCTIONS

  • IF SOFT EDIT MESSAGE DISPLAYED, ASK QUESTION AGAIN.


SOURCE

Pregnancy, Infection and Nutrition Study


(DUE_DATE_MM) MONTH:

|_____|_____|

     M        M


Label

Code

Go To

REFUSED

-1

BPLAN_CHANGE

DON'T KNOW

-2



(DUE_DATE_DD) DAY:

|_____|_____|

     D        D


Label

Code

Go To

REFUSED

-1

BPLAN_CHANGE

DON'T KNOW

-2



(DUE_DATE_YYYY) YEAR:

|____|____|____|____|

    Y      Y       Y       Y


Label

Code

Go To

REFUSED

-1

BPLAN_CHANGE

DON'T KNOW

-2

BPLAN_CHANGE


PROGRAMMER INSTRUCTIONS

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

    • 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 AND DUE_DATE_DD ≠ -1 AND IF DUE_DATE_YYYY ≠ -1 OR -2, GO TO DATE_KNOWN.


CPI06000/(DATE_KNOWN). DID PARTICIPANT GIVE DATE?


Label

Code

Go To

PARTICIPANT GAVE COMPLETE DATE

1


PARTICIPANT GAVE PARTIAL DATE

2



CPI07000/(BPLAN_CHANGE). Has the place where you plan to deliver your {baby/babies} changed since we last spoke with you?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

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


CPI08000/(BIRTH_PLAN). {So we make sure we have the correct information,} Where do you plan to deliver your {baby/babies}?


PROGRAMMER INSTRUCTIONS

  • IF BPLAN_CHANGE = 2, DISPLAY "So we make sure we have the correct information,"


Label

Code

Go To

In a hospital

1


A birthing center

2


At home

3

USE_PR_LOG

Some other place

4


REFUSED

-1

USE_PR_LOG

DON"T KNOW

-2

USE_PR_LOG


SOURCE

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


CPI09000. 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)


(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


DON'T KNOW

-2



(B_ADDRESS_2) ____________________________________________________________

ADDRESS 2


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

0



CPI10000/(USE_PR_LOG). Are you using the Pregnancy Health Care Log?  This is the booklet that you or your health care provider (doctor, midwife, nurse, etc.) uses to record information about your medical visits.


Label

Code

Go To

YES

1

NUM_PROV_PR_LOG

NO

2


REFUSED

-1

CPI17000

DON'T KNOW

-2

CPI17000


SOURCE

National Children's Study, Vanguard Phase (18M, 24M) (modified)


CPI11000/(REASON_NO_PR_LOG). Is that because . . .


INTERVIEWER INSTRUCTIONS

  • IF THE PREGNANT WOMAN REPORTS THEY HAVE "misplaced the log," DISTRIBUTE A NEW LOG OR OFFER TO MAIL ONE.


Label

Code

Go To

You haven't had a medical visit since our last interview

1

CPI17000

You've misplaced the log

2

CPI17000

You've forgotten to bring it to your medical visits

3

CPI14000

The log was too much trouble to complete

4

CPI14000

The log was too difficult to understand

5

CPI17000

OTHER

-5


REFUSED

-1

CPI14000

DON'T KNOW

-2

CPI14000


SOURCE

National Children's Study, Vanguard Phase (18M, 24M) (modified)


CPI12000/(REASON_NO_PR_LOG_OTH). SPECIFY:  ___________________________________________________


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children's Study, Vanguard Phase (18M, 24M) (modified)


PROGRAMMER INSTRUCTIONS

  • GO TO CPI17000.


CPI14000. This information is very important to the study.  Please keep the log in a safe place and bring the log with you to all of your medical visits.


PROGRAMMER INSTRUCTIONS

  • GO TO CPI17000.


CPI15000/(NUM_PROV_PR_LOG). How many health care providers have you seen since using this Pregnancy Health Care Log?

