27.5 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

30M Questionnaire – Adult, Phase 2g

OMB Specification

30M Questionnaire - Adult

Event Category:	Time-Based
Event:	30M
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:	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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30M Questionnaire - Adult

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

SOCIAL SUPPORT 3

MENTORING OR PARENT SUPPORT 9

PARENTAL STRESS 11

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30M 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.

SOCIAL SUPPORT

(TIME_STAMP_SS_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PARTICIPANT ID (P_ID) FOR ADULT CAREGIVER.

SS01000. Please tell me how much you agree or disagree with the following statements.

SS02000/(SPECIAL_PERSON_AROUND). There is a special person who is around when I am in need.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, SAY "Do you..." AT END OF QUESTION AND READ RESPONSE OPTIONS.

Label	Code	Go To
STRONGLY DISAGREE	1
DISAGREE	2
AGREE	3
STRONGLY AGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Multidimensional Scale of Perceived Social Support (MSPSS)

SS03000/(SPECIAL_PERSON_SHARE). There is a special person with whom I can share my joys and sorrows. 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, SAY "Do you..." AT END OF QUESTION AND READ RESPONSE OPTIONS.

Label	Code	Go To
STRONGLY DISAGREE	1
DISAGREE	2
AGREE	3
STRONGLY AGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Multidimensional Scale of Perceived Social Support (MSPSS)

SS04000/(FAMILY_HELP). My family really tries to help me.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, SAY "Do you..." AT END OF QUESTION AND READ RESPONSE OPTIONS.

Label	Code	Go To
STRONGLY DISAGREE	1
DISAGREE	2
AGREE	3
STRONGLY AGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Multidimensional Scale of Perceived Social Support (MSPSS)

SS05000/(EMOTIONAL_HELP). I get the emotional help I need from my family.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, SAY "Do you..." AT END OF QUESTION AND READ RESPONSE OPTIONS.

Label	Code	Go To
STRONGLY DISAGREE	1
DISAGREE	2
AGREE	3
STRONGLY AGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Multidimensional Scale of Perceived Social Support (MSPSS)

SS06000/(SPECIAL_PERSON_COMFORT). I have a special person who is a source of comfort to me. 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, SAY "Do you..." AT END OF QUESTION AND READ RESPONSE OPTIONS.

Label	Code	Go To
STRONGLY DISAGREE	1
DISAGREE	2
AGREE	3
STRONGLY AGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Multidimensional Scale of Perceived Social Support (MSPSS)

SS07000/(FRIENDS_HELP). My friends really try to help me.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, SAY "Do you..." AT END OF QUESTION AND READ RESPONSE OPTIONS.

Label	Code	Go To
STRONGLY DISAGREE	1
DISAGREE	2
AGREE	3
STRONGLY AGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Multidimensional Scale of Perceived Social Support (MSPSS)

SS08000/(FRIENDS_COUNT). I can count on my friends when things go wrong.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, SAY "Do you..." AT END OF QUESTION AND READ RESPONSE OPTIONS.

Label	Code	Go To
STRONGLY DISAGREE	1
DISAGREE	2
AGREE	3
STRONGLY AGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Multidimensional Scale of Perceived Social Support (MSPSS)

SS09000/(FAMILY_TALK). I can talk about my problems with my family.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, SAY "Do you..." AT END OF QUESTION AND READ RESPONSE OPTIONS.

Label	Code	Go To
STRONGLY DISAGREE	1
DISAGREE	2
AGREE	3
STRONGLY AGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Multidimensional Scale of Perceived Social Support (MSPSS)

SS10000/(FRIENDS_SHARE). I have friends with whom I can share joys and sorrows.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, SAY "Do you..." AT END OF QUESTION AND READ RESPONSE OPTIONS.

Label	Code	Go To
STRONGLY DISAGREE	1
DISAGREE	2
AGREE	3
STRONGLY AGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Multidimensional Scale of Perceived Social Support (MSPSS)

SS11000/(PERSON_CARING). There is a person in my life who cares about my feelings.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, SAY "Do you..." AT END OF QUESTION AND READ RESPONSE OPTIONS.

Label	Code	Go To
STRONGLY DISAGREE	1
DISAGREE	2
AGREE	3
STRONGLY AGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Multidimensional Scale of Perceived Social Support (MSPSS)

SS12000/(FAMILY_DECISIONS). My family is willing to help me make decisions.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, SAY "Do you..." AT END OF QUESTION AND READ RESPONSE OPTIONS.

