14.7 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

12M SAQ - Child, Phase 2g

OMB Specification

12M SAQ - Child

Event Category:	Time-Based
Event:	12M
Administration:	N/A
Instrument Target:	Child
Instrument Respondent:	Primary Caregiver
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:	4 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 SAQ - Child

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

12-MONTH SAQ SPECIFICATION - CHILD 3

FOR OFFICE USE ONLY: 14

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12M SAQ - 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.

12-MONTH SAQ SPECIFICATION - CHILD

SSC01000. Thank you for agreeing to participate in the National Children’s Study. This self-administered questionnaire will take about 4 minutes to complete. There are questions about your relationships and questions about your child’s diet.

 

Your answers are important to us. There are no right or wrong answers. You can skip over any question. We will keep everything that you tell us confidential.

SSC02000. The next questions will ask about the milk, formula, and food your child has eaten in the past 7 days. In answering include feedings by everyone who feeds the baby. Include snacks and night-time feedings. Use these guidelines in choosing how to respond:

 

• If the baby was fed this item once a day or more, write the number of feedings per day in the boxes and then mark the box before “Day.”

• If the baby was fed the item less than once a day, write the number of feedings per week in the boxes and then mark the box before “Week.”

• If the baby was not fed the item at all during the past 7 days, write “00” in the boxes.

SSC03000. In the past 7 days, how often was your baby fed breast milk? Please include both breast-fed and expressed or pumped breast milk.

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire) (modified)

(BREAST_MILK) |___|___| Number of times per 

(BREAST_MILK_UNIT) (select one below)

Label	Code	Go To
Day	1
Week	2

SSC04000. In the past 7 days, how often was your baby fed formula?

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire)

(FORMULA) |___|___| Number of times per 

(FORMULA_UNIT) (select one below)

Label	Code	Go To
Day	1
Week	2

SSC05000. In the past 7 days, how often was your baby fed cow’s milk?

SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)

(COW_MILK) |___|___| Number of times per 

(COW_MILK_UNIT) (select one below)

Label	Code	Go To
Day	1
Week	2

SSC06000. In the past 7 days, how often was your baby fed other milk (soy milk, rice milk, goat milk)?

SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)

(MILK_OTHER) |___|___| Number of times per 

(MILK_OTHER_UNIT) (select one below)

Label	Code	Go To
Day	1
Week	2

SSC07000/(BREAST_MILK_FED). Please tell me which best describes what your baby has been fed. My baby...

Label	Code	Go To
…is not drinking breast milk now, but was fed breast milk in the past	1
…is drinking breast milk now	2	FORMULA_FED
…was never fed breast milk	3	FORMULA_FED

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire)

SSC08000. How old was your baby when you completely stopped breastfeeding and pumping or expressing breast milk? (If your baby was less than one month, enter age in weeks. If your baby was older than one month, enter age in months.)

SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)

(BREAST_STOP) |___|___| Number of weeks or months 

(BREAST_STOP_UNIT) (select one below)

Label	Code	Go To
Week	1
Month	2

SSC09000/(PUMPED). Have you ever fed your baby pumped or expressed breast milk?

Label	Code	Go To
Yes	1
No	2	FORMULA_FED

SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)

SSC10000/(PUMPED_2). In the past 7 days, about how often was your baby fed pumped or expressed breast milk?  Include feedings by everyone who feeds the baby and include snacks and nighttime feedings.

Label	Code	Go To
1 time per week	1
2 to 4 times per week	2
Nearly every day	3
1 time per day	4
2 to 3 times per day	5
4 to 6 times per day	6
More than 6 times per day	7
Not applicable/I have not fed my baby pumped or expressed breast milk in the past 7 days	-7

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire)

SSC11000/(FORMULA_FED). How old was your baby when he/she was first fed formula on a daily basis?

Label	Code	Go To
Less than 1 month old	1
1 to 2 months old	2
3 to 4 months old	3
5 to 6 months old	4
More than 6 months old	5
Not applicable (never fed formula to baby)	-7

SOURCE

Infant Feeding Practices Study II Neonatal Questionnaire (modified)

PARTICIPANT INSTRUCTIONS

If you answered “00” to SSC04000 (your baby was not fed formula in the past 7 days) and “Not applicable (never fed formula to baby)" to SSC11000, go to SSC20000.

 

If you answered any number “01” or more to SSC04000, go to SSC13000.

