15.5 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

18M Questionnaire - Adult, Phase 2g

OMB Specification

18M Questionnaire - Adult

Event Category:	Time-Based
Event:	18M
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:	6 minutes
Multiple Child/Sibling Consideration:	Per Event
Special Considerations:	N/A
Version:	1.0
MDES Release:	MDES 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.

This page intentionally left blank.

18M Questionnaire - Adult

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

MARITAL STATUS 3

SLEEP ROUTINE 4

PHYSICAL ACTIVITY 6

This page intentionally left blank.

18M 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.

MARITAL STATUS

(TIME_STAMP_MS_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

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

MS01000/(MARISTAT). I’d like to ask about your marital status. Are you:

INTERVIEWER INSTRUCTIONS

• RECORD THE ADULT CAREGIVER’S CURRENT MARITAL STATUS

Label	Code	Go To
Married	1
Not married but living together with a partner	2
Never been married	3
Divorced	4
Separated	5
Widowed	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Survey of Family Growth Cycle 6 Female Questionnaire (modified)

(TIME_STAMP_MS_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

SLEEP ROUTINE

(TIME_STAMP_SLE_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

SLE01000. The following questions are about your sleep habits during the past 7 days. 

SOURCE

National Heart, Lung, and Blood Institute (NHLBI) - Assessing Child and Maternal Sleep in the Early Years

SLE02000. Thinking of the past 7 days, on a typical day, how much time did you sleep at night? 

SOURCE

National Heart, Lung, and Blood Institute (NHLBI) - Assessing Child and Maternal Sleep in the Early Years

(SLEEP_NIGHT_HRS)    |____|____| 

  HOURS            

Label	Code	Go To
REFUSED	-1	SLE03000
DON'T KNOW	-2	SLE03000

(SLEEP_NIGHT_MIN) |____|____|

MINUTES

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

SLE03000. During the past 7 days, on a typical day, how much time did you sleep during the day?

SOURCE

National Heart, Lung, and Blood Institute (NHLBI) - Assessing Child and Maternal Sleep in the Early Years

(SLEEP_DAY_HRS) |____|____| 

HOURS            

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

(SLEEP_DAY_MIN) |____|____|

 MINUTES

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

(TIME_STAMP_SLE_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PHYSICAL ACTIVITY

(TIME_STAMP_PA_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PA01000. The next questions are about physical activity.

 

I am going to ask you about the time you spent being physically active in the last 7 days. Please answer each question even if you do not consider yourself to be an active person.  Think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise, or sports.

 

Now, think about all the vigorous activities which take hard physical effort that you did in the last 7 days.  Vigorous activities make you breathe much harder than normal and may include jogging or running, swimming laps, aerobics, or fast bicycling.  Think only about those physical activities that you did for at least 10 minutes at a time.

PA02000/(VIGOROUS_ACT). During the last 7 days, on how many days did you do vigorous physical activities? Please think only about those physical activities you did for at least 10 minutes at a time.

 

|___|

DAYS PER WEEK

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

SOURCE

International Physical Activity Questionnaire, Short Form (modified)

PROGRAMMER INSTRUCTIONS

• RESPONSE MUST BE ≥ 0 AND < 8.

• IF VIGOROUS_ACT = 0, -1 OR -2 GO TO PA05000.

• OTHERWISE, GO TO PA03000.

PA03000. On those days, how much time did you usually spend doing​ vigorous physical activities? Think only about those physical activities you do for at least 10 minutes at a time.

INTERVIEWER INSTRUCTIONS

• IF NECESSARY, READ: "We are looking for an average time for the days on which you do vigorous activities."

• ENTER NUMBER AND THEN SELECT "HOURS" OR "MINUTES".

SOURCE

International Physical Activity Questionnaire, Short Form (modified)

(VIGOROUS_AMOUNT_NUM) |___|___|

Label	Code	Go To
REFUSED	-1	PA05000
DON'T KNOW	-2	PA04000

(VIGOROUS_AMOUNT_UNIT)

Label	Code	Go To
HOURS	1	PA05000
MINUTES	2	PA05000
REFUSED	-1
DON'T KNOW	-2

PA04000. How much time in total would you say you spent over the last 7 days doing vigorous physical activities?

INTERVIEWER INSTRUCTIONS

• ENTER NUMBER AND THEN SELECT "HOURS" OR "MINUTES".

SOURCE

International Physical Activity Questionnaire, Short Form

(VIGOROUS_AMT_AVG_NUM) |___|___|

Label	Code	Go To
REFUSED	-1	PA05000
DON'T KNOW	-2	PA05000

(VIGOROUS_AMT_AVG_UNIT)

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

PROGRAMMER INSTRUCTIONS

• CREATE DERIVED VARIABLE VIGOROUS_AMT_NUM_CALC, WHERE VIGOROUS_AMT_NUM_CALC = VIGOROUS_AMT_AVG_NUM / VIGOROUS_ACT.  

PA05000. Now think about activities which take moderate physical effort that you did in the last 7 days.  Moderate physical activities make you breathe somewhat harder than normal and may include carrying light loads, bicycling at a regular pace, or doing water aerobics.  Do not include walking or the vigorous activities we have already talked about.  Again, think about only those physical activities that you did for at least 10 minutes at a time.

SOURCE

International Physical Activity Questionnaire, Short Form

PA06000/(MODERATE_ACT). During the last 7 days, on how many days did you do moderate physical activities? Please think only about those physical activities you did for at least 10 minutes at a time.