 

|_____|_____|

NUMBER OF PROVIDERS


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children's Study, Vanguard Phase (18M, 24M) (modified)


PROGRAMMER INSTRUCTIONS

  • IF NUM_PROV_PR_LOG = 0, -1 OR -2, GO TO CPI17000.

  • OTHERWISE, GO TO ​NUM_PROV_REC.


CPI16000/(NUM_PROV_REC). Of those providers that you have seen, for how many providers have you recorded contact information such as their address or phone number?

 

|_____|_____|

NUMBER OF CONTACTS


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children's Study, Vanguard Phase (18M, 24M) (modified)


CPI17000. I am now going to ask some questions about visits to a doctor or other health care provider, such as a midwife or nurse. You may want to refer to {the Pregnancy Health Care Log that you received as part of this study or to} any other personal record or calendar that you keep that would help you to remember the dates of these visits. If you have this information available, please go and get it now.


PROGRAMMER INSTRUCTIONS

  • DISPLAY TEXT IN BRACKETS IN CPI17000 IF USE_PR_LOG = 1.


CPI18000. What was the date of your most recent doctor's visit or checkup since you've become pregnant?


INTERVIEWER INSTRUCTIONS

  • SHOW CALENDAR TO ASSIST IN DATE RECALL.

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


SOURCE

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


(DATE_VISIT_MM) MONTH:

|_____|_____|

    M        M


Label

Code

Go To

HAVE NOT HAD A VISIT

-7


REFUSED

-1


DON'T KNOW

-2



(DATE_VISIT_DD) DATE:

|_____|_____|

     D       D


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(DATE_VISIT_YYYY) YEAR:

|____|____|____|____|

   Y       Y       Y       Y


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



PROGRAMMER INSTRUCTIONS

  • IF USE_PR_LOG = 1 AND IF DATE_VISIT_MM, DATE_VISIT_DD, AND DATE_VISIT_YYYY ≠ -1 OR -7, GO TO CPI19000.

  • OTHERWISE, GO TO CPI20000.


CPI19000. If you haven't yet done so, please put a check mark in the box next to the visit you just told me about in your Pregnancy Health Care Log.


CPI20000. {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?


SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)


PROGRAMMER INSTRUCTIONS

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

  • OTHERWISE, DISPLAY ‘”At”.


CPI21000/(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 (NHANES) (modified)


CPI22000/(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 (NHANES) (modified)


CPI23000/(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 (NHANES) (modified)


CPI24000/(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 (NHANES) (modified)


CPI25000/(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 (NHANES) (modified)


CPI26000/(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 (NHANES) (modified)


CPI27000/(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 (NHANES) (modified)


CPI28000/(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 (NHANES) (modified)


CPI29000/(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 (NHANES) (modified)


CPI30000/(GROUP_B). Infection with a 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 (NHANES) (modified)


CPI31000/(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 (NHANES) (modified)


CPI32000/(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 (NHANES) (modified)


CPI33000/(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

HOSPITAL

REFUSED

-1

HOSPITAL

DON'T KNOW

-2

HOSPITAL


SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)


CPI34000/(CONDITION_OTH). SPECIFY:  ____________________________________________________


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)


CPI35000/(HOSPITAL). Since you've been pregnant, have you spent at least one night in the hospital?


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

Pregnancy Risk Assessment Monitoring System


CPI36000. What was the admission date of your most recent hospital stay?


SOURCE

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


(ADMIN_DATE_MM) MONTH:

|_____|_____|

     M       M


Label

Code

Go To

HAVE NOT BEEN HOSPITALIZED OVERNIGHT/NOT APPLICABLE

-7

TIME_STAMP_CPI_ET

REFUSED

-1


DON'T KNOW

-2



(ADMIN_DATE_DD) DAY:

|_____|_____|

     D       D


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(ADMIN_DATE_YYYY) YEAR:

|____|____|____|____|

    Y       Y       Y      Y


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



CPI37000/(HOSP_NIGHTS). How many nights did you stay in the hospital during this hospital stay?

