14.7 Survey

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

12MonthSAQChild

12-Month Interview

OMB: 0925-0593

Document [docx]
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OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

12M SAQ - Child, Phase 2g

OMB Specification


12M SAQ - Child


Event Category:

Time-Based

Event:

12M

Administration:

N/A

Instrument Target:

Child

Instrument Respondent:

Primary Caregiver

Domain:

Questionnaire

Document Category:

Questionnaire

Method:

Self-Administered

Mode (for this instrument*):

In-Person, PAPI

OMB Approved Modes:

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

Estimated Administration Time:

4 minutes

Multiple Child/Sibling Consideration:

Per Child

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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12M SAQ - Child



TABLE OF CONTENTS





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12M SAQ - Child



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.





12-MONTH SAQ SPECIFICATION - CHILD


SSC01000. Thank you for agreeing to participate in the National Children’s Study. This self-administered questionnaire will take about 4 minutes to complete. There are questions about your relationships and questions about your child’s diet.

 

Your answers are important to us. There are no right or wrong answers. You can skip over any question. We will keep everything that you tell us confidential.


SSC02000. The next questions will ask about the milk, formula, and food your child has eaten in the past 7 days. In answering include feedings by everyone who feeds the baby. Include snacks and night-time feedings. Use these guidelines in choosing how to respond:

 

  • If the baby was fed this item once a day or more, write the number of feedings per day in the boxes and then mark the box before “Day.”

  • If the baby was fed the item less than once a day, write the number of feedings per week in the boxes and then mark the box before “Week.”

  • If the baby was not fed the item at all during the past 7 days, write “00” in the boxes.


SSC03000. In the past 7 days, how often was your baby fed breast milk? Please include both breast-fed and expressed or pumped breast milk.


SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire) (modified)


(BREAST_MILK) |___|___| Number of times per 


(BREAST_MILK_UNIT) (select one below)


Label

Code

Go To

Day

1


Week

2



SSC04000. In the past 7 days, how often was your baby fed formula?


SOURCE

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


(FORMULA) |___|___| Number of times per 


(FORMULA_UNIT) (select one below)


Label

Code

Go To

Day

1


Week

2



SSC05000. In the past 7 days, how often was your baby fed cow’s milk?


SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)


(COW_MILK) |___|___| Number of times per 


(COW_MILK_UNIT) (select one below)


Label

Code

Go To

Day

1


Week

2



SSC06000. In the past 7 days, how often was your baby fed other milk (soy milk, rice milk, goat milk)?


SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)


(MILK_OTHER) |___|___| Number of times per 


(MILK_OTHER_UNIT) (select one below)


Label

Code

Go To

Day

1


Week

2



SSC07000/(BREAST_MILK_FED). Please tell me which best describes what your baby has been fed. My baby...


Label

Code

Go To

is not drinking breast milk now, but was fed breast milk in the past

1


is drinking breast milk now

2

FORMULA_FED

was never fed breast milk

3

FORMULA_FED


SOURCE

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


SSC08000. How old was your baby when you completely stopped breastfeeding and pumping or expressing breast milk? (If your baby was less than one month, enter age in weeks. If your baby was older than one month, enter age in months.)


SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)


(BREAST_STOP) |___|___| Number of weeks or months 


(BREAST_STOP_UNIT) (select one below)


Label

Code

Go To

Week

1


Month

2



SSC09000/(PUMPED). Have you ever fed your baby pumped or expressed breast milk?


Label

Code

Go To

Yes

1


No

2

FORMULA_FED


SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)


SSC10000/(PUMPED_2). In the past 7 days, about how often was your baby fed pumped or expressed breast milk?  Include feedings by everyone who feeds the baby and include snacks and nighttime feedings.


Label

Code

Go To

1 time per week

1


2 to 4 times per week

2


Nearly every day

3


1 time per day

4


2 to 3 times per day

5


4 to 6 times per day

6


More than 6 times per day

7


Not applicable/I have not fed my baby pumped or expressed breast milk in the past 7 days

-7



SOURCE

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


SSC11000/(FORMULA_FED). How old was your baby when he/she was first fed formula on a daily basis?


Label

Code

Go To

Less than 1 month old

1


1 to 2 months old

2


3 to 4 months old

3


5 to 6 months old

4


More than 6 months old

5


Not applicable (never fed formula to baby)

-7



SOURCE

Infant Feeding Practices Study II Neonatal Questionnaire (modified)


PARTICIPANT INSTRUCTIONS

If you answered “00” to SSC04000 (your baby was not fed formula in the past 7 days) and “Not applicable (never fed formula to baby)" to SSC11000, go to SSC20000.

