37.6 Survey

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

60MQuestionnaire Adult

60-Month Interview

OMB: 0925-0593

Document [docx]
Download: docx | pdf

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

60M Questionnaire –Adult, Phase 2g

OMB Specification


60M Questionnaire - Adult


Event Category:

Time-Based

Event:

60M

Administration:

N/A

Instrument Target:

Primary Caregiver

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:

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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60M Questionnaire - Adult



TABLE OF CONTENTS





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60M 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.





HOUSEHOLD COMPOSITION AND DEMOGRAPHICS


(TIME_STAMP_HCA_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP

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


HCA01000. Next, I’d like to ask some questions about your race and ethnicity.


HCA02000/(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, TO TO ETHNIC_ORIGIN_2.

  • IF ETHNIC_ORIGIN ≠ 1 AND

    • IF MODE = CAPI, GO TO RACE_NEW.

    • IF MODE = CATI, GO TO RACE_1.


HCA03000/(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 = -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.

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


HCA04000/(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


HCA05000/(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 = ANY COMBINATION OF 1 THROUGH 14, 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 =  -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PARTICIPANT_SEX.


HCA06000/(RACE_NEW_OTH). SPECIFY: _____________________________ 


Label

Code

Go To

REFUSED

-1

PARTICIPANT_SEX

DON'T KNOW

-2

PARTICIPANT_SEX


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.


HCA07000/(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.


HCA08000/(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)


DATA COLLECTOR INSTRUCTIONS

  • 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.

  • OTHERWISE, GO TO PARTICIPANT_SEX.


HCA09000/(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 = ANY COMBINATION WITH 4 AND 5, GO TO RACE_3.

  • OTHERWISE, GO TO PARTICIPANT_SEX


HCA10000/(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)


HCA11000/(PARTICIPANT_SEX). WHAT IS THE SEX OF THE PARENT/CAREGIVER?


INTERVIEWER INSTRUCTIONS

  • DO NOT ADMINISTER THIS QUESTION TO THE ADULT CAREGIVER.


Label

Code

Go To

MALE

1


FEMALE

2


DON'T KNOW

-2



HCA12000/(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

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


HCA13000/(HH_NONENGLISH_NEW). Do you speak a language other than English at home?


Label

Code

Go To

YES

1


NO

2

DIFF_HEAR

REFUSED

-1

DIFF_HEAR

DON'T KNOW

-2

DIFF_HEAR


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


HCA14000/(OTHER_LANG ). What is this language?


Label

Code

Go To

Spanish

1

DIFF_HEAR

Other

-5


REFUSED

-1

DIFF_HEAR

DON'T KNOW

-2

DIFF_HEAR


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


HCA15000/(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


HCA16000/(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


HCA17000/(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


HCA18000/(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


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


HCA19000/(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


HCA20000/(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


HCA21000/(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


(TIME_STAMP_HCA_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.

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