 

|____|____|____|

NUMBER OF NIGHTS


INTERVIEWER INSTRUCTIONS

  • CONFIRM RESPONSE


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

Pregnancy Risk Assessment Monitoring System (modified)


CPI38000/(DIAGNOSE). Did a doctor or other health care provider give you a diagnosis during this hospital stay?


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


CPI39000/(DIAGNOSE_2). What was the diagnosis?


INTERVIEWER INSTRUCTIONS

  • PROBE FOR MULTIPLE RESPONSES.

  • SELECT ALL THAT APPLY.


Label

Code

Go To

DEHYDRATION

1


PRETERM LABOR

2


HYPEREMESIS

3


PREECLAMPSIA

4


RUPTURE OF MEMBRANES

5


KIDNEY DISORDER

6


OTHER

-5


REFUSED

-1


DON'T KNOW

-2



SOURCE

Pregnancy Risk Assessment Monitoring System (modified)


PROGRAMMER INSTRUCTIONS

  • IF DIAGNOSE_2 = ANY COMBINATION OF 1 - 6 AND

    • IF USE_PR_LOG = 1, GO TO CPI41000.

    • IF USE_PR_LOG = 2, -1, OR -2, GO TO TIME_STAMP_CPI_ET.

  • IF DIAGNOSE_2 = -5, OR ANY COMBINATION OF VALUES 1 - 6 AND -5, GO TO DIAGNOSIS_OTH.

  • IF DIAGNOSE_2 = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND

    • IF USE_PR_LOG = 1, GO TO CPI41000.

    • IF USE_PR_LOG - 2, -1, OR -2, TIME_STAMP_CPI_ET.


CPI40000/(DIAGNOSIS_OTH). SPECIFY:  ____________________________________________________


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

Pregnancy Risk Assessment Monitoring System (modified)


PROGRAMMER INSTRUCTIONS

  • IF USE_PR_LOG = 1, GO TO CPI41000.

  • OTHERWISE, GO TO TIME_STAMP_CPI_ET.


CPI41000. If you haven't yet, please put a check mark in the box next to the visit you just told me about in your Pregnancy Health Care Log.


SOURCE

National Children's Study, Vanguard Phase (18M, 24M)


(TIME_STAMP_CPI_ET).


PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP



BABY'S FATHER IDENTIFICATION


(TIME_STAMP_BFI_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP.

  • IF FATHER_KNOW_PREG = 2 AND CONTACT_F_LATER = 1 IN PREGNANCY VISIT 1 SAQ, GO TO BFI01000.

  • OTHERWISE, GO TO TIME_STAMP_BFI_ET.


BFI01000. Part of the National Children's Study includes a planned study visit with the baby's father.


PROGRAMMER INSTRUCTIONS

  • IF F_F_NAME AND F_L_NAME COLLECTED IN PREGNANCY VISIT 1 SAQ AND ≠ -1 OR -2, GO TO FATHER_NAME_CONFIRM.

  • OTHERWISE, IF F_F_NAME AND F_L_NAME NOT COLLECTED IN PREGNANCY VISIT 1 SAQ OR IF = -1 OR -2, GO TO BFI03000.  


BFI02000/(FATHER_NAME_CONFIRM). Just to confirm, is the first name of your baby's father {F_F_NAME}?


Label

Code

Go To

YES

1

FATHER_SAME_HH

NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Survey of Child and Adolescent Well-Being Caregiver Interview (NSCAW) (modified); Saving for Education, Entrepreneurship and Down Payment for Oklahoma Kids (SEED) Baseline and Follow-Up Interview; and National Longitudinal Survey of Youth (NLSY).


PROGRAMMER INSTRUCTIONS

  • DISPLAY F_F_NAME FROM PV1 SAQ.

  • IF FATHER_NAME_CONFIRM = 1,  DISPLAY F_F_NAME THROUGHOUT INSTRUMENT.

  • OTHERWISE, DISPLAY "the father of your baby" OR "the father" AS APPROPRIATE THROUGHOUT THE INSTRUMENT.


