14.5 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

12M Questionnaire - Child, Phase 2g

OMB Specification

12M Questionnaire - Child

Event Category:	Time-Based
Event:	12M
Administration:	N/A
Instrument Target:	Child
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 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 Questionnaire - Child

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

MEDICAL CONDITIONS 3

PRODUCT USE - HOUSEHOLD 6

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12M Questionnaire - 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.

MEDICAL CONDITIONS

(TIME_STAMP_MC_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

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

• PRELOAD FIRST NAME OF CHILD (C_FNAME) FROM PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE AND DISPLAY APPROPRIATE NAME IN "C_FNAME" THROUGHOUT THE INSTRUMENT.

• OTHERWISE, IF C_FNAME IN PARTICIPANT VERIFICATION, SCHEDULING & TRACING QUESTIONNAIRE = -1 OR -2, DISPLAY "the child" IN APPROPRIATE FIELDS THROUGHOUT THE INSTRUMENT.

MC01000. Now I have some questions about specific conditions or health problems {C_FNAME/the child} may have.

MC02000/(BLIND). Has a doctor ever told you that {C_FNAME/the child} is blind?

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

SOURCE

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

MC03000/(DIFF_SEEING). Has a doctor ever told you that {C_FNAME/the child} has difficulty seeing, including nearsightedness or farsightedness?

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

SOURCE

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

MC04000/(DIFF_HEARING). Has a doctor ever told you that {C_FNAME/the child} has difficulty hearing or deafness?  Do not include a temporary loss of hearing due to a cold or congestion.

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

SOURCE

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

MC05000/(CONGENITAL). Has a doctor ever told you that {C_FNAME/the child} has any congenital anomaly or birth defect such as a cleft lip or palate, heart defect, or spina bifida?

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

SOURCE

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

MC06000/(CONGENITAL_OTH). What type of congenital anomaly or birth defect have you been told {C_FNAME/the child} has?

 

SPECIFY:  ____________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children's Study, Vanguard Phase (12M)

MC07000/(GENETIC_COND). Has a doctor ever told you that {C_FNAME/the child} has Down Syndrome, Turner Syndrome, or any other inherited or genetic condition?

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

SOURCE

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

MC08000/(GENETIC_COND_OTH). What type of condition have you been told {C_FNAME/the child} has?

 

SPECIFY:  ____________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children's Study, Vanguard Phase (12M)

(TIME_STAMP_MC_ET).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

PRODUCT USE - HOUSEHOLD

(TIME_STAMP_PUH_ST).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

PUH01000. The next questions ask about lice exposure and treatment.

PUH02000/(INSECT_REPELLENT). In the past 6 months, about how often have you used any insect repellent spray, lotion, or towelettes on {C_FNAME/the child}?

Label	Code	Go To
Every day	1
A few times a week	2
About once a week	3
1-3 times a month	4
Less than once a month	5
Not at all	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children's Study Legacy Phase (T1) (modified)

PUH03000/(TREAT_LICE). In the past 6 months, have you treated {C_FNAME/the child} in your home for lice or scabies?

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

SOURCE

National Children's Study, Vanguard Phase (12M, 18M, 24M)

(TIME_STAMP_PUH_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.