Form 31.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

PPG Follow-Up Questionnaire, Phase 2g

OMB Specification

PPG Follow-Up Questionnaire

Event Category:	Trigger-Based
Event:	PPG Follow-Up
Administration:	N/A
Instrument Target:	Pre-Pregnant Woman
Instrument Respondent:	Pre-Pregnant Woman
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:	15 minutes
Multiple Child/Sibling Consideration:	Per Event
Special Considerations:	N/A
Version:	2.0
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.
ASSUME PRE-PREGNANCY VISIT WAS ADMINISTERED UNLESS NOTED

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PPG Follow-Up Questionnaire

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

INITIAL CONVERSATION WITH OUTGOING CALLER 3

PREGNANCY SCREENER 4

TRACING QUESTIONS 11

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PPG Follow-Up Questionnaire

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.

INITIAL CONVERSATION WITH OUTGOING CALLER

(TIME_STAMP_ICW_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD RESPONDENT ID (R_P_ID) AND PARTICIPANT ID (P_ID) FOR BIOLOGICAL MOTHER.

ICW01000. Hello. My name is [INTERVIEWER FIRST AND LAST NAME] from the National Children’s Study. It’s been a few months since we have spoken with you.

                                                 

We’re following up with women of childbearing age and our first questions are always about pregnancy. We first want to know…

(TIME_STAMP_ICW_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PREGNANCY SCREENER

(TIME_STAMP_PS_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PS01000/(PREGNANT). Are you pregnant now?

INTERVIEWER INSTRUCTIONS

• IF THE RESPONDENT SAYS "NO" AND DOES NOT PROVIDE ANY ADDITIONAL INFORMATION, SELECT "NO, NO ADDITIONAL INFORMATION PROVIDED" 

• IF PARTICIPANT SAYS "NO" AND VOLUNTEERS ADDITIONAL INFORMATION, SELECT THE "NO" OPTION THAT BEST MATCHES THAT INFORMATION.

• IF PARTICIPANT STATES THAT SHE IS UNSURE, BUT MIGHT BE PREGNANT, ENTER "YES" EVEN IF UNSURE.

Label	Code	Go To
YES	1	PS03000
NO (NO ADDITIONAL INFORMATION PROVIDED)	2
NO, RECENTLY LOST PREGNANCY (MISCARRIAGE/ABORTION)	3
NO, RECENTLY GAVE BIRTH	4
NO, UNABLE TO HAVE CHILDREN (HYSTERECTOMY, TUBAL LIGATION)	5	MED_UNABLE
REFUSED	-1
DON’T KNOW	-2

SOURCE

Pregnancy Risk Assessment & Monitoring System (PRAMS) (modified)

PROGRAMMER INSTRUCTIONS

• IF PREGNANT = 1; SET PPG_FIRST = 1 (PREGNANT AND ELIGIBLE)

• IF PREGNANT = 3; SET PPG_FIRST = 3 (HIGH PROBABILITY – RECENT LOSS)

• IF PREGNANT = 4; SET PPG_FIRST = 4 (OTHER PROBABILITY – NOT PREGNANT AND NOT TRYING)

PS02000/(TRYING). Are you currently trying to become pregnant?

Label	Code	Go To
YES	1	PS11000
NO	2	MED_UNABLE
RECENTLY LOST PREGNANCY (MISCARRIAGE OR ABORTION)	3	PS12000
RECENTLY GAVE BIRTH	4	PS13000
UNABLE TO HAVE CHILDREN (E.G., HYSTERECTOMY, TUBAL LIGATION)	5	MED_UNABLE
REFUSED	-1	MED_UNABLE
DON’T KNOW	-2	MED_UNABLE

SOURCE

National Survey of Family Growth

PROGRAMMER INSTRUCTIONS

• IF TRYING = 1; SET PPG_FIRST = 2 (HIGH PROBABILITY - TRYING TO CONCEIVE).

• IF TRYING = 3; SET PPG_FIRST = 3 (HIGH PROBABILITY-RECENT LOSS).