BFI03000. What is the father's first and last name?


SOURCE

National Survey of Child and Adolescent Well-Being Caregiver Interview (NSCAW) (modified); National Longitudinal Survey of Youth (NLSY) (modified)


(F_F_NAME) ___________________________________________

FIRST NAME 


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(F_L_NAME) ___________________________________________

LAST NAME 


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



PROGRAMMER INSTRUCTIONS

  • IF F_F_NAME ≠ -1 OR -2 DISPLAY F_F_NAME THROUGHOUT INSTRUMENT.

  • OTHERWISE, DISPLAY "the father of your baby" OR "the father" AS APPROPRIATE THROUGHOUT THE INSTRUMENT.


BFI04000/(FATHER_SAME_HH). Is {F_F_NAME/the father of your baby} living in the same household as you?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

Early Childhood Longitudinal Study, Birth Cohort (modified)


BFI05000/(FATHER_KNOW_PREG). Is {F_F_NAME/the father} aware of your pregnancy?


Label

Code

Go To

YES

1


NO

2

TIME_STAMP_BFI_ET

REFUSED

-1

TIME_STAMP_BFI_ET

DON'T KNOW

-2

TIME_STAMP_BFI_ET


SOURCE

National Children's Study, Vanguard Phase (PV1 SAQ)


BFI06000/(CONTACT_F_NOW). May we have your permission to contact {F_F_NAME/the father} and invite him to participate in the Study?


Label

Code

Go To

YES

1


NO

2

TIME_STAMP_BFI_ET

REFUSED

-1

TIME_STAMP_BFI_ET

DON'T KNOW

-2

TIME_STAMP_BFI_ET


SOURCE

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


BFI07000. What is {F_F_NAME/the father}'s home address?


SOURCE

National Children's Study, Vanguard Phase (PV1 SAQ)


(F_ADDR1_2) ____________________________________________________________

ADDRESS 1 - STREET/PO BOX


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(F_ADDR2_2) ____________________________________________________________

ADDRESS 2


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(F_UNIT_2) ____________________________________________

UNIT


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(F_CITY_2) ____________________________________________

CITY


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(F_STATE_2) |_____|_____|

STATE


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(F_ZIPCODE_2) |____|____|____|____|

ZIP CODE


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(F_ZIP4_2) |____|____|____|____|

ZIP4


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



BFI08000/(F_PHONE). What is {F_F_NAME/the father}'s telephone number?

 

|____|____|____|  -  |____|____|____|  -  |____|____|____|____|


INTERVIEWER INSTRUCTIONS

  • IF FATHER HAS NO TELEPHONE, ASK FOR TELEPHONE NUMBER WHERE HE RECEIVES CALLS.


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2


FATHER HAS NO TELEPHONE

-7



SOURCE

National Children's Study, Legacy Phase (T1 Mother) (modified)


BFI09000/(F_EMAIL). What is the best email address to reach {F_F_NAME/the father}?

 

_________________________________________________

EMAIL ADDRESS


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2


FATHER HAS NO EMAIL ADDRESS

-7



SOURCE

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


BFI10000/(F_AGE). What is {F_F_NAME/the father}'s age?

 

|_____|_____|

AGE IN YEARS


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children's Study, Vanguard Phase (PV1 SAQ)


PROGRAMMER INSTRUCTIONS

  • IF F_AGE ≥ LOCAL AGE OF MAJORITY, GO TO TIME_STAMP_BFI_ET.

  • IF F_AGE < AGE OF MAJORITY, GO TO BFI12000.

  • OTHERWISE, IF F_AGE = -1 OR -2, GO TO F_AGE_MAJORITY.


BFI11000/(F_AGE_MAJORITY). Is the father {LOCAL AGE OF MAJORITY} or older?


INTERVIEWER INSTRUCTIONS

  • EXPLAIN HOW THE ANSWER TO THIS QUESTION DETERMINES THE FATHER'S ELIGIBILITY AND THAT ALL DATA ARE KEPT CONFIDENTIAL AND SECURE.


