2.2 Survey

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

PrePregnancyQuestionnaireAdult

Pre-Pregnancy Interview

OMB: 0925-0593

Document [docx]
Download: docx | pdf

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Pre-Pregnancy Questionnaire - Adult, Phase 2g

OMB Specification


Pre-Pregnancy Questionnaire - Adult


Event Category:

Trigger-Based

Event:

Pre-Pregnancy

Administration:

N/A

Instrument Target:

Pre-Pregnant Woman

Instrument Respondent:

Pre-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:

12 minutes

Multiple Child/Sibling Consideration:

Per Event

Special Considerations:

N/A

Recruitment Groups:

All

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.


This page intentionally left blank.


Pre-Pregnancy Questionnaire - Adult



TABLE OF CONTENTS





This page intentionally left blank.



Pre-Pregnancy 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.





INTERVIEW INTRODUCTION


(TIME_STAMP_II_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP

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

  • PRELOAD R_FNAME, R_LNAME, PERSON_DOB_MM, PERSON_DOB_DD, AND PERSON_DOB_YYYY.


II01000. Thank you for agreeing to participate in the National Children’s Study.  This interview will take about 12 minutes to complete.  Your answers are important to us.  There are no right or wrong answers, just those that help us understand your situation.  During this interview, we will ask about yourself, your health, where you live, and your feelings about being a part of the National Children’s Study.  You can skip over any questions or stop the interview at any time.  We will keep everything that you tell us confidential.

 

First, we’d like to make sure we have your correct name and birth date.


PROGRAMMER INSTRUCTIONS

  • IF R_FNAME AND R_LNAME COLLECTED PREVIOUSLY AND ≠ -1 OR -2, GO TO NAME_CONFIRM.

  • OTHERWISE, GO TO ​II03000.


II02000/(NAME_CONFIRM). Is your name {PARTICIPANT NAME}?


Label

Code

Go To

YES

1

DOB_CONFIRM

NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children’s Study, Vanguard Phase


PROGRAMMER INSTRUCTIONS

  • DISPLAY R_FNAME ​AS PARTICIPANT NAME.


II03000. What is your full name?


SOURCE

National Children’s Study, Legacy Phase (PregScreener)


(R_FNAME) _____________________    

FIRST NAME


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(R_LNAME) _____________________

LAST NAME


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



INTERVIEWER INSTRUCTIONS

  • IF PARTICIPANT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS, ASK FOR INITIALS OR SOME OTHER NAME SHE WOULD LIKE TO BE CALLED

  • CONFIRM SPELLING OF FIRST NAME IF NOT PREVIOUSLY COLLECTED AND OF LAST NAME.


PROGRAMMER INSTRUCTIONS

  • IF PERSON_DOB_MM, PERSON_DOB_DD, AND PERSON_DOB_YYYY COLLECTED PREVIOUSLY AND ≠ -1 OR -2, GO TO DOB_CONFIRM.

  • OTHERWISE, GO TO II05000.


II04000/(DOB_CONFIRM). Is your birth date {PARTICIPANT’S DATE OF BIRTH}?


Label

Code

Go To

YES

1

AGE_ELIG

NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children’s Study, Vanguard Phase


PROGRAMMER INSTRUCTIONS

  • DISPLAY PERSON_DOIB_MM, PERSON_DOB_DD, AND PERSON_DOB_YYYY AS PARTICIPANT'S DATE OF BIRTH.

  • IF DOB_CONFIRM = 1, SET PERSON_DOB_MM, PERSON_DOB_DD, AND PERSON_DOB_YYYY TO KNOWN VALUE


INTERVIEWER INSTRUCTIONS

  • IF PARTICIPANT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB IS REQUIRED TO DETERMINE ELIGIBILITY


II05000. What is your date of birth?


