11.6 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

3M Questionnaire - Biological Mother, Phase 2g

OMB Specification

3M Questionnaire - Biological Mother

Event Category:	Time-Based
Event:	3M
Administration:	N/A
Instrument Target:	Biological Mother
Instrument Respondent:	Biological Mother
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:	2 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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3M Questionnaire - Biological Mother

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

MOTHER BIRTH CONDITIONS AND EXPERIENCES 3

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3M Questionnaire - Biological Mother

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.

MOTHER BIRTH CONDITIONS AND EXPERIENCES

(TIME_STAMP_MBC_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PARTICIPANT ID (P_ID) AND RESPONDENT ID (R_P_ID) FOR ADULT CAREGIVER.

• PRELOAD MULT_CHILD, CHILD_NUM (IF MULT_CHILD = 1), AND CHILD_QNUM  FROM THE PARTICIPANT VERIFICATION, SCHEDULING & TRACING QUESTIONNAIRE.

• PRELOAD FIRST NAME OF CHILD (C_FNAME) FROM  PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE AND DISPLAY APPROPRIATE NAME IN “C_FNAME” THROUGHOUT THE INSTRUMENT.

• OTHERWISE, IF C_FNAME FROM  PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE = -1 OR -2, DISPLAY “the child” IN APPROPRIATE FIELDS THROUGHOUT THE INSTRUMENT.

• IF CHILD_SEX IN PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE = 1, DISPLAY “his”, “he”, OR “himself” IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

• IF CHILD_SEX IN PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE = 2, DISPLAY “her”, “she”, OR “herself” IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

• IF MULT_CHILD = 1, LOOP THROUGH ITEMS MBC01000, CHILD_SEX, MBC03000, MBC04000, MBC06000, TRANS_DEPT_BIRTH, AND TRANS_DEPT_BIRTH_OTH (IF TRANS_DEPT_BIRTH = 1) FOR EACH CHILD_QNUM UNTIL NUMBER OF LOOPS = CHILD_NUM BEFORE PROCEEDING TO DELIVER_CES.

• INCREMENT CHILD_QNUM BY ONE FOR EACH LOOP.

MBC01000. Now I’d like to ask a few questions about {C_FNAME/the child}’s birth.

MBC02000/(CHILD_SEX). Is your child a boy or a girl?

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

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

MBC03000. How much did {C_FNAME/the child} weigh when he/she was born?

INTERVIEWER INSTRUCTIONS

• RECORD CHILD'S WEIGHT IN POUNDS AND OUNCES.

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

(BIRTH_WEIGHT_LBS) |___|___|

POUNDS 

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

PROGRAMMER INSTRUCTIONS

• DISPLAY HARD EDIT IF ANSWER < 0 OR > 20 LBS.

• DISPLAY SOFT EDIT IF ANSWER < 3 OR > 13 LBS.

(BIRTH_WEIGHT_OZ) |___|___|

OUNCES

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

MBC04000/(BIRTH_LENGTH_IN). How many inches was {C_FNAME/the child} when he/she was born?

 

|___|___|

INCHES

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

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

PROGRAMMER INSTRUCTIONS

• DISPLAY SOFT EDIT IF RESPONSE < 6 OR > 30.

• IF CHILD_QNUM = 1 AND FIRST LOOP OR MULT_CHILD = 2, GO TO DELIVER_WEEK.

• OTHERWISE, GO TO MBC06000.

MBC05000/(DELIVER_WEEK). In which week of your pregnancy did you give birth?

 

|___|___|

WEEK

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

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

PROGRAMMER INSTRUCTIONS

• DISPLAY SOFT EDIT IF RESPONSE ≤ 0 OR > 44.

MBC06000. How long was your child in the hospital after the birth?

INTERVIEWER INSTRUCTIONS

• ENTER VALUE AND SELECT WHETHER DAYS OR WEEKS.

• IF RESPONDENT REPORTS THE CHILD WAS IN THE HOSPITAL FOR LESS THAN 1 DAY, ENTER "1."