Label

Code

Go To

YES

1

TIME_STAMP_BFI_ET

NO

2


REFUSED

-1

TIME_STAMP_BFI_ET

DON'T KNOW

-2

TIME_STAMP_BFI_ET


SOURCE

New


PROGRAMMER INSTRUCTIONS

  • PRELOAD LOCAL AGE OF MAJORITY


BFI12000. Because the father is legally considered a minor, we will not contact him to participate in the Study at this time.


(TIME_STAMP_BFI_ET).


PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP



EMPLOYMENT


(TIME_STAMP_EMP_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP


EMP01000. Now, I’d like to ask some questions about your current employment status.


EMP02000. The next questions may be similar to those asked the last time we spoke, but we are asking them again because sometimes the answers change. 


EMP03000/(WORK_CURRENTLY). Are you currently employed?


Label

Code

Go To

YES

1


NO

2

TIME_STAMP_EMP_ET

REFUSED

-1

TIME_STAMP_EMP_ET

DON'T KNOW

-2

TIME_STAMP_EMP_ET


SOURCE

Pregnancy, Infection, and Nutrition Study


EMP04000/(HOURS). Approximately how many hours each week are you working? 

 

|_____|_____|_____|

 

NUMBER OF HOURS


PROGRAMMER INSTRUCTIONS

  • DISPLAY A SOFT EDIT IF RESPONSE > 60.


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

Pregnancy, Infection, and Nutrition Study (modified)


EMP05000/(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)


PROGRAMMER INSTRUCTIONS

  • IF WORK_NAME PREVIOUSLY COLLECTED AND ≠ -1 OR -2, GO TO WORK_NAME_CONFIRM.

  • IF WORK_NAME NOT PREVIOUSLY COLLECTED OR = -1 OR -2, GO TO WORK_NAME.


EMP06000/(WORK_NAME_CONFIRM). Let me confirm the name of the place where you work.  I have it as {PARTICIPANT’S WORK PLACE NAME}.  Is this correct?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

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


PROGRAMMER INSTRUCTIONS

  • PRELOAD WORK PLACE NAME FROM WORK_NAME IN PREGNANCY VISIT 1 INTERVIEW.

  • IF WORK_NAME_CONFIRM = 1, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING WORK_NAME.

  • OTHERWISE, IF WORK_NAME_CONFIRM = 2, -1, OR -2, GO TO WORK_NAME.


EMP07000/(WORK_NAME). What is the name of the place where you work?

 

__________________________________________________


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)


PROGRAMMER INSTRUCTIONS

  • IF WORK_ADDRESS_1, WORK_ADDRESS_2, WORK_UNIT, WORK_CITY, WORK_STATE, WORK_ZIP, AND WORK_ZIP4 NOT COLLECTED PREVIOUSLY OR = -1 OR -2, GO TO EMP09000.

  • IF WORK_ADDRESS_1, WORK_ADDRESS_2, WORK_UNIT, WORK_CITY, WORK_STATE, WORK_ZIP, AND ​WORK_ZIP4 COLLECTED PREVIOUSLY AND ≠ -1 OR -2, GO TO WORK_ADDRESS_VARIABLES_CONFIRM


EMP08000/(WORK_ADDRESS_VARIABLES_CONFIRM). Let me confirm your work address. I have it as {PARTICIPANT’S WORK ADDRESS}. Is this correct?


Label

Code

Go To

YES

1

TIME_STAMP_EMP_ET

NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

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


PROGRAMMER INSTRUCTIONS

  • PRELOAD AND DISPLAY WORK PLACE ADDRESS AS WORK_ADDRESS_1, WORK_ADDRESS_2, WORK_UNIT, WORK_CITY, WORK_STATE, WORK_ZIP, AND WORK_ZIP4 FROM PREGNANCY VISIT 1.


EMP09000. What is the address where you work?