SOURCE

National Children’s Study, Legacy Phase (P1 and T1 Mom)


(PERSON_DOB_MM) MONTH: |___|___|

                M   M


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(PERSON_DOB_DD) DAY: |___|___|

           D    D


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(PERSON_DOB_YYYY) YEAR: |___|___|___|___|

             Y    Y     Y     Y


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



INTERVIEWER INSTRUCTIONS

  • IF PARTICIPANT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB IS REQUIRED TO DETERMINE ELIGIBILITY

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


PROGRAMMER INSTRUCTIONS

  • INCLUDE A SOFT EDIT/WARNING IF CALCULATED AGE IS LESS THAN LOCAL AGE OF MAJORITY OR GREATER THAN 50


II06000/(AGE_ELIG).


Label

Code

Go To

PARTICIPANT IS AGE-ELIGIBLE

1

TIME_STAMP_II_ET

PARTICIPANT IS YOUNGER THAN AGE OF MAJORITY

2


PARTICIPANT IS OVER AGE 49

3


AGE ELIGIBILITY IS UNKNOWN

-6

TIME_STAMP_II_ET


INTERVIEWER INSTRUCTIONS

  • IF VALUE IS “REFUSED” OR “DON’T KNOW” FLAG CASE FOR SUPERVISOR REVIEW AT ROC TO CONFIRM AGE ELIGIBILITY POST-INTERVIEW.


PROGRAMMER INSTRUCTIONS

  • BASED ON DOB_CONFIRM OR PERSON_DOB_MM, PERSON_DOB_DD, AND ​PERSON_DOB_YYYY CALCULATE AGE.  USING KNOWN LOCAL AGE OF MAJORITY DETERMINE IF SHE IS ELIGIBLE (AT LEAST AGE OF MAJORITY AND LESS THAN AGE 50); SET AGE_ELIG AS APPROPRIATE.


(TIME_STAMP_II_ET).


PROGRAMMER INSTRUCTIONS

  • INSERT/TIMESTAMP



MEDICAL HISTORY


(TIME_STAMP_MH_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP


MH01000. Next, I have some general questions about your health and health care.


MH02000/(HEALTH). Would you say your health in general is . . .


Label

Code

Go To

Excellent

1


Very good

2


Good

3


Fair

4


Poor

5


REFUSED

-1


DON'T KNOW

-2



SOURCE

Behavioral Risk Factor Surveillance System


MH03000/(EVER_PREG). Have you ever been pregnant?  Please include live births, miscarriages, stillbirths, ectopic pregnancies, and pregnancy terminations.


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

Avon Longitudinal Study of Parents and Children


MH04000. The next questions are about medical conditions or health problems you might have now or may have had in the past.


MH05000/(ASTHMA). Have you ever been told by a doctor or other health care provider that you had asthma?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Health and Nutrition Examination Survey (modified)


MH06000/(HIGHBP). (Have you ever been told by a doctor or other health care provider that you had)…

 

Hypertension or high blood pressure {when you’re not pregnant}?


INTERVIEWER INSTRUCTIONS

  • RE-READ INTRODUCTORY STATEMENT AS NEEDED


PROGRAMMER INSTRUCTIONS

  • IF EVER_PREG ≠ 2 DISPLAY, “when you’re not pregnant"


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Health and Nutrition Examination Survey (modified)


MH07000/(DIABETES_1). (Have you ever been told by a doctor or other health care provider that you had)…

 

High blood sugar or Diabetes {when you’re not pregnant}?


INTERVIEWER INSTRUCTIONS

  • RE-READ INTRODUCTORY STATEMENT AS NEEDED


PROGRAMMER INSTRUCTIONS

  • IF EVER_PREG ≠ 2 DISPLAY, “when you’re not pregnant


Label

Code

Go To

YES

1


NO

2

THYROID_1

REFUSED

-1

THYROID_1

DON'T KNOW

-2

THYROID_1


SOURCE

National Health and Nutrition Examination Survey (modified)


MH08000/(DIABETES_2). Have you taken any medicine or received other medical treatment for diabetes in the past 12 months?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Health and Nutrition Examination Survey (modified)


MH09000/(DIABETES_3). Have you ever taken insulin?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Health and Nutrition Examination Survey (modified)


MH10000/(THYROID_1). (Have you ever been told by a doctor or other health care provider that you had) Hypothyroidism, that is, an under-active thyroid?


