12.4 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

6M Questionnaire - Household, Phase 2g

OMB Specification

6M Questionnaire - Household

Event Category:	Time-Based
Event:	6M
Administration:	N/A
Instrument Target:	Child's Primary Residence
Instrument Respondent:	Primary Caregiver
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:	3 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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6M Questionnaire - Household

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

FINANCIAL SECURITY 3

LANGUAGE USE 6

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6M Questionnaire - Household

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

FINANCIAL SECURITY

(TIME_STAMP_FS_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PRIMARY RESIDENCE ID (VARIABLE NAME) AND RESPONDENT ID (R_P_ID) FOR ADULT CAREGIVER.

• PRELOAD MULT_CHILD FROM PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE.

• IF MULT_CHILD IN PARTICIPANT VERFICATION, SCHEDULING & TRACING QUESTIONNAIRE = 1, DISPLAY “the children” IN APPROPRIATE FIELDS THROUGHOUT THE INSTRUMENT

• IF MULT_CHILD IN PARTICIPANT VERFICATION, SCHEDULING & TRACING QUESTIONNAIRE = 2, DISPLAY “the child” IN APPROPRIATE FIELDS THROUGHOUT THE INSTRUMENT.

FS01000/(AFFORD_HOME). At this time, do you feel you are able to afford a home suitable for yourself and your family?

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

SOURCE

Pregnancy Infection and Nutrition Study (PINS)

FS02000/(AFFORD_FURNITURE). Do you feel you are able to afford the furniture or household equipment that you need? 

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

SOURCE

Pregnancy Infection and Nutrition Study (PINS)

FS03000/(AFFORD_CAR). Do you feel you are able to afford the kind of car you need?

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

SOURCE

Pregnancy Infection and Nutrition Study (PINS)

FS04000/(AFFORD_FOOD). At this time, do you have enough money for the kinds of food you think you and your family should have?

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

SOURCE

Pregnancy Infection and Nutrition Study (PINS)

FS05000/(AFFORD_MED_CARE). Do you have enough money for the kind of medical care you and your family should have?

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

SOURCE

Pregnancy Infection and Nutrition Study (PINS)

FS06000/(AFFORD_CLOTHING). At this time, do you have enough money for the kind of clothing you and your family should have?

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

SOURCE

Pregnancy Infection and Nutrition Study (PINS)

FS07000/(AFFORD_LEISURE). Do you have enough money for the leisure activities you and your family want?

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

SOURCE

Pregnancy Infection and Nutrition Study (PINS)

FS08000/(DIFF_PAY_BILLS). How difficult is it for you and your family to pay your bills? Would you say it is…

Label	Code	Go To
Very difficult	1
Somewhat difficult	2
Not very difficult	3
Not difficult at all	4
REFUSED	-1
DON’T’ KNOW	-2

SOURCE

Pregnancy Infection and Nutrition Study (PINS)

FS09000/(MONEY_END_MONTH). At the end of the month, how much money would you say you end up with?

Label	Code	Go To
Not enough money	1
Just enough money	2
Some money left over	3
A lot of money left over	4
REFUSED	-1
DON’T’ KNOW	-2

SOURCE

Pregnancy Infection and Nutrition Study (PINS)

(TIME_STAMP_FS_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

LANGUAGE USE

(TIME_STAMP_LU_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

LU01000. These next questions are about the primary language spoken at home or to {the child/children}.

LU02000/(LANGUAGE_NON_ENG). Is any language other than English regularly spoken in your home?

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

SOURCE

Early Childhood Longitudinal Study, Kindergarten Cohort Spring Parent Interview

LU03000/(LANGUAGE_TYPE). What languages other than English are spoken in your home? 

INTERVIEWER INSTRUCTIONS

• LANGUAGES ARE LISTED IN ALPHABETICAL ORDER EXCEPT FOR SPANISH. 

