4.4 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Pregnancy Visit 1 SAQ, Phase 2g

OMB Specification

Pregnancy Visit 1 SAQ

Event Category:	Trigger-Based
Event:	PV1
Administration:	N/A
Instrument Target:	Pregnant Woman
Instrument Respondent:	Pregnant Woman
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:	8 minutes
Multiple Child/Sibling Consideration:	Per Event
Special Considerations:	N/A
Recruitment Groups:	x.x
Version:	4.1
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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Pregnancy Visit 1 SAQ

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

PREGNANCY VISIT 1 SAQ 3

PARTICIPATION QUESTIONS 11

FOR OFFICE USE ONLY: 17

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Pregnancy Visit 1 SAQ

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.

PREGNANCY VISIT 1 SAQ

PV00100. Thank you for agreeing to participate in this study. This self-administered questionnaire will take about 8 minutes to complete. It contains questions about your current pregnancy and your lifestyle. We will also ask you about your satisfaction with our visit today.

 

Your answers are important to us. There are no right or wrong answers. You can always refuse to answer any question or group of questions, and your answers will be kept confidential. Please choose only one response per question.

PV01000/(PLANNED). Regarding this pregnancy, were you trying to become pregnant?

Label	Code	Go To
Yes	1
No	2	WANTED

SOURCE

National Survey of Family Growth (NSFG) (modified)

PV02000/(MONTH_TRY). For about how many months were you trying to become pregnant?

 

l___l___l (If less than 1 month, enter 01.)

SOURCE

Pregnancy Risk Assessment Monitoring System

PV03000/( WANTED). When you became pregnant, did you yourself actually want to have a baby at some time, either right then or in the future?

Label	Code	Go To
Yes	1
No	2	PV05000

SOURCE

National Survey of Family Growth (NSFG) (modified)

PV04000/(TIMING). Would you say you became pregnant too soon, at about the right time, or later than you wanted?

Label	Code	Go To
Too soon	1
Right time	2
Later	3
Didn't Care	4

SOURCE

National Survey of Family Growth (NSFG) (modified)

PV05000. Part of the National Children’s Study includes a planned study visit with the baby’s father. What is the first and last name of your baby’s father?

SOURCE

National Children’s Study, Legacy Phase (T1 Mother) (modified)

(F_F_NAME) First Name: _________________________________

(F_L_NAME) Last Name: ____________________________________________

PV07000/(FATHER_SAME_HH). Is the father of your baby living in the same household as you?

Label	Code	Go To
Yes	1
No	2

SOURCE

National Children’s Study, Legacy Phase (T1 Mother) (modified)

PV08000/(FATHER_KNOW_PREG). Is the father aware of your pregnancy?

Label	Code	Go To
Yes	1
No	2	CONTACT_F_LATER

SOURCE

National Children’s Study, Vanguard Phase

PV09000/(CONTACT_F_NOW). May we have your permission to contact the father and invite him to participate in the Study?

Label	Code	Go To
Yes	1
No	2

SOURCE

National Children’s Study, Legacy Phase (T1 Mother) (modified)

PARTICIPANT INSTRUCTIONS

• If your baby's father is not living in the same household and you give us permission to contact him, go to PV11000.

• If your baby's father is living in the same household and you give us permission to contact him, go to PV12000.

• If you do not want us to contact your baby's father, go to PV21000.

PV10000/(CONTACT_F_LATER). Once you have shared the information about your pregnancy with the father, may we have your permission to contact him and invite him to participate in the Study?

 

Label	Code	Go To
Yes	1
No	2	PAST_PREG

SOURCE

National Children’s Study, Vanguard Phase

PV11000. The next time we follow up with you, we will ask if you have shared the information about your pregnancy with the father so that we know if it is the right time to contact him.

 

What is the father’s home address?

SOURCE

National Children’s Study, Legacy Phase (T1 Mother)

(F_ADDR1_2) Street Address __________________________________________________

(F_ADDR2_2) Street Address _________________________________________________________

(F_UNIT_2) Apartment/Unit Number ______________________________________________________

(F_CITY_2) City __________________________________________

(F_STATE_2) State |___|___|

(F_ZIPCODE_2) Zip Code |___|___|___|___|___|

(F_ZIP4_2) Zip Code +|___|___|___|___|

PV12000/(F_PHONE). What is the father's telephone number?

 

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

PV20000/(F_AGE). What is the father's age?

 

|___|___| Years

SOURCE

National Children’s Study, Vanguard Phase

PARTICIPANT INSTRUCTIONS

• If this is your first pregnancy that is being followed by the study, go to PV21000.

• If this is not your first pregnancy that is being followed by the study, go to PV24000.

PV21000/(PAST_PREG). These next questions are about any previous pregnancies you may have had.