Label

Code

Go To

YES

1


NO

2

VITAMIN

REFUSED

-1

VITAMIN

DON'T KNOW

-2

VITAMIN


SOURCE

National Health and Nutrition Examination Survey (modified)


MH11000/(THYROID_2). Have you taken any medicine or received other medical treatment for a thyroid problem in the past 12 months?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Health and Nutrition Examination Survey (modified)


MH12000/(VITAMIN). Do you currently take multivitamins, prenatal vitamins, folic acid, or folate?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Health and Nutrition Examination Survey (modified)


MH13000. This next question is about where you go for routine health care.


MH14000/(HLTH_CARE). What kind of place do you usually go to when you need routine or preventive care, such as a physical examination or check-up?


Label

Code

Go To

Clinic or health center

1


Doctor's office or Health Maintenance Organization (HMO)

2


Hospital emergency room

3


Hospital outpatient department

4


Some other place

5


DOESN'T GO TO ONE PLACE MOST OFTEN

6


DOESN'T GET PREVENTIVE CARE ANYWHERE

-7


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children’s Study, Vanguard Phase


(TIME_STAMP_MH_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 to another subject and ask about health insurance.


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

National Health Interview Survey (modified)


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


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 (modified)


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


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 (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 (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 (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 (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 (modified)


(TIME_STAMP_HI_ET).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP



HOUSEHOLD COMPOSITION AND DEMOGRAPHICS


(TIME_STAMP_HCA_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP


HCA01000. Now, I’d like to ask some questions about your schooling and employment.


HCA02000/(EDUC). What is the highest degree or level of school that you have completed?


INTERVIEWER INSTRUCTIONS

  • IF USING SHOW CARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

  • IF NOT USING SHOW CARDS, READ RESPONSE OPTIONS.


Label

Code

Go To

LESS THAN A HIGH SCHOOL DIPLOMA OR GED

1


HIGH SCHOOL DIPLOMA OR GED

2


SOME COLLEGE BUT NO DEGREE

3


ASSOCIATE DEGREE

4


BACHELOR’S DEGREE (E.G., BA, BS)

5


POST GRADUATE DEGREE (E.G., MASTERS OR DOCTORAL)

6


REFUSED

-1


DON'T KNOW

-2



SOURCE

U.S. Decennial Census


HCA03000/(WORK_CURRENTLY). Are you currently employed?


Label

Code

Go To

YES

1


NO

2

HCA06000

REFUSED

-1

HCA06000

DON'T KNOW

-2

HCA06000


SOURCE

Pregnancy, Infection, and Nutrition Study


HCA04000/(HOURS). Approximately how many hours each week are you working?

 

|___|___|___|

NUMBER OF HOURS


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

Pregnancy, Infection and Nutrition Study


PROGRAMMER INSTRUCTIONS

  • INCLUDE A SOFT EDIT IF RESPONSE > 60


HCA05000/(SHIFT_WORK). Do you currently work a shift that starts after 2pm?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

Avon Longitudinal Study of Parents and Children (modified)


HCA06000. The next questions may be similar to those asked the last time we contacted you, but we are asking them again because sometimes the answers change.


HCA07000/(MARISTAT). I’d like to ask about your marital status. Are you:


INTERVIEWER INSTRUCTIONS

  • PROBE FOR CURRENT MARITAL STATUS.


Label

Code

Go To

Married,

1


Not married but living together with a partner

2


Never been married,

3

TIME_STAMP_HCA_ET

Divorced,

4

TIME_STAMP_HCA_ET

Separated, or

5

TIME_STAMP_HCA_ET

Widowed?