 

|___|

DAYS PER WEEK

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

SOURCE

International Physical Activity Questionnaire, Short Form

PROGRAMMER INSTRUCTIONS

• RESPONSE MUST BE ≥ 0 AND < 8.

• IF MODERATE_ACT = 0, -1 OR -2, GO TO PA09000.

• OTHERWISE, GO TO ?PA07000.

PA07000. On those days, how much time did you usually spend doing moderate physical activities? Think only about those physical activities that you do for at least 10 minutes at a time.

INTERVIEWER INSTRUCTIONS

• READ IF NECESSARY: "We are looking for an average time for the days on which you do moderate activities."

• ENTER NUMBER AND THEN SELECT "HOURS" OR "MINUTES".

SOURCE

International Physical Activity Questionnaire, Short Form (modified)

(MODERATE_AMT_NUM) |___|___|

Label	Code	Go To
REFUSED	-1	PA09000
DON'T KNOW	-2	PA08000

(MODERATE_AMT_UNIT)

Label	Code	Go To
HOURS	1	PA09000
MINUTES	2	PA09000
REFUSED	-1
DON'T KNOW	-2

PA08000. How much time in total would you say you spent over the last 7 days doing moderate physical activities?

INTERVIEWER INSTRUCTIONS

•  ENTER NUMBER AND THEN SELECT "HOURS" OR "MINUTES".

SOURCE

International Physical Activity Questionnaire, Short Form

(MODERATE_AMT_AVG_NUM) |___|___|

Label	Code	Go To
REFUSED	-1	PA09000
DON'T KNOW	-2	PA09000

(MODERATE_AMT_AVG_UNIT)

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

PROGRAMMER INSTRUCTIONS

• CREATE DERIVED VARIABLE MODERATE_AMT_NUM_CALC, WHERE MODERATE_AMT_NUM_CALC = MODERATE_AMT_AVG_NUM / MODERATE_ACT.  

PA09000. Now think about the time you spent walking in the last 7 days.  This includes at work and at home, walking to get from place to place, and any walking that you have done solely for recreation, sport, exercise, or leisure.

SOURCE

International Physical Activity Questionnaire, Short Form

PA10000/(WALK_NUM). During the last 7 days, on how many days did you walk for at least 10 minutes at a time?

 

|___|

DAYS PER WEEK

INTERVIEWER INSTRUCTIONS

• IF RESPONDENT NEEDS CLARIFICATION, SAY: Think only about the walking that you do for at least 10 minutes at a time.

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

SOURCE

International Physical Activity Questionnaire, Short Form

PROGRAMMER INSTRUCTIONS

• RESPONSE MUST BE ≥ 0 AND < 8.

• IF WALK_NUM = 0, -1 OR -2, GO TO PA13000.

• OTHERWISE, GO TO ?PA11000.

PA11000. On those days, how much time did you usually spend walking?

INTERVIEWER INSTRUCTIONS

• IF NECESSARY, READ: "We are looking for an average time for the days on which you walk."

• ENTER NUMBER AND THEN SELECT "HOURS" OR "MINUTES".

SOURCE

International Physical Activity Questionnaire, Short Form

(WALK_AMOUNT_NUM) |___|___|

Label	Code	Go To
REFUSED	-1	PA13000
DON'T KNOW	-2	PA12000

(WALK_AMOUNT_UNIT)

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

PA12000. What is the total amount of time you spent walking over the last 7 days?

SOURCE

International Physical Activity Questionnaire, Short Form

(WALK_AMT_AVG_NUM) |___|___|

Label	Code	Go To
REFUSED	-1	PA13000
DON'T KNOW	-2	PA13000

(WALK_AMT_AVG_UNIT)

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

PROGRAMMER INSTRUCTIONS

• CREATE DERIVED VARIABLE WALK_AMT_AVG_NUM_CALC, WHERE WALK_AMT_AVG_NUM_CALC = WALK_AMT_AVG_NUM / WALK_NUM.  

PA13000. Now think about the time you spent sitting on week days during the last 7 days.  Include time spent at work, at home, while doing course work, and during leisure time.  This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television.

SOURCE

International Physical Activity Questionnaire, Short Form

PA14000. During the last 7 days, how much time did you usually spend sitting on a week day? Include time spent lying down (awake) as well as sitting.

INTERVIEWER INSTRUCTIONS

• IF NECESSARY, READ: "We are looking for an average time per day spent sitting."

• ENTER NUMBER AND THEN SELECT "HOURS" OR "MINUTES".

SOURCE

International Physical Activity Questionnaire, Short Form

(SIT_AMOUNT_NUM) |___|___|

Label	Code	Go To
REFUSED	-1	PA16000
DON'T KNOW	-2	PA15000

(SIT_AMOUNT_UNIT)

Label	Code	Go To
HOURS	1	PA16000
MINUTES	2	PA16000
REFUSED	-1
DON'T KNOW	-2

PA15000. What is the total amount of time you spent sitting last Wednesday?

INTERVIEWER INSTRUCTIONS

• ENTER NUMBER AND THEN SELECT "HOURS" OR "MINUTES".

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

SOURCE

International Physical Activity Questionnaire, Short Form

(SIT_AMOUNT_AVG_NUM) |___|___|

Label	Code	Go To
REFUSED	-1	PA16000
DON'T KNOW	-2	PA16000

(SIT_AMOUNT_AVG_UNIT)

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

PA16000. Thank you for answering these questions.

(TIME_STAMP_PA_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 6 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.