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

(LENGTH_HOSP_TIME) |___|___| 

Label	Code	Go To
CHILD STILL IN HOSPITAL	0
CHILD NOT BORN IN HOSPITAL	-7
REFUSED	-1
DON'T KNOW	-2

PROGRAMMER INSTRUCTIONS

• IF LENGTH_HOSP_TIME = -7, AND

• IF MULT_CHILD = 2 OR IF NUMBER OF LOOPS = CHILD_NUM, GO TO PREG_COMP.

• OTHERWISE, GO TO TIME_STAMP_MCS_ST AND BEGIN SUBSEQUENT LOOP.

• IF LENGTH_HOSP_TIME = 0, -7, OR -2, GO TO TRANS_DEPT_BIRTH.

(LENGTH_HOSP_BIRTH_UNIT)

Label	Code	Go To
DAYS	1
WEEKS	2

MBC07000/(TRANS_DEPT_BIRTH). Was your child transferred to another department or hospital after the birth?

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

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

PROGRAMMER INSTRUCTIONS

• IF TRANS_DEPT_BIRTH = 1, GO TO TRANS_DEPT_BIRTH_OTH.

• IF TRANS_DEPT_BIRTH = 2, -1, OR -2, AND
  
  

• IF MULT_CHILD = 2 OR IF NUMBER OF LOOPS = CHILD_NUM, GO TO DELIVER_CES.

• OTHERWISE, GO TO TIME_STAMP_MCS_ST AND BEGIN SUBSEQUENT LOOP.

MBC08000/(TRANS_DEPT_BIRTH_OTH). SPECIFY: ________________________________________________

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

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

PROGRAMMER INSTRUCTIONS

• IF MULT_CHILD = 2 OR IF NUMBER OF LOOPS = CHILD_NUM, GO TO DELIVER_CES.

• OTHERWISE, GO TO TIME_STAMP_MCS_ST AND BEGIN SUBSEQUENT LOOP.

MBC09000/(DELIVER_CES). Was your child delivered by caesarean section?

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

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

MBC10000/(CES_PLAN). Was the caesarean section planned?

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

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

MBC11000/(CES_PLAN_REASON). Why?

Label	Code	Go To
Breech presentation	1	PREG_COMP
Previous cesarean	2	PREG_COMP
Pregnancy complication or mother taken ill	3	PREG_COMP
Poor growth or other factor relating to the fetus	4	PREG_COMP
Own preference	5	PREG_COMP
OTHER	-5
REFUSED	-1	PREG_COMP
DON'T KNOW	-2	PREG_COMP

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

MBC12000/(CES_PLAN_REASON_OTH). SPECIFY: ________________________________________

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

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

MBC13000/(PREG_COMP). Were there any complications during the pregnancy?

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

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

MBC14000/(PREG_COMP_OTH). SPECIFY: ___________________________________

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

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

MBC15000/(PREG_COMP_HOSP). Either before or after your baby's birth, were you admitted or transferred to another department or hospital due to complications in connection with the birth? 

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

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire (modified)

MBC16000. Where?

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

(PREG_COMP_HOSP_DEPT) DEPARTMENT: ______________________________________

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

(PREG_COMP_HOSP_NAME) HOSPITAL: _____________________________

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

MBC17000. How many days were you in the hospital in connection with the birth?

INTERVIEWER INSTRUCTIONS

• PROBE TO DETERMINE NUMBER OF DAYS IN HOSPITAL BEFORE CHILD'S BIRTH AND NUMBER OF DAYS IN HOSPITAL AFTER CHILD'S BIRTH.

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

(PREG_COMP_HOSP_TIME_PRIOR) BEFORE THE BIRTH: |___|___| NUMBER OF DAYS

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

(PREG_COMP_HOSP_TIME_AFTER) AFTER THE BIRTH: |___|___| NUMBER OF DAYS

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

MBC18000/(FAMILY_PRESENT_BIRTH). Was anyone from your close family present at the birth?

Label	Code	Go To
Yes, child's father	1
Yes, someone else	2
No	3
REFUSED	-1
DON'T KNOW	-2

SOURCE

Norwegian Mother and Child Cohort Study, 6-Month Questionnaire

(TIME_STAMP_MBC_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 2 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.