 

Before this pregnancy, have you ever been pregnant? Please include live births, miscarriages, stillbirths, ectopic pregnancies, abortions and pregnancy terminations.

These next questions are about any previous pregnancies you may have had.

Label	Code	Go To
Yes	1
No	2	CIG_PAST

SOURCE

National Children’s Study, Legacy Phase (T1 Mother) (modified)

PV22000/(NUM_PREG). Including this pregnancy, how many times total have you been pregnant?

|___|___| Times

SOURCE

Avon Longitudinal Study of Parents and Children

PV23000/(AGE_FIRST). How old were you when you became pregnant for the first time?

 

|___|___| Years

SOURCE

Pregnancy Risk Assessment Monitoring System (modified)

PARTICIPANT INSTRUCTIONS

Go to PV25000

PV24000/(NUM_PREG_SUBPREG). Including this pregnancy, how many times total have you been pregnant? Please include live births, miscarriages, stillbirths, ectopic pregnancies, abortions and pregnancy terminations.

 

|___|___| Times

SOURCE

Avon Longitudinal Study of Parents and Children (modified)

PV25000/(PREMATURE). Did any of your previous pregnancies end in the birth of a child more than 3 weeks early, before his or her due date? 

Label	Code	Go To
Yes	1
No	2

SOURCE

Avon Longitudinal Study of Parents and Children (modified)

PV26000/(MISCARRY). Did any of your previous pregnancies end in a miscarriage or stillbirth?

Label	Code	Go To
Yes	1
No	2

SOURCE

Avon Longitudinal Study of Parents and Children (modified)

PV27000/(CIG_PAST). The next questions are about your use of cigarettes and alcohol just before your current pregnancy.

 

In the 3 months before you knew you were pregnant, did you smoke any cigarettes?

Label	Code	Go To
Yes	1
No	2	CIG_NOW

SOURCE

National Health and Nutrition Examination Survey (modified)

PV28000/(CIG_PAST_FREQ). Did you smoke cigarettes:

Label	Code	Go To
Every day	1
5 or 6 days a week	2
2-4 days a week	3
Once a week	4
1-3 days a month	5
Less than once a month	6

SOURCE

National Children’s Study, Legacy Phase (T1 Mother)

PV29000/(CIG_PAST_NUM). On days that you smoked, how many cigarettes did you smoke per day? If you smoked 1 cigarette or less each day, please enter “01.” ​

 

|___|___| Number per day

SOURCE

Modified from National Health and Nutrition Examination Survey

PV30000/(CIG_NOW). Currently, do you smoke cigarettes?

Label	Code	Go To
Yes	1
No	2	DRINK_PAST

SOURCE

National Health and Nutrition Examination Survey (modified)

PV31000/(CIG_NOW_FREQ). Do you smoke cigarettes:

Label	Code	Go To
Every day	1
5 or 6 days a week	2
2-4 days a week	3
Once a week	4
1-3 days a month	5
Less than once a month	6

SOURCE

National Children’s Study, Legacy Phase (T1 Mother)

PV32000/(CIG_NOW_NUM). On days that you smoke, how many cigarettes do you smoke per day? If you smoke 1 cigarette or less each day, please enter “01.”

 

|___|___| Number per day

SOURCE

National Health and Nutrition Examination Survey (modified)

PV33000/(DRINK_PAST). In the 3 months before you knew you were pregnant, how often did you drink alcoholic beverages including wine, beer, drinks containing hard liquor, wine coolers, hard lemonade, or hard cider?

Label	Code	Go To
5 or more times a week	1
2-4 times a week	2
Once a week	3
1-3 times a month	4
Less than once a month	5
Never	6	DRINK_NOW

SOURCE

National Children’s Study, Legacy Phase (T1 Mother) (modified)

PV34000/(DRINK_PAST_NUM). In the 3 months before you knew you were pregnant, on days that you drank alcoholic beverages, how many did you have per day? If you had one drink or less, please enter “01.”

 

|___|___| Number of drinks

SOURCE

Pregnancy Risk Assessment Monitoring System (modified)

PV34100/(DRINK_PAST_5). In the 3 months before you knew you were pregnant, how often did you have 5 or more drinks within a couple of hours?

Label	Code	Go To
Never	1
About once a month	2
About once a week	3
About once a day	4

SOURCE

Pregnancy Risk Assessment Monitoring System (modified)

PV35000/(DRINK_NOW). How often do you currently drink alcoholic beverages including wine, beer, drinks containing hard liquor, wine coolers, hard lemonade, or hard cider?

Label	Code	Go To
5 or more times a week	1
2-4 times a week	2
Once a week	3
1-3 times a month	4
Less than once a month	5
Never	6	EQ00100

SOURCE

National Children’s Study, Legacy Phase (T1 Mother) (modified)

PV36000/(DRINK_NOW_NUM). Currently, on days that you drink alcoholic beverages, how many did you have per day? If you have one drink or less, please enter “01.”

