14.8 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

12M SAQ – Adult, Phase 2g

OMB Specification

12M SAQ – Adult

Event Category:	Time-Based
Event:	12M
Administration:	N/A
Instrument Target:	Primary Caregiver
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:	1 minute
Multiple Child/Sibling Consideration:	Per Event
Special Considerations:	Administer only if primary caregiver is married or is unmarried but living with a partner.
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 – Adult

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

12-MONTH SAQ SPECIFICATION - ADULT CAREGIVER 3

FOR OFFICE USE ONLY: 5

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12M SAQ – 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.

12-MONTH SAQ SPECIFICATION - ADULT CAREGIVER

SSA01100. Thank you for agreeing to participate in the National Children’s Study. This self-administered questionnaire will take about 1 minute to complete. There are questions about your relationships. 

 

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.

SSA01200. These items are about your relationship with your spouse or partner. Please indicate the extent to which you agree or disagree with each statement.

SSA01000/(SP_LISTEN). My spouse/partner listens to me when I need someone to talk to.

Label	Code	Go To
Strongly disagree	1
Somewhat disagree	2
Neither agree nor disagree	3
Somewhat agree	4
Strongly agree	5

SOURCE

NICHD Study of Early Child Care Love and Relationships Questionnaire (modified)

SSA02000/(SP_FEEL). I can state my feelings without my spouse/partner getting defensive.

Label	Code	Go To
Strongly disagree	1
Somewhat disagree	2
Neither agree nor disagree	3
Somewhat agree	4
Strongly agree	5

SOURCE

NICHD Study of Early Child Care Love and Relationships Questionnaire (modified)

SSA03000/(SP_DISTANT). I often feel distant from my spouse/partner.

Label	Code	Go To
Strongly disagree	1
Somewhat disagree	2
Neither agree nor disagree	3
Somewhat agree	4
Strongly agree	5

SOURCE

NICHD Study of Early Child Care Love and Relationships Questionnaire (modified)

SSA04000/(SP_UNDERSTAND). My spouse/partner can really understand my hurts and joys.

Label	Code	Go To
Strongly disagree	1
Somewhat disagree	2
Neither agree nor disagree	3
Somewhat agree	4
Strongly agree	5

SOURCE

NICHD Study of Early Child Care Love and Relationships Questionnaire (modified)

SSA05000/(SP_NEGLECT). I feel neglected at times by my spouse/partner.

Label	Code	Go To
Strongly disagree	1
Somewhat disagree	2
Neither agree nor disagree	3
Somewhat agree	4
Strongly agree	5

SOURCE

NICHD Study of Early Child Care Love and Relationships Questionnaire (modified)

SSA06000/(SP_LONELY). I sometimes feel lonely when we’re together.

Label	Code	Go To
Strongly disagree	1
Somewhat disagree	2
Neither agree nor disagree	3
Somewhat agree	4
Strongly agree	5

SOURCE

NICHD Study of Early Child Care Love and Relationships Questionnaire (modified)

SSA07000. 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:_____________________________________

Public reporting burden for this collection of information is estimated to average 1 minute 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.