 

If you were unable to answer SSC04000, go to SSC12000.

SSC12000/(FORMULA_LAST7). Has your baby had formula in the last seven days?

Label	Code	Go To
Yes	1
No	2	SSC20000
Not applicable (never fed formula to baby)	-7	SSC20000

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire)

SSC13000/(FORMULA_BRAND). What kind of infant formula was your baby fed in the past 7 days? Select all of the formulas that you feed your baby. Include any formula the baby was fed in the past 7 days that is not included on the list under “Other.”

Label	Code	Go To
Baby’s Only Organic Dairy	1
Baby’s Only Organic Soy	2
Baby’s Only Organic Lactose Free	3
Bright Beginnings milk-based	4
Bright Beginnings Gentle milk-based	5
Bright Beginnings Organic	6
Bright Beginnings milk-based 2	7
Bright Beginnings NeoCare	8
Earth’s Best Organic Infant Formula with DHA ARA	9
Earth’s Best Organic Soy Infant Formula with DHA ARA	10
EleCare®	11
Enfamil® Premium with Triple Health Guard	12
Enfamil® Premium Next Step	13
Enfamil® ProSobee®	14
Enfamil® RestFull	15
Enfamil AR®	16
Enfamil® Gentlease®	17
Enfamil® Gentlease® Next Step	18
Enfamil® Enfacare	19
Enfamil® Premature	20
Enfamil® Premium Vanilla or Chocolate	21
Enfamil® Soy Next Step	22
Gerber® Good Start® Gentle Plus	23
Gerber® Good Start® Gentle Plus 2	24
Gerber® Good Start® Protect Plus	25
Gerber® Good Start® Protect Plus 2	26
Gerber® Good Start® Soy Plus	27
Gerber® Good Start® Soy Plus 2	28
Nutramigen® with Enflora LGG	29
Nutramigen® AA	30
Pregestimil®	31
Similac® Advance® EarlyShield	32
Similac Isomil® Advance®	33
Similac Isomil® DF	34
Similac® Organic	35
Similac® Go Grow	36
Similac® Go Grow EarlyShield	37
Similac® Sensitive	38
Similac® Sensitive R.S.	39
Similac® Alimentum®	40
Similac® Neosure®	41
Store brand Milk based (like Member’s Mark, Kirkland, Target up up)	42
Store brand Gentle or partially broken down whey protein formula (like Member’s Mark or Target up up)	43
Store brand Soy based (like Target up up)	44
Store brand Next step (like Target up up)	45
Store brand Lacto sensitive (like Target up up)	46
Store brand Prebiotic (like Target up up)	47
Other	-5

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire) (modified)

PARTICIPANT INSTRUCTIONS

If you selected "Other" and any other response for SSC13000, go to SSC14000.

 

If you did not select "Other," go to SSC15000.

SSC14000/(FORMULA_BRAND_OTH). __________________________________________________________

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire) (modified) 

SSC15000/(FORMULA_TYPE). Was the formula ready-to-feed, liquid concentrate, powder from a can that makes a single-serving, or powder from single-serving packets?   Select all of the formulas you feed your baby.

Label	Code	Go To
Ready-to-feed	1
Liquid concentrate	2
Powder from a can that makes more than one bottle	3
Powder from single-serving packets	4

SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)

PARTICIPANT INSTRUCTIONS

If your baby was ONLY fed ready-to-feed formula, go to SSC19000.

 

Otherwise, go to SSC16000.

SSC16000/(WATER_1). During the past 7 days, what types of water have you and others who care for your baby used for mixing your baby’s formula?  Select all of the types of water you have used for mixing your baby’s formula.  If you have used any other type of water, please list the water type on the line below.

Label	Code	Go To
Tap water from the cold faucet	1
Warm tap water from the hot faucet	2
Bottled water	3
Other type of water used	-5

SOURCE

Infant Feeding Practices Study II Month 9 Questionnaire (modified)

PARTICIPANT INSTRUCTIONS

If you selected "Other type of water used" and any other response, go to SSC17000.

If you did not select "Other type of water used," go to SSC18000.

SSC17000/(WATER_1_OTH). _________________________________________________________

SOURCE

Infant Feeding Practices Study II Month 9 Questionnaire (modified)

SSC18000/(WATER_2). Was the water used to mix the formula boiled?