 

If you answered any number “01” or more to SSC04000, go to SSC13000.

 

If you were unable to answer SSC04000, go to SSC12000.


SSC12000/(FORMULA_LAST7). Has your baby had formula in the last seven days?


Label

Code

Go To

Yes

1


No

2

SSC20000

Not applicable (never fed formula to baby)

-7

SSC20000


SOURCE

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


SSC13000/(FORMULA_BRAND). What kind of infant formula was your baby fed in the past 7 days? Select all of the formulas that you feed your baby. Include any formula the baby was fed in the past 7 days that is not included on the list under “Other.”


Label

Code

Go To

Baby’s Only Organic Dairy

1


Baby’s Only Organic Soy

2


Baby’s Only Organic Lactose Free

3


Bright Beginnings milk-based

4


Bright Beginnings Gentle milk-based

5


Bright Beginnings Organic

6


Bright Beginnings milk-based 2

7


Bright Beginnings NeoCare

8


Earth’s Best Organic Infant Formula with DHA ARA

9


Earth’s Best Organic Soy Infant Formula with DHA ARA

10


EleCare®

11


Enfamil® Premium with Triple Health Guard

12


Enfamil® Premium Next Step

13


Enfamil® ProSobee®

14


Enfamil® RestFull

15


Enfamil AR®

16


Enfamil® Gentlease®

17


Enfamil® Gentlease® Next Step

18


Enfamil® Enfacare

19


Enfamil® Premature

20


Enfamil® Premium Vanilla or Chocolate

21


Enfamil® Soy Next Step

22


Gerber® Good Start® Gentle Plus

23


Gerber® Good Start® Gentle Plus 2

24


Gerber® Good Start® Protect Plus

25


Gerber® Good Start® Protect Plus 2

26


Gerber® Good Start® Soy Plus

27


Gerber® Good Start® Soy Plus 2

28


Nutramigen® with Enflora LGG

29


Nutramigen® AA

30


Pregestimil®

31


Similac® Advance® EarlyShield

32


Similac Isomil® Advance®

33


Similac Isomil® DF

34


Similac® Organic

35


Similac® Go Grow

36


Similac® Go Grow EarlyShield

37


Similac® Sensitive

38


Similac® Sensitive R.S.

39


Similac® Alimentum®

40


Similac® Neosure®

41


Store brand Milk based (like Member’s Mark, Kirkland, Target up up)

42


Store brand Gentle or partially broken down whey protein formula (like Member’s Mark or Target up up)

43


Store brand Soy based (like Target up up)

44


Store brand Next step (like Target up up)

45


Store brand Lacto sensitive (like Target up up)

46


Store brand Prebiotic (like Target up up)

47


Other

-5



SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire) (modified)


PARTICIPANT INSTRUCTIONS

If you selected "Other" and any other response for SSC13000, go to SSC14000.

 

If you did not select "Other," go to SSC15000.


SSC14000/(FORMULA_BRAND_OTH). __________________________________________________________


SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire) (modified) 


SSC15000/(FORMULA_TYPE). Was the formula ready-to-feed, liquid concentrate, powder from a can that makes a single-serving, or powder from single-serving packets?   Select all of the formulas you feed your baby.


Label

Code

Go To

Ready-to-feed

1


Liquid concentrate

2


Powder from a can that makes more than one bottle

3


Powder from single-serving packets

4



SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)


PARTICIPANT INSTRUCTIONS

If your baby was ONLY fed ready-to-feed formula, go to SSC19000.

 

Otherwise, go to SSC16000.


SSC16000/(WATER_1). During the past 7 days, what types of water have you and others who care for your baby used for mixing your baby’s formula?  Select all of the types of water you have used for mixing your baby’s formula.  If you have used any other type of water, please list the water type on the line below.


Label

Code

Go To

Tap water from the cold faucet

1


Warm tap water from the hot faucet

2


Bottled water

3


Other type of water used

-5



SOURCE

Infant Feeding Practices Study II Month 9 Questionnaire (modified)


PARTICIPANT INSTRUCTIONS

If you selected "Other type of water used" and any other response, go to SSC17000.

If you did not select "Other type of water used," go to SSC18000.


SSC17000/(WATER_1_OTH). _________________________________________________________


SOURCE

Infant Feeding Practices Study II Month 9 Questionnaire (modified)


SSC18000/(WATER_2). Was the water used to mix the formula boiled?