6

TIME_STAMP_HCA_ET

REFUSED

-1

TIME_STAMP_HCA_ET

DON'T KNOW

-2

TIME_STAMP_HCA_ET


SOURCE

National Survey of Family Growth


HCA08000/(SP_EDUC). What is the highest degree or level of school that your spouse or partner has completed?


INTERVIEWER INSTRUCTIONS

  • IF USING SHOW CARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

  • IF NOT USING SHOW CARDS, READ RESPONSE OPTIONS.


Label

Code

Go To

LESS THAN A HIGH SCHOOL DIPLOMA OR GED

1


HIGH SCHOOL DIPLOMA OR GED

2


SOME COLLEGE BUT NO DEGREE

3


ASSOCIATE DEGREE

5


BACHELOR’S DEGREE (E.G., BA, BS)

5


POST GRADUATE DEGREE (E.G., MASTERS OR DOCTORAL)

6


REFUSED

-1


DON'T KNOW

-2



SOURCE

U.S. Decennial Census


HCA09000/(SP_ETHNIC_1). Is your spouse or partner 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 SP_ETHNIC_1 = 1, GO TO SP_ETHNIC_2.

  • IF SP_ETHNIC_1 ≠ 1, AND

    • IF MODE = CAPI, GO TO SP_RACE_NEW.

    • IF MODE = CATI, GO TO SP_RACE_1.


HCA10000/(SP_ETHNIC_2). Is your spouse or partner 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 SP_ETHNIC_2 = -5, OR ANY COMBINATION OF 1 THROUGH 4 AND -5, GO TO SP_ETHNIC_2_OTH.

  • IF SP_ETHNIC_2 = ANY COMBINATION OF 1 THROUGH 4, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING SP_ETHNIC_2_OTH. 

  • IF SP_ETHNIC_2 = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PROGRAMMER INSTRUCTIONS FOLLOWING SP_ETHNIC_2_OTH.


HCA11000/(SP_ETHNIC_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 SP_RACE_NEW.

  • IF MODE = CATI, GO TO SP_RACE_1.


HCA12000/(SP_RACE_NEW). What is your spouse or partner’s race? (One or more categories may be selected).


INTERVIEWER INSTRUCTIONS

  • IF USING SHOW CARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

  • IF NOT USING SHOW CARDS, READ RESPONSE OPTIONS.

  • 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 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 SP_RACE_NEW = ANY COMBINATION OF 1 THROUGH 14, GO TO TIME_STAMP_HCA_ET.

  • IF SP_RACE_NEW = -5 OR ANY COMBINATION OF 1 THROUGH 14 AND -5, GO TO SP_RACE_NEW_OTH.

  • IF SP_RACE_NEW = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO TIME_STAMP_HCA_ET.


HCA13000/(SP_RACE_NEW_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

  • GO TO TIME_STAMP_HCA_ET.


HCA14000/(SP_RACE_1). ​What is your spouse or partner’s 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 SP_RACE_1 = ANY COMBINATION OF 1 THROUGH 3, GO TO TIME_STAMP_HCA_ET.
    IF SP_RACE_1 = 4 OR ANY COMBINATION OF 4 AND 1, 2, 3, AND/OR 5, GO TO SP_RACE_2.
    IF SP_RACE_1 = 5 OR ANY COMBINATION OF 5 AND 1 THROUGH 3, GO TO SP_RACE_3.
    IF SP_RACE_1 = -5, OR ANY COMBINATION OF 1 THROUGH 5 AND -5, GO TO SP_RACE_1_OTH.
    IF SP_RACE_1 =  -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO TIME_STAMP_HCA_ET.


HCA15000/(SP_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)


PROGRAMMER INSTRUCTIONS

  • IF SP_RACE_1 = 4 OR 4 AND ANY COMBINATION OF 1, 2, 3, AND/OR 5, GO TO SP_RACE_2.