Label	Code	Go To
Yes	1
No	2

SOURCE

Infant Feeding Practices Study II Month 2 Questionnaire  

SSC19000/(OUNCES). In the past 7 days, on the average, how many ounces of formula did your baby drink at each feeding?

 

|___|___| Ounces

SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)

SSC20000. In the past 7 days, about how often did your baby drink from each of the following types of bottles and cups?

SSC21000/(B_TYPE_1). Plastic baby bottle with disposable bottle liner.

Label	Code	Go To
Never	1
Sometimes	2
Most of the time	3
Always	4

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire)

SSC22000/(B_TYPE_2). Plastic baby bottle without disposable liner.

Label	Code	Go To
Never	1
Sometimes	2
Most of the time	3
Always	4

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire)

SSC23000/(B_TYPE_3). Other plastic bottle (for example, a water bottle).

Label	Code	Go To
Never	1
Sometimes	2
Most of the time	3
Always	4

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire)

SSC24000/(B_TYPE_4). Glass baby bottle.

Label	Code	Go To
Never	1
Sometimes	2
Most of the time	3
Always	4

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire)

SSC25000/(B_TYPE_5). Plastic “no spill” cup.

Label	Code	Go To
Never	1
Sometimes	2
Most of the time	3
Always	4

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire)

SSC26000/(PACIFIER). Has your baby used a pacifier in the past 7 days?

Label	Code	Go To
Yes	1
No	2

SOURCE

Infant Feeding Practices Study II 9 Month Questionnaire

SSC27000/(COWS_MILK_1). Has your baby ever been fed cow’s milk that was not sold especially for babies? (This includes whole, low-fat, nonfat, or chocolate milk).

Label	Code	Go To
Yes	1
No	2	CEREAL

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire)

SSC28000/(COWS_MILK_2). How old was your baby when he/she was first fed cow’s milk that was not sold especially for babies?

 

|___|___| . |___| Age in months.

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire)

SSC29000/(CEREAL). How old was your baby when he/she was first fed cereal, including baby cereal, on a daily basis?

Label	Code	Go To
Less than 1 month old	1
1 to 2 months old	2
3 to 4 months old	3
5 to 6 months old	4
More than 6 months old	5
Not applicable (never fed cereal)	-7

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire)

SSC30000/(PUREED). How old was your baby when he/she was first fed pureed baby food on a daily basis? Please include commercial (store-bought) and homemade baby food.

Label	Code	Go To
Less than 1 month old	1
1 to 2 months old	2
3 to 4 months old	3
5 to 6 months old	4
More than 6 months old	5
Not applicable (never fed pureed baby food)	-7

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire)

SSC31000/(TABLE_FOOD). How old was your baby when he/she was first fed table food such as eggs, cheese, or potatoes on a daily basis?

Label	Code	Go To
Less than 1 month old	1
1 to 2 months old	2
3 to 4 months old	3
5 to 6 months old	4
More than 6 months old	5
Not applicable (never fed table food)	-7

SOURCE

National Children’s Study, Legacy Phase (6M Infant Feeding Questionnaire)

SSC32000/(SUPPLEMENT). Check the box beside all of the supplements your child has taken during the past 2 weeks for at least 3 days a week. If your child has taken any other vitamins or supplements, please list them on the line beside “Other vitamins or supplements.

Label	Code	Go To
Fluoride	1
Iron	2
Vitamin D	3
Other vitamins or supplements	-5
Not applicable (child not given supplements)	-7

SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)

PARTICIPANT INSTRUCTIONS

If you selected "Not applicable (child not given supplements)" do not select any additional responses.

 

If you selected "Other vitamins or supplements" and any other response, go to SSC33000.

If you did not select "Other vitamins or supplements," go to ​SSC34000.

SSC33000/(SUPPLEMENT_OTH). ____________________________________________________________

SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)

SSC34000/(HERBAL). Was your baby given any herbal or botanical preparations or any kind of tea or home remedy in the past 7 days?  Do not count preparations put on the baby’s skin or anything the baby may have gotten from breast milk after you took an herbal or botanical preparation.

Label	Code	Go To
Yes	1
No	2

SOURCE

Infant Feeding Practices Study II Month 6 Questionnaire (modified)

SSC35000. ​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). PARTICIPANT ID:___________________________________

FOU02000/(R_P_ID). RESPONDENT ID:______________________________________

Public reporting burden for this collection of information is estimated to average 4 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.