Form 18.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Pregnancy Screener – Sibling Birth Cohort SAQ, Phase 2g

OMB Specification

Pregnancy Screener – Sibling Birth Cohort SAQ

Event Category:	Time-Based
Event:	Pregnancy Screener
Administration:	N/A
Instrument Target:	Biological Mother
Instrument Respondent:	Biological Mother
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:	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.

This page intentionally left blank.

Pregnancy Screener – Sibling Birth Cohort SAQ

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

PREGNANCY STATUS UPDATE 3

FOR OFFICE USE ONLY: 5

This page intentionally left blank.

Pregnancy Screener – Sibling Birth Cohort SAQ

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.

PREGNANCY STATUS UPDATE

PSU01000. Thank you for participating in the National Children’s Study.  Your ongoing involvement is very important to us. 

 

We are beginning a new phase of the Study and will be enrolling newborn members of families already participating in the National Children’s Study.  To find out if you are able to take part please answer the questions below.  The questions should only take about 3 minutes to complete and we have included a postage-paid envelope for you to mail back the survey to us or you may give it to the data collector.  

 

There are no right or wrong answers and we will keep everything that you tell us confidential.

PSU02000/(PREG_CURRENT_SIB). Are you pregnant now?

Label	Code	Go To
Yes	1
No	2	TRY_PREG_SIB

SOURCE

National Children's Study, Legacy Phase (Pregnancy Screener)

PSU03000. When is your baby due?

SOURCE

National Children's Study, Legacy Phase (Pregnancy Screener)

(DUE_DATE_SIB_MM) |___|___|

  M     M

(DUE_DATE_SIB_DD) |___|___|

   D    D

(DUE_DATE_SIB_YYYY) |___|___|___|___|

  Y      Y     Y    Y

PARTICIPANT INSTRUCTIONS

• If you provided a complete date for the baby's due date, go to PSU06000.

• If you were unable to provide a complete date for the baby's due date, go to PSU04000.

PSU04000/(WEEKS_PREG_SIB). About how many weeks pregnant are you?  If not sure, please make your best guess.

 

|___|___|

WEEKS

SOURCE

National Children's Study, Legacy Phase (Pregnancy Screener)

PARTICIPANT INSTRUCTIONS

• Go to PSU06000.

PSU05000/(TRY_PREG_SIB). Are you currently trying to become pregnant?

Label	Code	Go To
Yes	1
No	2

SOURCE

National Children's Study, Legacy Phase (Pregnancy Screener)

PSU06000. Thank you for your dedication to the National Children’s Study.  Please place your completed survey in the postage-paid envelope and drop off at any mailbox or give it to the data collector.

 

If you have any questions or concerns about this survey or the National Children’s Study, please call us at {INSERT TOLL-FREE ROC NUMBER}.  

PROGRAMMER INSTRUCTIONS

• PRELOAD AND DISPLAY TOLL-FREE ROC NUMBER

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 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.