Form 26.2 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Core Questionnaire – Adult, Phase 2g

OMB Specification

Core Questionnaire - Adult

Event Category:	Time-Based
Event:	6M, 12M, 24M, 36M, 48M, 60M
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:	2 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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Core Questionnaire - Adult

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

GENERAL HEALTH - (6M, THEN ANNUAL AT 12 M) 3

EMPLOYMENT - (6M, THEN ANNUAL AT 12 M) 4

OCCUPATION - (6M, THEN ANNUAL AT 12 M) 8

EDUCATION - (6M, THEN ANNUAL AT 12 M) 10

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Core 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.

GENERAL HEALTH - (6M, THEN ANNUAL AT 12 M)

(TIME_STAMP_GH_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

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

GH01000. Now I’d like ask about your general health.

GH02000/(HEALTH). Would you say your health in general is ...

Label	Code	Go To
Excellent	1
Very good	2
Good	3
Fair	4
Poor	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System (BRFSS) 2011

(TIME_STAMP_GH_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

EMPLOYMENT - (6M, THEN ANNUAL AT 12 M)

(TIME_STAMP_EMP_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

EMP01000. Because people's work situations can change, the next set of questions is about your work in just the past 12 months.

EMP02000/(WORK_LAST_CONTACT). In the past 12 months, have you been employed at a job or business?

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

SOURCE

National Children’s Study, Vanguard Phase 

EMP03000/(WORK_CURRENTLY). Are you currently employed?

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

SOURCE

Avon Longitudinal Survey of Parents And Children (ALSPAC) New Mother Questionnaire

EMP04000/(WORK_HRS). How many hours per week do you work? 

 

|___|___|___|

  HOURS

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

SOURCE

Herald Study

PROGRAMMER INSTRUCTIONS

• DISPLAY HARD EDIT IF WORK_HRS < 0 OR > 112.

• DISPLAY SOFT EDIT IF WORK_HRS IS > 80 BUT ≤ 112.

• IF WORK_NAME COLLECTED DURING PREVIOUS INTERVIEW FOR R_P_ID AND WORK_NAME ≠ -1 OR -2:

• GO TO WORK_NAME_CONFIRM.

• PRELOAD LAST VALUE FOR WORK_NAME FOR R_P_ID.

• OTHERWISE, GO TO WORK_NAME.

EMP05000/(WORK_NAME_CONFIRM). Let me confirm the name of the place where you work.  I have it as {PARENT/CAREGIVER’S WORK PLACE NAME}.  Is this correct?

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

SOURCE

Evaluation of Community Health Marriage Incentive and NLSY (modified)

PROGRAMMER INSTRUCTIONS

• DISPLAY LAST VALUE OF WORK_NAME FOR R_P_ID IN "PARENT/CAREGIVER'S WORK PLACE NAME".

• IF WORK_NAME_CONFIRM =1, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING  WORK_NAME.

• OTHERWISE, IF WORK_NAME_CONFIRM = - 2, -1, OR -2, GO TO WORK_NAME.

EMP06000/(WORK_NAME). What is the name of the place where you work?

 

______________________________________ 

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

SOURCE

Evaluation of Community Health Marriage Incentive and NLSY (modified)

PROGRAMMER INSTRUCTIONS

• IF WORK_ADDRESS_1, WORK_ADDRESS_2, WORK_CITY, WORK_STATE, AND WORK_ZIP COLLECTED DURING A PREVIOUS INTERVIEW FOR CURRENT R_P_ID AND ALL VALUES ≠ -1 OR -2:

• GO TO WORK_ADDRESS_VAR_CONFIRM_NEW.

• PRELOAD LAST COLLECTED WORK_ADDRESS_1, WORK_ADDRESS_2, WORK_UNIT, WORK_CITY, WORK_STATE, WORK_ZIP, AND WORK_ZIP4 FOR CURRENT R_P_ID.

• OTHERWISE, IF WORK_ADDRESS_1, WORK_ADDRESS_2, WORK_CITY, WORK_STATE, AND WORK_ZIP NOT COLLECTED PREVIOUSLY FOR CURRENT R_P_ID OR ALL VALUES = -1 OR -2, GO TO EMP08000.

EMP07000/(WORK_ADDRESS_VAR_CONFIRM_NEW). Let me confirm your work address. I have it as {PARENT/CAREGIVER’S WORK ADDRESS}. Is this correct?

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

SOURCE

National Children’s Study, Vanguard Phase

PROGRAMMER INSTRUCTIONS

• DISPLAY LAST COLLECTED WORK_ADDRESS_1, WORK_ADDRESS_2, WORK_UNIT, WORK_CITY, WORK_STATE, WORK_ZIP, AND WORK_ZIP4 FOR CURRENT R_P_ID IN "PARENT/CAREGIVER'S WORK ADDRESS".

• IF WORK_ADDRESS_VAR_CONFIRM_NEW = 2, -1, OR -2, GO TO EMP08000.

• OTHERWISE, GO TO TIME_STAMP_EMP_ET.

EMP08000. What is your work address?