• IF TRYING = 4; SET PPG_FIRST = 4 (OTHER PROBABILITY – NOT PREGNANT AND NOT TRYING).

PS03000. Congratulations. When is your baby due?

SOURCE

Pregnancy, Infection, & Nutrition Study

(PPG_DUE_DATE_MM) MONTH:

|_____|_____|

   M       M

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

(PPG_DUE_DATE_DD) DAY:

|_____|_____|

   D       D

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

(PPG_DUE_DATE_YYYY) YEAR:

|_____|_____|_____|_____|

   Y        Y        Y       Y

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

INTERVIEWER INSTRUCTIONS

• ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR.

PROGRAMMER INSTRUCTIONS

• CHECK REPORTED DUE DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE HARD EDIT MESSAGE:
  
  

• IF DATE IS MORE THAN 9 MONTHS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 9 MONTHS FROM TODAY. RE-ENTER DATE.”

• IF DATE IS MORE THAN 1 MONTH BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT OCCURRED MORE THAN A MONTH BEFORE TODAY. RE-ENTER DATE.”

• IF PPG_DUE_DATE_MM, PPG_DUE_DATE_DD, AND PPG_DUE_DATE_YYYY BETWEEN 1 MONTH AND 9 MONTHS FROM PRESENT DATE, SET PPG_DUE_DATE_1 = YYYYMMDD AS REPORTED;  SET PPG_FIRST = 1; GO TO PS10000

• IF PPG_DUE_DATE_MM, PPG_DUE_DATE_DD, AND PPG_DUE_DATE_YYYY IS NOT BETWEEN 1 MONTH AND 9 MONTHS FROM PRESENT DATE OR = -1 OR -2, GO TO PS04000.

PS04000. What was the first day of your last menstrual period?

SOURCE

National Health & Nutrition Examination Survery (NHANES)

(DATE_PERIOD_MM) MONTH:

|_____|_____|

    M       M

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

(DATE_PERIOD_DD) DAY:

|_____|_____|

    D       D

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

(DATE_PERIOD_YYYY) YEAR:

|_____|_____|_____|_____|

     Y      Y        Y       Y

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

INTERVIEWER INSTRUCTIONS

• ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR.

• IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE. 

PROGRAMMER INSTRUCTIONS

• CHECK REPORTED MENSTRUAL DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE HARD EDIT MESSAGE:
  
  
  

• IF DATE > 10 MONTHS BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 10 MONTHS BEFORE TODAY.  CONFIRM DATE.”

• IF DATE IS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT HAS NOT OCCURRED YET.  RE-ENTER DATE.”

• IF DATE_PERIOD_MM, DATE_PERIOD_DD, AND DATE_PERIOD_YYYY IS WITHIN THE LAST 10 MONTHS BEFORE CURRENT DATE, CALCULATE DUE DATE FROM THE FIRST DATE OF LAST MENSTRUAL PERIOD AND SET PPG_DUE_DATE_1 YYYYMMDD = DATE_PERIOD_MM, DATE_PERIOD_DD, AND DATE_PERIOD_YYYY + 280 DAYS; GO TO PS10000; SET PPG_FIRST = 1

• IF DATE_PERIOD_MM, DATE_PERIOD_DD, AND DATE_PERIOD_YYYY = -1 OR -2, GO TO WEEKS_PREG.

PS05000/(WEEKS_PREG). How many weeks pregnant are you now? If you’re not sure, please make your best guess.

 

|____|____|

NUMBER OF WEEKS 

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

INTERVIEWER INSTRUCTIONS

• IF RESPONSE IS EITHER LESS THAN 1 WEEK OR GREATER THAN 43 WEEKS, ASK QUESTION AGAIN AND PROBE FOR RESPONSE WITHIN THOSE VALUES.

PROGRAMMER INSTRUCTIONS

• REJECT RESPONSES THAT ARE EITHER < 1 WEEK OR > 43 WEEKS.