Label	Code	Go To
SPANISH	1
ARABIC	2
BENGALI	3
CHINESE (INCLUDING MANDARIN, CANTONESE)	4
FARSI (PERSIAN)	5
FRENCH	6
FRENCH CREOLE	7
GERMAN	8
GREEK	9
HINDI	10
ITALIAN	11
KOREAN	12
POLISH	13
PORTUGUESE	14
PUNJABI	15
RUSSIAN	16
TAGALOG	17
VIETNAMESE	18
URDU	19
SIGN LANGUAGE	20
OTHER	-5
REFUSED	-1
DON’T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Kindergarten Cohort Fall Parent Interview (modified) 

PROGRAMMER INSTRUCTIONS

• IF LANGUAGE_TYPE = 1 THROUGH 20, -1, OR -2, GO TO PRIMARY_LANGUAGE.

• IF LANGUAGE_TYPE = -5 OR ANY COMBINATION OF 1 THROUGH 20 AND -5, GO TO LANGUAGE_TYPE_OTH.

LU04000/(LANGUAGE_TYPE_OTH). SPECIFY: ____________________________________________

SOURCE

Early Childhood Longitudinal Study, Kindergarten Cohort Fall Parent Interview (modified) 

LU05000/(PRIMARY_LANGUAGE). What is the primary language spoken in your home? 

INTERVIEWER INSTRUCTIONS

• LANGUAGES ARE LISTED IN ALPHABETICAL ORDER EXCEPT FOR ENGLISH AND SPANISH. 

Label	Code	Go To
ENGLISH	1	TIME_STAMP_LU_ET
SPANISH	2	ENGLISH_REGULAR
ARABIC	3	ENGLISH_REGULAR
BENGALI	4	ENGLISH_REGULAR
CHINESE (INCLUDING MANDARIN, CANTONESE)	5	ENGLISH_REGULAR
FARSI (PERSIAN)	6	ENGLISH_REGULAR
FRENCH	7	ENGLISH_REGULAR
FRENCH CREOLE	8	ENGLISH_REGULAR
GERMAN	9	ENGLISH_REGULAR
GREEK	10	ENGLISH_REGULAR
HINDI	11	ENGLISH_REGULAR
ITALIAN	12	ENGLISH_REGULAR
KOREAN	13	ENGLISH_REGULAR
POLISH	14	ENGLISH_REGULAR
PORTUGUESE	15	ENGLISH_REGULAR
PUNJABI	16	ENGLISH_REGULAR
RUSSIAN	17	ENGLISH_REGULAR
TAGALOG	18	ENGLISH_REGULAR
VIETNAMESE	19	ENGLISH_REGULAR
URDU	20	ENGLISH_REGULAR
SIGN LANGUAGE	21	ENGLISH_REGULAR
OTHER	-5
REFUSED	-1	TIME_STAMP_LU_ET
DON’T KNOW	-2	TIME_STAMP_LU_ET

SOURCE

Early Childhood Longitudinal Study, Kindergarten Cohort Fall Parent Interview (modified) 

LU06000/(PRIMARY_LANGUAGE_OTH). SPECIFY: ____________________________________________

SOURCE

Early Childhood Longitudinal Study, Kindergarten Cohort Fall Parent Interview (modified) 

LU07000/(ENGLISH_REGULAR). Is English also regularly spoken in your home?

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

SOURCE

High School Longitudinal Study of 2009, First Follow-Up Questionnaire

LU08000/(CHILD_LANGUAGE). What language do you usually speak to {the child/children} in your home?