INTERVIEWER INSTRUCTIONS

• PROBE AND ENTER AS MUCH INFORMATION AS ADULT CAREGIVER KNOWS.

SOURCE

National Children’s Study, Vanguard Phase

(WORK_ADDRESS_1) __________________________________________________

ADDRESS 1 - STREET/PO BOX

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

(WORK_ADDRESS_2) ______________________________                                                                                                      

ADDRESS 2

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

(WORK_UNIT) ________________________                                                                                                      

UNIT

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

(WORK_CITY) ____________________                                                                                                      

CITY

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

(WORK_STATE) |___|___|                            

  STATE  

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

(WORK_ZIP) |___|___|___|___|___|-

 ZIP CODE  

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

(WORK_ZIP4) |___|___|___|___|

 ZIP+4 

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

(TIME_STAMP_EMP_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS

IF WORK_LAST_CONTACT OR WORK_CURRENTLY=2, -1, OR -2, GO TO TIME_STAMP_EDU_ST.

OCCUPATION - (6M, THEN ANNUAL AT 12 M)

(TIME_STAMP_OCC_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

OCC01000. Next, I’d like to ask some questions about the type of work you do. 

OCC02000/(WORK_GROUP). Which one of the following groups does your job fall into?

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
MANAGEMENT	1	TIME_STAMP_OCC_ET
BUSINESS AND FINANCIAL	2	TIME_STAMP_OCC_ET
COMPUTER AND MATHEMATICS	3	TIME_STAMP_OCC_ET
ARCHITECTURE AND ENGINEERING	4	TIME_STAMP_OCC_ET
LIFE,PHYSICAL AND SOCAIL SCIENCES	5	TIME_STAMP_OCC_ET
COMMUNITY AND SOCIAL SERVICES	6	TIME_STAMP_OCC_ET
LEGAL	7	TIME_STAMP_OCC_ET
EDUCATION, TRAINING, AND LIBRARY SCIENCE	8	TIME_STAMP_OCC_ET
ARTS, DESIGN, ENTERTAINMENT, SPORTS, AND MEDIA	9	TIME_STAMP_OCC_ET
HEALTHCARE PRACTITIONERS AND TECHNICIANS	10	TIME_STAMP_OCC_ET
HEALTH CARE SUPPORT	11	TIME_STAMP_OCC_ET
PROTECTIVE SERVICES	12	TIME_STAMP_OCC_ET
FOOD PREPARATION AND SERVING	13	TIME_STAMP_OCC_ET
BUILDING AND GROUNDS CLEANING AND MAINTENANCE	14	TIME_STAMP_OCC_ET
PERSONAL CARE AND SERVICE	15	TIME_STAMP_OCC_ET
SALES AND RELATED WORK	16	TIME_STAMP_OCC_ET
OFFICE AND ADMINISTRATIVE SUPPORT	17	TIME_STAMP_OCC_ET
FARMING , FISHING, AND FORESTRY	18	TIME_STAMP_OCC_ET
CONSTRUCTION AND EXTRACTION	19	TIME_STAMP_OCC_ET
INSTALLATION, MAINTENANCE, AND REPAIR	20	TIME_STAMP_OCC_ET
PRODUCTION	21	TIME_STAMP_OCC_ET
TRANSPORTATION AND MATERIAL MOVING	22	TIME_STAMP_OCC_ET
MILITARY SPECIFIC	23	TIME_STAMP_OCC_ET
OTHER OCCUPATION	-5
REFUSED	-1	TIME_STAMP_OCC_ET
DON'T KNOW	-2	TIME_STAMP_OCC_ET

SOURCE

Bureau of Labor Statistics, Standard Occupational Classification 2010 (modified)

OCC03000/(WORK_GROUP_OTH). SPECIFY: ____________________________

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

SOURCE

Bureau of Labor Statistics, Standard Occupational Classification 2010 (modified)

(TIME_STAMP_OCC_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

EDUCATION - (6M, THEN ANNUAL AT 12 M)

(TIME_STAMP_EDU_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

EDU01000. Next, I would like to ask you about your education.

EDU02000/(EDUC). What is the highest degree or level of school you have completed?

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
LESS THAN A HIGH SCHOOL DIPLOMA OR GED	1
HIGH SCHOOL DIPLOMA OR GED	2
SOME COLLEGE BUT NO DEGREE	3
ASSOCIATE DEGREE	4
BACHELOR’S DEGREE (FOR EXAMPLE, BA, BS)	5
POST-GRADUATE DEGREE (FOR EXAMPLE, MASTER'S OR DOCTORAL)	6
REFUSED	-1
DON’T KNOW	-2

SOURCE

American Community Survey (ACS) 2007 (modified)

EDU03000/(SCHOOL_CURRENTLY). Are you currently attending or enrolled in any courses from a school, college, or university?

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

SOURCE

Early Childhood Longitudinal Program, Kindergarten Cohort (ECLS-K)

EDU04000/(SCHOOL_FT). Are you currently taking courses full-time or part-time?

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

SOURCE

Early Childhood Longitudinal Program, Kindergarten Cohort (ECLS-K)

(TIME_STAMP_EDU_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 2 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.