 

|___|___| Number of drinks

SOURCE

Pregnancy Risk Assessment Monitoring System (modified)

PV37000/(DRINK_NOW_5). Currently, how often do you have 5 or more drinks within a couple of hours:

Label	Code	Go To
Never	1
About once a month	2
About once a week	3
About once a day	4

SOURCE

Pregnancy Risk Assessment Monitoring System (modified)

PARTICIPATION QUESTIONS

EQ00100. We would now like to take a few minutes to ask some questions about your experience in the study. There are no right or wrong answers. You can always refuse to answer any question or group of questions, and your answers will be kept confidential.

EQ01000/(LEARN). How important was each of the following in your decision to take part in the National Children’s Study?

 

How important was… Learning more about my health or the health of my child? 

Label	Code	Go To
Not at all important	1
Somewhat important	2
Very important	3

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ02000/(HELP). How important was… Feeling as if I can help children now and in the future?

Label	Code	Go To
Not at all important	1
Somewhat important	2
Very important	3

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ03000/(INCENT). How important was… Receiving money or gifts for taking part in the study?

Label	Code	Go To
Not at all important	1
Somewhat important	2
Very important	3

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ04000/(RESEARCH). How important was… Helping doctors and researchers learn more about children and their health?

Label	Code	Go To
Not at all important	1
Somewhat important	2
Very important	3

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ05000/(ENVIR). How important was… Helping researchers learn how the environment may affect children’s health? 

Label	Code	Go To
Not at all important	1
Somewhat important	2
Very important	3

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ06000/(COMMUNITY). How important was… Feeling part of my community?

Label	Code	Go To
Not at all important	1
Somewhat important	2
Very important	3

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ07000/(KNOW_OTHERS). How important was… Knowing other women in the study?

Label	Code	Go To
Not at all important	1
Somewhat important	2
Very important	3

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ08000/(FAMILY). How important was… Having family members or friends support my choice to take part in the study?

Label	Code	Go To
Not at all important	1
Somewhat important	2
Very important	3

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ09000/(DOCTOR). How important was… Having my doctor or health care provider support my choice to take part in the study?

Label	Code	Go To
Not at all important	1
Somewhat important	2
Very important	3

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ10000/(STAFF). How important was… Feeling comfortable with the study staff who come to my home?

Label	Code	Go To
Not at all important	1
Somewhat important	2
Very important	3

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ11000/(OPIN_SPOUSE). How do each of the following people feel about you taking part in the National Children’s Study?

 

Your spouse or partner?

Label	Code	Go To
Very Negative	1
Somewhat Negative	2
Neither Positive or Negative	3
Somewhat Positive	4
Very Positive	5
Not Applicable	-7

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ12000/(OPIN_FAMILY). Other family members

Label	Code	Go To
Very Negative	1
Somewhat Negative	2
Neither Positive or Negative	3
Somewhat Positive	4
Very Positive	5
Not Applicable	-7

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ13000/(OPIN_FRIEND). Your friends

Label	Code	Go To
Very Negative	1
Somewhat Negative	2
Neither Positive or Negative	3
Somewhat Positive	4
Very Positive	5
Not Applicable	-7

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ14000/(OPIN_DR). Your doctor or health care provider

Label	Code	Go To
Very Negative	1
Somewhat Negative	2
Neither Positive or Negative	3
Somewhat Positive	4
Very Positive	5
Not Applicable	-7

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ15000/(EXPERIENCE). In general, has your experience with the National Children's Study been...

Label	Code	Go To
Mostly Negative	1
Somewhat Negative	2
Neither Positive or Negative	3
Somewhat Positive	4
Mostly Positive	5
Not Applicable	-7

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ16000/(IMPROVE). In your opinion, how much do you think the National Children's Study will help improve the health of children now and in the future?

Label	Code	Go To
Not at all	1
A little	2
Some	3
A lot	4

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ17000/(INT_LENGTH). Did you think the interview was

Label	Code	Go To
Too short	1
Too long	2
Just about right	3

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ18000/(INT_STRESS). Do you think the interview was

Label	Code	Go To
Not at all stressful	1
A little stressful	2
Somewhat stressful	3
Very stressful	4

SOURCE

National Children’s Study, Legacy Phase (P1 Participant Evaluation Questionnaire, T1 Participant Evaluation Questionnaires, T3 Prior Participant Evaluation Questionnaire) (modified)

EQ19000/(INT_REPEAT). If you were asked, would you participate in an interview like this again?

Label	Code	Go To
Yes	1
No	2

SOURCE

National Children's Study, Vanguard Phase

EQ20000. 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). Insert participant ID label here.

Public reporting burden for this collection of information is estimated to average 8 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.