Label

Code

Go To

Yes

1


No

2



SOURCE

Infant Feeding Practices Study II Month 2 Questionnaire  


SSC19000/(OUNCES). In the past 7 days, on the average, how many ounces of formula did your baby drink at each feeding?

 

|___|___| Ounces


SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)


SSC20000. In the past 7 days, about how often did your baby drink from each of the following types of bottles and cups?


SSC21000/(B_TYPE_1). Plastic baby bottle with disposable bottle liner.


Label

Code

Go To

Never

1


Sometimes

2


Most of the time

3


Always

4



SOURCE

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


SSC22000/(B_TYPE_2). Plastic baby bottle without disposable liner.


Label

Code

Go To

Never

1


Sometimes

2


Most of the time

3


Always

4



SOURCE

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


SSC23000/(B_TYPE_3). Other plastic bottle (for example, a water bottle).


Label

Code

Go To

Never

1


Sometimes

2


Most of the time

3


Always

4



SOURCE

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


SSC24000/(B_TYPE_4). Glass baby bottle.


Label

Code

Go To

Never

1


Sometimes

2


Most of the time

3


Always

4



SOURCE

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


SSC25000/(B_TYPE_5). Plastic “no spill” cup.


Label

Code

Go To

Never

1


Sometimes

2


Most of the time

3


Always

4



SOURCE

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


SSC26000/(PACIFIER). Has your baby used a pacifier in the past 7 days?


Label

Code

Go To

Yes

1


No

2



SOURCE

Infant Feeding Practices Study II 9 Month Questionnaire


SSC27000/(COWS_MILK_1). Has your baby ever been fed cow’s milk that was not sold especially for babies? (This includes whole, low-fat, nonfat, or chocolate milk).


Label

Code

Go To

Yes

1


No

2

CEREAL


SOURCE

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


SSC28000/(COWS_MILK_2). How old was your baby when he/she was first fed cow’s milk that was not sold especially for babies?

 

|___|___| . |___| Age in months.


SOURCE

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


SSC29000/(CEREAL). How old was your baby when he/she was first fed cereal, including baby cereal, on a daily basis?


Label

Code

Go To

Less than 1 month old

1


1 to 2 months old

2


3 to 4 months old

3


5 to 6 months old

4


More than 6 months old

5


Not applicable (never fed cereal)

-7



SOURCE

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


SSC30000/(PUREED). How old was your baby when he/she was first fed pureed baby food on a daily basis? Please include commercial (store-bought) and homemade baby food.


Label

Code

Go To

Less than 1 month old

1


1 to 2 months old

2


3 to 4 months old

3


5 to 6 months old

4


More than 6 months old

5


Not applicable (never fed pureed baby food)

-7



SOURCE

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


SSC31000/(TABLE_FOOD). How old was your baby when he/she was first fed table food such as eggs, cheese, or potatoes on a daily basis?


Label

Code

Go To

Less than 1 month old

1


1 to 2 months old

2


3 to 4 months old

3


5 to 6 months old

4


More than 6 months old

5


Not applicable (never fed table food)

-7



SOURCE

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


SSC32000/(SUPPLEMENT). Check the box beside all of the supplements your child has taken during the past 2 weeks for at least 3 days a week. If your child has taken any other vitamins or supplements, please list them on the line beside “Other vitamins or supplements.


Label

Code

Go To

Fluoride

1


Iron

2


Vitamin D

3


Other vitamins or supplements

-5


Not applicable (child not given supplements)

-7



SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)


PARTICIPANT INSTRUCTIONS

If you selected "Not applicable (child not given supplements)" do not select any additional responses.

 

If you selected "Other vitamins or supplements" and any other response, go to SSC33000.

If you did not select "Other vitamins or supplements," go to ​SSC34000.


SSC33000/(SUPPLEMENT_OTH). ____________________________________________________________


SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)


SSC34000/(HERBAL). Was your baby given any herbal or botanical preparations or any kind of tea or home remedy in the past 7 days?  Do not count preparations put on the baby’s skin or anything the baby may have gotten from breast milk after you took an herbal or botanical preparation.


Label

Code

Go To

Yes

1


No

2



SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)


SSC35000. ​Thank you for participating in the National Children’s Study and for taking the time to complete this survey.



FOR OFFICE USE ONLY:


FOU01000/(P_ID). PARTICIPANT ID:___________________________________


FOU02000/(R_P_ID). RESPONDENT ID:______________________________________


Public reporting burden for this collection of information is estimated to average 4 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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