  • IF SP_RACE_1 = 5 OR 5 AND ANY COMBINATION OF 1 THROUGH 3, GO TO SP_RACE_3.

  • OTHERWISE, GO TO TIME_STAMP_HCA_ET.


HCA16000/(SP_RACE_2). ​What is your spouse or partner’s 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 SP_RACE_1 = ANY COMBINATION WITH 4 AND 5, GO TO SP_RACE_3.

  • OTHERWISE, GO TO ​TIME_STAMP_HCA_ET.


HCA17000/(SP_RACE_3). ​What is your spouse or partner’s 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)


(TIME_STAMP_HCA_ET).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP



TRACING QUESTIONS


(TIME_STAMP_TQ_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP


TQ01000. The next set of questions asks about different ways we might be able to keep in touch with you.  Please remember that all the information you provide is confidential and will not be provided to anyone outside the National Children’s Study.


TQ02000/(HAVE_EMAIL). Do you have an email address?


Label

Code

Go To

YES

1


NO

2

CELL_PHONE_1

REFUSED

-1

CELL_PHONE_1

DON'T KNOW

-2

CELL_PHONE_1


SOURCE

National Children’s Study, Vanguard Phase (modified)


TQ03000/(EMAIL_2). May we use your personal email address to make future study appointments or send appointment reminders?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children’s Study, Vanguard Phase


TQ04000/(EMAIL_3). May we use your personal email address for questionnaires (like this one) that you can answer over the Internet?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children’s Study, Vanguard Phase


TQ05000/(EMAIL). What is the best email address to reach you?

 

ENTER E-MAIL ADDRESS: ___________________________________


PROGRAMMER INSTRUCTIONS


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children’s Study, Vanguard Phase


TQ06000/(CELL_PHONE_1). Do you have a personal cell phone?


Label

Code

Go To

YES

1


NO

2

CONTACT_1

REFUSED

-1

CONTACT_1

DON'T KNOW

-2

CONTACT_1


SOURCE

National Children’s Study, Vanguard Phase (modified)


TQ07000/(CELL_PHONE_2). May we use your personal cell phone to make future study appointments or for appointment reminders?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children’s Study, Vanguard Phase


TQ08000/(CELL_PHONE_3). Do you send and receive text messages on your personal cell phone?


Label

Code

Go To

YES

1


NO

2

CELL_PHONE

REFUSED

-1

CELL_PHONE

DON'T KNOW

-2

CELL_PHONE


SOURCE

National Children’s Study, Vanguard Phase


TQ09000/(CELL_PHONE_4). May we send text messages to make future study appointments or for appointment reminders?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children’s Study, Vanguard Phase


TQ10000/(CELL_PHONE). What is your personal cell phone number?

 

|___|___|___|___|___|___|___|___|___|___|

PHONE NUMBER


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children’s Study, Vanguard Phase


TQ11000/(CONTACT_1). Sometimes if people move or change their telephone number, we have difficulty reaching them.  Could I have the name of a friend or relative not currently living with you who should know where you could be reached in case we have trouble contacting you?


Label

Code

Go To

YES

1


NO

2

TQ21100

REFUSED

-1

TQ21100

DON'T KNOW

-2

TQ21100


SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


TQ12000. What is this person’s name?


SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


(CONTACT_FNAME_1) __________________             

FIRST NAME                    


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(CONTACT_LNAME_1) __________________   

     LAST NAME


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



INTERVIEWER INSTRUCTIONS

  • IF PARTICIPANT DOES NOT WANT TO PROVIDE NAME OF CONTACT, ASK FOR INITIALS

  • CONFIRM SPELLING OF FIRST AND LAST NAMES.


TQ13000/(CONTACT_RELATE_1). What is his/her relationship to you?