INTERVIEWER INSTRUCTIONS

  • PROBE AND ENTER AS MUCH INFORMATION AS PARTICIPANT KNOWS.


SOURCE

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


(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



(TIME_STAMP_EMP_ET).


PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP



SOCIAL SUPPORT


(TIME_STAMP_SS_ST).


PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP


SS01000. The following questions ask about your feelings and thoughts during the last month. For the following questions, please refer to the card and choose the answer that best describes your life now.


SS02000/(LISTEN). How often is there someone available to you whom you can count on to listen to you when you need to talk? 


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

NONE OF THE TIME

1


A LITTLE OF THE TIME

2


SOME OF THE TIME

3


MOST OF THE TIME

4


ALL OF THE TIME

5


REFUSED

-1


DON'T KNOW

-2



SOURCE

Medical Outcomes Study (modified)


SS03000/(ADVICE). How often is there someone available to give you good advice about a problem?


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

NONE OF THE TIME

1


A LITTLE OF THE TIME

2


SOME OF THE TIME

3


MOST OF THE TIME

4


ALL OF THE TIME

5


REFUSED

-1


DON'T KNOW

-2



SOURCE

Medical Outcomes Study (modified)


SS04000/(AFFECTION). How often is there someone available to you who shows you love and affection?


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

NONE OF THE TIME

1


A LITTLE OF THE TIME

2


SOME OF THE TIME

3


MOST OF THE TIME

4


ALL OF THE TIME

5


REFUSED

-1


DON'T KNOW

-2



SOURCE

Medical Outcomes Study (modified)


SS05000/(DAILY_HELP). How often is there someone available to help you with daily chores?


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

NONE OF THE TIME

1


A LITTLE OF THE TIME

2


SOME OF THE TIME

3


MOST OF THE TIME

4


ALL OF THE TIME

5


REFUSED

1


DON'T KNOW

2



SOURCE

Medical Outcomes Study (modified)


SS06000/(EMOT_SUPPORT). How often can you count on anyone to provide you with emotional support (talking over problems or helping you make a difficult decision)?


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

NONE OF THE TIME

1


A LITTLE OF THE TIME

2


SOME OF THE TIME

3


MOST OF THE TIME

4


ALL OF THE TIME

5


REFUSED

-1


DON'T KNOW

-2



SOURCE

Medical Outcomes Study (modified)


SS07000/(AMT_SUPPORT). How often do you have as much contact as you would like with someone you feel close to, someone in whom you can trust and confide?


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

NONE OF THE TIME

1


A LITTLE OF THE TIME

2


SOME OF THE TIME

3


MOST OF THE TIME

4


ALL OF THE TIME

5


REFUSED

-1


DON'T KNOW

-2



SOURCE

Medical Outcomes Study (modified)


(TIME_STAMP_SS_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 the subject and ask about health insurance.  The next questions are similar to those asked the last time we contacted you, but we are asking them again because sometimes the answers change.


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)


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


SOURCE

American Community Survey 2006 (modified)


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)


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


INTERVIEWER INSTRUCTIONS

  • PROVIDE EXAMPLES OF LOCAL MEDICAID PROGRAMS

  • 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)


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)


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)


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)


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)


(TIME_STAMP_HI_ET).


PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP



CLOSING SCRIPTS


(TIME_STAMP_CS_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP

  • IF PREGNANT = 2, GO TO CS01000.

  • OTHERWISE, GO TO CS02000.


CS01000. 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 BRACKETED TEXT:  We’ll send the information packet you requested as soon as possible.

  • GO TO TIME_STAMP_CS_ET.


CS02000. Thank you for participating in the National Children’s Study and for taking the time to complete this survey. This concludes the interview.


DATA COLLECTOR INSTRUCTIONS

  • EXPLAIN SAQS AND RETURN PROCESS.

  • END INTERVIEW.


(TIME_STAMP_CS_ET).


PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP


Public reporting burden for this collection of information is estimated to average 10 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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