14.6 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

12M Questionnaire - Adult, Phase 2g

OMB Specification

12M Questionnaire - Adult

Event Category:	Time-Based
Event:	12M
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:	3 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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12M Questionnaire - Adult

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

PARENTING 3

HEALTH BEHAVIORS 6

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12M 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.

PARENTING

(TIME_STAMP_PAR_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

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

• PRELOAD MULT_CHILD AND C_FNAME FROM PARTICIPANT VERIFICATION, SCHEDULING & TRACING QUESTIONNAIRE. 

• IF MULT_CHILD = 1, DISPLAY "the children" AS APPROPRIATE THROUGHOUT THE INSTRUMENT.

• IF MULT_CHILD ≠ 1, AND 

• IF C_FNAME IN PARTICIPANT VERIFICATION, SCHEDULING & TRACING QUESTIONNAIRE ≠ -1, -2, OR -4, DISPLAY CHILD'S FIRST 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.

PAR01000. These next questions are about different things you may do as a parent or caregiver.  How often do you feel the following ways or do the following things?

PAR02000/(TALK_CHILD). How often do you talk a lot about {C_FNAME/the child/the children} to friends and family?  

INTERVIEWER INSTRUCTIONS

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

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
ALL OF THE TIME	1
SOME OF THE TIME	2
RARELY	3
NEVER	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort

PAR03000/(CARRY_PICS). How often do you carry pictures of {C_FNAME/the child/the children} with you wherever you go?

INTERVIEWER INSTRUCTIONS

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

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
ALL OF THE TIME	1
SOME OF THE TIME	2
RARELY	3
NEVER	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort

PAR04000/(THINK_CHILD_FREQ). How often do you find yourself thinking about {C_FNAME/the child/the children}?

INTERVIEWER INSTRUCTIONS

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

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
ALL OF THE TIME	1
SOME OF THE TIME	2
RARELY	3
NEVER	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort

PAR05000/(ENJOY_HOLD_CHILD). How often do you think holding and cuddling {C_FNAME/the child/the children} is fun?

INTERVIEWER INSTRUCTIONS

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

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
ALL OF THE TIME	1
SOME OF THE TIME	2
RARELY	3
NEVER	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort

PAR06000/(NEW_THINGS_CHILD). How often do you think it's more fun to get {C_FNAME/the child/the children} something new than to get yourself something new?

INTERVIEWER INSTRUCTIONS

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

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
ALL OF THE TIME	1
SOME OF THE TIME	2
RARELY	3
NEVER	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort

(TIME_STAMP_PAR_ET).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

HEALTH BEHAVIORS

(TIME_STAMP_HB_ST).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

HB00100/(HB00100_INSTRUCTIONS). ​These next questions are about drinking alcoholic beverages. Included are liquor such as whiskey or gin, beer, wine, wine coolers, and any other type of alcoholic beverage

SOURCE

NIHS

HB01000/(DRINK_ALCOHOL). Do you drink any type of alcoholic beverage?

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

SOURCE

Early Childhood Longitudinal Study, Birth Cohort:  Pre-School Parent Interview (modified)

HB02000/(ALCOHOL_FREQ). How often do you currently drink alcoholic beverages?

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	TIME_STAMP_HB_ET
REFUSED	-1	TIME_STAMP_HB_ET
DON'T KNOW	-2	TIME_STAMP_HB_ET

SOURCE

National Health Interview Survey (NHIS) 2003:  Adult Section (modified)

HB03000/(ALCOHOL_NUM). Currently, on days that you drink alcoholic beverages, how many drinks do you have per day? 

 

|____|  NUMBER OF DRINKS

INTERVIEWER INSTRUCTIONS

• IF PARTICIPANT REPORTS HAVING 1 OR LESS DRINKS PER DAY, ENTER "1."

• IF NEEDED SAY, "By a drink, we mean a can or bottle of beer, a glass of wine or wine cooler, a shot of liquor, or a mixed drink with liquor in it.  We are not asking about times when you only had a sip or two from a drink."

PARTICIPANT INSTRUCTIONS

• FOR WEB BASED INSTRUMENT: If you drink 1 or less drinks per day, enter 1.

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

SOURCE

Pregnancy Risk Assessment Monitoring System

HB04000/(BINGE_DRINK_FREQ). 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
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health Interview Survey (NHIS) 2003: Adult Section (modified)

(TIME_STAMP_HB_ET).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 3 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.