• IF RESPONSE BETWEEN 1 AND 43, CALCULATE PPG_DUE_DATE_1 YYYYMMDD = TODAY’S DATE + 280 DAYS – WEEKS_PREG *7; SET PPG_FIRST = 1, AND GO TO PS10000.

• IF WEEKS PREG = -1 OR -2, GO TO MONTH_PREG.

PS06000/(MONTH_PREG). About how many months pregnant are you? If you’re not sure, please make your best guess. 

 

|___|___|

NUMBER OF MONTHS

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

SOURCE

National Children's Study, Legacy Phase (PregScreener)

INTERVIEWER INSTRUCTIONS

• IF RESPONSE WAS < 1 MONTH OR > 9 MONTHS, ASK QUESTION AGAIN AND PROBE FOR RESPONSE WITHIN THOSE VALUES.

PROGRAMMER INSTRUCTIONS

• IF RESPONSE >1 AND < 10 MONTHS IS PROVIDED, GO TO [APPROPRIATE END SCRIPT].

• REJECT RESPONSES THAT ARE EITHER < 1 MONTH OR GREATER THAN 9 MONTHS

• IF RESPONSE BETWEEN 1 AND 10, CALCULATE DUE DATE FROM NUMBER OF MONTHS PREGNANT WHERE PPG_DUE_DATE_1 YYYYMMDD = TODAY’S DATE + 280 DAYS – MONTH_PREG*30 -15; GO TO STATUS; SET PPG_FIRST = 1, AND GO TO PS10000.

• IF MONTH_PREG = -1 OR -2, GO TO TRIMESTER.

PS07000/(TRIMESTER). Are you currently in your First, Second, or Third trimester?

Label	Code	Go To
1ST (1 TO 3 MONTHS PREGNANT)	1	PS10000
2ND (4 TO 6 MONTHS PREGNANT)	2	PS10000
3RD (7 TO 9 MONTHS PREGNANT)	3	PS10000
REFUSED	-1	PS10000
DON’T KNOW	-2	PS10000

SOURCE

National Children’s Study, Legacy Phase (PregScreener)

PROGRAMMER INSTRUCTIONS

• CALCULATE DUE DATE FROM REPORTED TRIMESTER
  
  

• IF TRIMESTER = 1: PPG_DUE_DATE_1 = TODAY’S DATE + (280 DAYS – 46 DAYS).

• IF TRIMESTER = 2: SET PPG_DUE_DATE_1 = TODAY’S DATE +(280 DAYS – 140 DAYS).

• IF TRIMESTER = 3: SET PPG_DUE_DATE_1 = TODAY’S DATE + (280 DAYS – 235 DAYS).

• IF TRIMESTER = -1 OR -2: SET PPG_DUE_DATE_1 = TODAY’S DATE + (280 DAYS – 140 DAYS).

• SET PPG_DUE_DATE_1 = YYYYMMDD AS CALCULATED.

• SET PPG_FIRST = 1.

PS08000/(MED_UNABLE). Do any of the following apply to you? Have you had a hysterectomy; both ovaries removed; your tubes tied; gone through menopause; or any other medical reason why you cannot become pregnant?

Label	Code	Go To
YES	1	PS14000
NO	2	PS13000
REFUSED	-1	PS13000
DON'T KNOW	-2	PS13000

SOURCE

National Children’s Study, Legacy Phase (PregScreener) (modified)

PROGRAMMER INSTRUCTIONS

• IF MED_UNABLE = 1; SET PPG_FIRST = 5 (INELIGIBLE -- UNABLE TO CONCEIVE)

• IF MED_UNABLE = 2, -1, OR -2; SET PPG_FIRST= 4 (OTHER PROBABILITY – NOT PREGNANT AND NOT TRYING)

PS10000. Thank you for taking time to answer these questions. Congratulations again on your pregnancy.  We would like to set up a time to talk about the National Children’s Study.  If you have any other questions before that time, please call {XXX-XXX-XXXX}, which is {LOCAL ROC}’s local toll free National Children’s Study office.