Label	Code	Go To
ENGLISH	1	NONENGLISH_FREQ
SPANISH	2	NONENGLISH_FREQ
ARABIC	3	NONENGLISH_FREQ
BENGALI	4	NONENGLISH_FREQ
CHINESE (INCLUDING MANDARIN, CANTONESE)	5	NONENGLISH_FREQ
FARSI (PERSIAN)	6	NONENGLISH_FREQ
FRENCH	7	NONENGLISH_FREQ
FRENCH CREOLE	8	NONENGLISH_FREQ
GERMAN	9	NONENGLISH_FREQ
GREEK	10	NONENGLISH_FREQ
HINDI	11	NONENGLISH_FREQ
ITALIAN	12	NONENGLISH_FREQ
KOREAN	13	NONENGLISH_FREQ
POLISH	14	NONENGLISH_FREQ
PORTUGUESE	15	NONENGLISH_FREQ
PUNJABI	16	NONENGLISH_FREQ
RUSSIAN	17	NONENGLISH_FREQ
TAGALOG	18	NONENGLISH_FREQ
VIETNAMESE	19	NONENGLISH_FREQ
URDU	20	NONENGLISH_FREQ
SIGN LANGUAGE	21	NONENGLISH_FREQ
OTHER	-5
REFUSED	-1	LANG_CHILD_SPEAK
DON’T KNOW	-2	LANG_CHILD_SPEAK

SOURCE

High School Longitudinal Study (HSLS) of 2009, First Follow-Up Questionnaire (modified) 

LU09000/(CHILD_LANGUAGE_OTH). SPECIFY: ___________________________________________

SOURCE

High School Longitudinal Study (HSLS) of 2009, First Follow-Up Questionnaire (modified) 

LU10000/(NONENGLISH_FREQ). How often do you use a language other than English when speaking to {the child/the children}? Would you say…

INTERVIEWER INSTRUCTIONS

• PROBE “We just need to know in general?”

Label	Code	Go To
Never	1
Sometimes	2
Often	3
Very often	4
REFUSED	-1
DON’T KNOW	-2

SOURCE

Early Childhood Longitudinal Program, Birth Cohort 9-Month Parent Interview (modified) 

LU11000/(LANG_CHILD_SPEAK). What language does {the child/children} usually speak to you in your home?

Label	Code	Go To
ENGLISH	1	TIME_STAMP_LU_ET
SPANISH	2	OTHER_LANG_FREQ
ARABIC	3	OTHER_LANG_FREQ
BENGALI	4	OTHER_LANG_FREQ
CHINESE (INCLUDING MANDARIN, CANTONESE)	5	OTHER_LANG_FREQ
FARSI (PERSIAN)	6	OTHER_LANG_FREQ
FRENCH	7	OTHER_LANG_FREQ
FRENCH CREOLE	8	OTHER_LANG_FREQ
GERMAN	9	OTHER_LANG_FREQ
GREEK	10	OTHER_LANG_FREQ
HINDI	11	OTHER_LANG_FREQ
ITALIAN	12	OTHER_LANG_FREQ
KOREAN	13	OTHER_LANG_FREQ
POLISH	14	OTHER_LANG_FREQ
PORTUGUESE	15	OTHER_LANG_FREQ
PUNJABI	16	OTHER_LANG_FREQ
RUSSIAN	17	OTHER_LANG_FREQ
TAGALOG	18	OTHER_LANG_FREQ
VIETNAMESE	19	OTHER_LANG_FREQ
URDU	20	OTHER_LANG_FREQ
SIGN LANGUAGE	21	OTHER_LANG_FREQ
OTHER	-5
REFUSED	-1	TIME_STAMP_LU_ET
DON’T KNOW	2	TIME_STAMP_LU_ET

SOURCE

High School Longitudinal Study (HSLS) of 2009, First Follow-Up Questionnaire (modified) 

LU12000/(LANG_CHILD_SPEAK_OTH). SPECIFY: ____________________________________________

SOURCE

High School Longitudinal Study (HSLS) of 2009, First Follow-Up Questionnaire (modified) 

LU13000/(OTHER_LANG_FREQ). How often does {the child/children} use this language when speaking to you? Would you say…

INTERVIEWER INSTRUCTIONS

• PROBE “We just need to know in general?”

Label	Code	Go To
Rarely	1
Sometimes	2
Often	3
Very often	4
All the time	5
REFUSED	-1
DON’T KNOW	-2

SOURCE

New

(TIME_STAMP_LU_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 3 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.