Label

Code

Go To

MOTHER/FATHER

1


BROTHER/SISTER

2


AUNT/UNCLE

3


GRANDPARENT

4


NEIGHBOR

5


FRIEND

6


OTHER

-5


REFUSED

-1


DON'T KNOW

-2



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


TQ14000/(CONTACT_RELATE1_OTH). SPECIFY: _____________________________


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


TQ15000. What is his/her address?


INTERVIEWER INSTRUCTIONS

  • PROMPT AS NECESSARY TO COMPLETE INFORMATION


SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


(C_ADDR1_1) ____________________________________________________

STREET


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(C_ADDR_2_1) ____________________________________________________

STREET


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(C_UNIT_1) ____________________________________________________

UNIT


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(C_CITY_1) ____________________________________________________

CITY 


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(C_STATE_1)

|___|___|  

STATE 


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(C_ZIPCODE_1) |___|___|___|___|___| 

ZIP CODE


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(C_ZIP4_1) - |___|___|___|___|

   +4


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



TQ16000/(CONTACT_PHONE_1). What is his/her telephone number?

 

|___|___|___|___|___|___|___|___|___|___|

PHONE NUMBER


Label

Code

Go To

CONTACT HAS NO TELEPHONE

1


REFUSED

-1


DON'T KNOW

-2



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


INTERVIEWER INSTRUCTIONS

  • IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS


TQ17000. Now I’d like to collect information on a second contact who does not currently live with you. What is this person’s name?


INTERVIEWER INSTRUCTIONS

  • CONFIRM SPELLING OF FIRST AND LAST NAMES.


SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


(CONTACT_FNAME_2) ______________        

FIRST NAME              


Label

Code

Go To

NO SECOND CONTACT PROVIDED

-7

TQ21100

REFUSED

-1

TQ21100

DON'T KNOW

-2

TQ21100


(CONTACT_LNAME_2) __________________

LAST NAME


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



INTERVIEWER INSTRUCTIONS

  • IF PARTICIPANT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS

  • CONFIRM SPELLING OF FIRST AND LAST NAMES.


TQ18000/(CONTACT_RELATE_2). What is his/her relationship to you?


Label

Code

Go To

MOTHER/FATHER

1


BROTHER/SISTER

2


AUNT/UNCLE

3


GRANDPARENT

4


NEIGHBOR

5


FRIEND

6


OTHER

-5


REFUSED

-1


DON'T KNOW

-2



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


TQ19000/(CONTACT_RELATE2_OTH). SPECIFY: _____________________________


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


TQ20000. What is his/her address?


INTERVIEWER INSTRUCTIONS

  • PROMPT AS NECESSARY TO COMPLETE INFORMATION


SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


(C_ADDR1_2) ____________________________________________________

STREET


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(C_ADDR_2_2) ____________________________________________________

STREET


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(C_UNIT_2) ____________________________________________________

UNIT


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(C_CITY_2) ____________________________________________________

CITY


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(C_STATE_2) |___|___|  

STATE 


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(C_ZIPCODE_2)

|___|___|___|___|___| 

ZIP CODE


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



(C_ZIP4_2) |___|___|___|___|

+4


Label

Code

Go To

REFUSED

-1


DON'T KNOW

-2



TQ21000/(CONTACT_PHONE_2). |___|___|___|___|___|___|___|___|___|___|

PHONE NUMBER


Label

Code

Go To

CONTACT HAS NO TELEPHONE

-7


REFUSED

-1


DON'T KNOW

-2



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


INTERVIEWER INSTRUCTIONS

  • IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS


TQ21100. Thank you for participating in the National Children’s Study and for taking the time to complete this survey.  This concludes the interview portion of our visit.


INTERVIEWER INSTRUCTIONS

EXPLAIN SAQS AND RETURN PROCESS


(TIME_STAMP_TQ_ET).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP


Public reporting burden for this collection of information is estimated to average 12 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.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Modified0000-00-00
File Created2021-01-27

© 2024 OMB.report | Privacy Policy