PROGRAMMER INSTRUCTIONS

• PRELOAD NAME AND TOLL-FREE PHONE NUMBER OF LOCAL ROC AND DISPLAY WITHIN ABOVE SCRIPT.

• GO TO PS_TIME_STAMP_ET.

PS11000. Thank you for taking time to answer these questions.  You are able to take part in this important study because you are currently trying to become pregnant.  We would like to set up a time to talk about the National Children’s Study.  If you have any other questions or find out that you’re pregnant before our next call, please call {XXX-XXX-XXXX}, which is {LOCAL ROC}’s local toll free National Children’s Study office.

PROGRAMMER INSTRUCTIONS

• PRELOAD NAME AND TOLL-FREE PHONE NUMBER OF LOCAL ROC AND DISPLAY WITHIN ABOVE SCRIPT.

• GO TO PS_TIME_STAMP_ET.

PS12000. I’m so sorry to hear that you’ve lost your baby.  I know this can be a hard time.  Because your address is in the study area, we may be back in touch at a later time to update your household information.  If you have any other questions before that time, please call {XXX-XXX-XXXX}, which is {LOCAL ROC}’s local toll free National Children’s Study office.  Thank you for taking time to answer these questions.

PROGRAMMER INSTRUCTIONS

• PRELOAD AND DISPLAY NAME AND TOLLFREE PHONE NUMBER OF LOCAL ROC;

• GO TO TIME_STAMP_PS_ET.

PS13000. Thank you for taking time to answer these questions. We will call you again in a couple of months to ask a few quick questions.  If you have any other questions before that time, please call {XXX-XXX-XXXX}, which is {LOCAL ROC}’s local toll free National Children’s Study office.

PROGRAMMER INSTRUCTIONS

• PRELOAD NAME AND TOLL-FREE PHONE NUMBER OF LOCAL ROC AND DISPLAY WITHIN ABOVE SCRIPT.

• GO TO PS_TIME_STAMP_ET.

PS14000. Thank you for taking time to answer these questions.  Based on what you’ve told me, we will not ask you to take part in the study at this time. We may be back in touch at a later time to update your household information.  If you have any other questions before that time, please call {XXX-XXX-XXXX}, which is {LOCAL ROC}’s local toll free National Children’s Study office.

PROGRAMMER INSTRUCTIONS

• PRELOAD NAME AND TOLL-FREE PHONE NUMBER OF LOCAL ROC AND DISPLAY WITHIN ABOVE SCRIPT.

• GO TO TIME_STAMP_PS_ET.

(TIME_STAMP_PS_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

TRACING QUESTIONS

(TIME_STAMP_TQ_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• IF MODE = CATI, GO TO BST_NMBR.

• OTHERWISE, GO TO ​TQ04000.

TQ01000/(BST_NMBR). Just to confirm, is this the best phone number to reach you?

Label	Code	Go To
YES	1	TQ04000
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Vanguard Phase (P1, T1 Mother)

TQ02000/(PHONE_NBR). What is the best phone number to reach you?

 

 

|___|___|___| - |___|___|___| - |___|___|___|___| 

INTERVIEWER INSTRUCTIONS

• ENTER PHONE NUMBER AND CONFIRM.

Label	Code	Go To
RESPONDENT HAS NO TELEPHONE	-7
REFUSED	-1
DON’T KNOW	-2

SOURCE

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

TQ03000/(PHONE_TYPE). Is that your home, work, cell, or another phone number?

INTERVIEWER INSTRUCTIONS

• CONFIRM IF KNOWN.

Label	Code	Go To
HOME	1
WORK	2
CELL	3
FRIEND/RELATIVE	4
OTHER	-5
REFUSED	-1
DON’T KNOW	-2

SOURCE

National Children’s Study, Legacy Phase (PregScreener)

TQ04000. Thank you taking the time to answer our questions. 

(TIME_STAMP_TQ_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 15 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.