Label	Code	Go To
STRONGLY DISAGREE	1
DISAGREE	2
AGREE	3
STRONGLY AGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Multidimensional Scale of Perceived Social Support (MSPSS)

SS13000/(FRIENDS_PROBLEMS). I can talk about my problems with my friends.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, SAY "Do you..." AT END OF QUESTION AND READ RESPONSE OPTIONS.

Label	Code	Go To
STRONGLY DISAGREE	1
DISAGREE	2
AGREE	3
STRONGLY AGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Multidimensional Scale of Perceived Social Support (MSPSS)

(TIME_STAMP_SS_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

MENTORING OR PARENT SUPPORT

(TIME_STAMP_MOP_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

MOP01000/(PARENT_SUPP_ANY). In the past 6 months have you or anyone in your household received any type of parenting support, training, or mentoring, such as from a nurse, a doctor, a neighbor, or your mother or mother-in-law?

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

SOURCE

National Children’s Study, Vanguard Phase

MOP02000/(PARENT_SUPP_CLASSES). Did you attend any parenting classes, workshops, or conferences? 

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

SOURCE

National Children’s Study, Vanguard Phase

MOP03000/(PARENT_SUPP_GROUP). Did you participate in a parent support group?

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

SOURCE

National Children’s Study, Vanguard Phase

MOP04000/(PARENT_SUPP_COUNSEL). Did you seek counseling from a mental health, healthcare, or other professional , such as a member of the clergy to discuss parenting issues?

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

SOURCE

National Children’s Study, Vanguard Phase

MOP05000/(PARENT_SUPP_BOOKS). Did you receive parenting information from books, magazines, or instructional videos or DVDs?

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

SOURCE

National Children’s Study, Vanguard Phase

MOP06000/(PARENT_SUPP_FRIEND). Do you have a friend, neighbor, or family member who you can go to for parenting advice or guidance?

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

SOURCE

National Children’s Study, Vanguard Phase

(TIME_STAMP_MOP_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PARENTAL STRESS

(TIME_STAMP_PS_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PS01000. Now I would like to ask you a few questions about your feelings and thoughts during the last month.  In each case, you will be asked to indicate how often you felt or thought a certain way

SOURCE

Cohen’s Perceived Stress Scale (PSS)

PS02000/(UPSET_UNEXPECTED). In the last month, how often have you been upset because of something that happened unexpectedly?

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
NEVER	1
ALMOST NEVER	2
SOMETIMES	3
FAIRLY OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cohen’s Perceived Stress Scale (PSS)

PS03000/(CONTROL_LIFE). In the last month, how often have you felt that you were unable to control the important things in your life?

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
NEVER	1
ALMOST NEVER	2
SOMETIMES	3
FAIRLY OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cohen’s Perceived Stress Scale (PSS)

PS04000/(STRESSED). In the last month, how often have you felt nervous and “stressed”?

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
NEVER	1
ALMOST NEVER	2
SOMETIMES	3
FAIRLY OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cohen’s Perceived Stress Scale (PSS)

PS05000/(HANDLE_PROBLEMS). In the last month, how often have you felt confident about your ability to handle your personal problems?

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
NEVER	1
ALMOST NEVER	2
SOMETIMES	3
FAIRLY OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cohen’s Perceived Stress Scale (PSS)

PS06000/(GOING_YOUR_WAY). In the last month, how often have you felt that things were going your way?

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
NEVER	1
ALMOST NEVER	2
SOMETIMES	3
FAIRLY OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cohen’s Perceived Stress Scale (PSS)

PS07000/(NOT_COPE). In the last month, how often have you found that you could not cope with all the things that you had to do?

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
NEVER	1
ALMOST NEVER	2
SOMETIMES	3
FAIRLY OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cohen’s Perceived Stress Scale (PSS)

PS08000/(CONTROL_IRRITATIONS). In the last month, how often have you been able to control irritations in your life?

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
NEVER	1
ALMOST NEVER	2
SOMETIMES	3
FAIRLY OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cohen’s Perceived Stress Scale (PSS)

PS09000/(TOP_THINGS). In the last month, how often have you felt that you were on top of things?

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
NEVER	1
ALMOST NEVER	2
SOMETIMES	3
FAIRLY OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cohen’s Perceived Stress Scale (PSS)

PS10000/(OUTSIDE_CONTROL). In the last month, how often have you been angered because of things that were outside of your control?

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
NEVER	1
ALMOST NEVER	2
SOMETIMES	3
FAIRLY OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cohen’s Perceived Stress Scale (PSS)

PS11000/(DIFFICULTIES_OVERCOME). In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

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
NEVER	1
ALMOST NEVER	2
SOMETIMES	3
FAIRLY OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cohen’s Perceived Stress Scale (PSS)

(TIME_STAMP_PS_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.