39.3 Survey

Continuation of National Children's Study Vanguard (Pilot) Study Data Collection: Study Visits through 60-Months

ParticipantInfoUpdateMoneyLaterSAQ

Participant Information Update - Incentive Substudy

OMB: 0925-0593

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OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Participant Information Update (SAQ), Phase 2g

OMB Specification


Participant Information Update Monetary Incentive Later SAQ


Event Category:

Time-Based

Event:

24M, 30M, 36M, 42M, 48M, 54M, 60M

Administration:

N/A

Instrument Target:

Primary Caregiver

Instrument Respondent:

Primary Caregiver

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:

5 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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Participant Information Update Monetary Incentive Later SAQ



TABLE OF CONTENTS





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Participant Information Update Monetary Incentive Later 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.





PARTICIPANT INFORMATION UPDATE


PIU01000. Thank you for participating in the National Children’s Study.  To make sure we can reach you for your next Study visit please answer a few questions about how to best find you.  The survey should only take about 5 minutes to complete.  We have included a postage-paid envelope for you to mail it back to us. 

 

Your participation in the Study is very important to us. As a token of our appreciation for your involvement, we will send you $10 when we receive your completed survey.

 

There are no right or wrong answers. You can skip over any question. We will keep everything that you tell us confidential.


PIU02000. What is your first and last name?


SOURCE

National Children's Study, Legacy Phase (Modified)


(CHILD2_AGE) Child's Age: l___l___l months


(R_LNAME) Last Name: ____________________________________________


PIU03000. What is the first name and age of the child enrolled in the National Children’s Study?


SOURCE

New


(CHILD1_FNAME) Child's First Name: ____________________________________________


(CHILD1_AGE) Child's Age: l___l___l months


PIU03100. If you have more than one child enrolled in the Study, please provide their names and ages below.


SOURCE

New


(CHILD2_FNAME) Child's First Name: ____________________________________________


(CHILD3_FNAME) Child's First Name: ____________________________________________


(CHILD3_AGE) Child's Age: l___l___l months


(CHILD4_FNAME) Child's First Name: ____________________________________________


(CHILD4_AGE) Child's Age:  l___l___l months


PIU04000/(R_REL_CHILD). What is your relationship to the child?  Are you his/her…


Label

Code

Go To

Mother/Father

1


Aunt/Uncle

2


Grandmother/Grandfather

3


Other Relative

4


Other Primary Caregiver

5


Other

-5



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


PIU04100/(R_REL_CHILD_OTH). Please specify: ________________________________________


SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


PIU05000/(CELL_NUM). What is your cell phone number?

 

_____________________________________________


Label

Code

Go To

Do not have a cell phone

-1



SOURCE

National Children's Study, Legacy Phase (6M Mother)


PIU06000/(HOME_NUM). What is your home phone number?

 

__________________________________________


Label

Code

Go To

Do not have a home phone/land line

-1



SOURCE

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


PIU07000/(WORK_NUM). What is your office phone number?

 

____________________________________________


Label

Code

Go To

Do not have an office/work phone

-1



SOURCE

New


PIU08000/(EMAIL_ADD). What is your email address?

 

______________________________________


Label

Code

Go To

Do not have an email address

-1



SOURCE

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


PIU09000/(BEST_CONTACT). What is the best way to get in touch with you?


Label

Code

Go To

Cell phone

1


Home phone

2


Office phone

3


Email

4


Text Message

5


Social Media (such as Facebook)

6


Other

-5



SOURCE

New


PIU09100/(BEST_CONTACT_FB_OTH). Please specify: ________________________________________


SOURCE

New


PIU09200/(BEST_CONTACT_OTH). Please specify: ___________________________________________


SOURCE

New


PIU10000/(PLAN_MOVE). Do you plan on moving from your current address in the next few months?


Label

Code

Go To

Yes

1


No

2

ADULT_HH


SOURCE

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


PIU11000. What is the address of your new home?        


Label

Code

Go To

Does not know address of new home

-2

ADULT_HH


SOURCE

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


(NEW_HOME_ST_NUM) Street Number:   _____________________


(NEW_HOME_ST_NAME) Street Name:  _____________________________________________


(NEW_HOME_UNIT)  Apartment/Unit Number:  ________________   


(NEW_HOME_CITY) City:  _____________________________________


(NEW_HOME_STATE) State:  l___l___l


(NEW_HOME_ZIP) Zip code:   l___l___l___l___l___l


(NEW_HOME_ZIP4_1)  

- l___l___l___l___l

           +4


PIU12000/(ADULT_HH). Is there another adult who lives with you in your household? 


Label

Code

Go To

Yes

1


No

2

OTHER_CONTACT


SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


PIU13000. What is his/her first and last name?  If you live with more than one other adult, please choose the one who will always know how to get in touch with you. 


SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


(PERS_FNAME) First Name: _____________________________________


(PERS_LNAME) Last Name:  _________________________________________________


PIU14000/(PERS_AGE). What is his/her age?

 

l___l___l

Age in years  


Label

Code

Go To

Don't Know

-1



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


PIU15000/(PERS_REL). What is your relationship to this adult?  Are you his/her…


Label

Code

Go To

Biological mother

2


Biological father

4


Spouse

6


Partner/Significant Other

7


Child

8


Sibling

9


Grandparent

10


Other Relative

11


Friend

12


Co-Worker

14


Caregiver

15


Teacher

16


Aunt

19


Uncle

20


Cousin

21


Other Non-Relative

22


Adoptive Mother

23


Adoptive Father

24


Social Mother

25


Social Father

26


Step Mother

27


Step Father

28


Step Brother

29


Step Sister

30


Adoptive Brother

31


Adoptive Sister

32


Grandmother

33


Grandfather

34



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


PIU16000/(PERS_CELL_NUM). What is his/her cell phone number?

 

________________________________________


Label

Code

Go To

Does not have a cell phone

-1



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


PIU17000/(PERS_EMAIL). What is his/her email address?

 

________________________________________________


Label

Code

Go To

Does not have an email address

-1



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


PIU18000/(OTHER_CONTACT). Is there a relative or friend, who does not live in your household, who will always know how to reach you?  We will only contact this person if we cannot find you to schedule your next Study Visit.  


Label

Code

Go To

Yes

1


No

2

PIU25000


SOURCE

New


PIU19000. What is his/her first and last name? 


SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


(OTHER_CONT_FNAME)  First Name: ___________________________________________


(OTHER_CONT_LNAME) Last Name:___________________________________________


PIU20000/(OTHER_CONT_AGE). What is his/her age? 



 

l___l___l

Age in years                                                                                                  


Label

Code

Go To

Don't Know

-1



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


PIU21000/(OTHER_CONT_REL). What is your relationship to this person?  Are you his/her… 


Label

Code

Go To

Biological Mother

2


Biological Father

4


Spouse

6


Partner/Significant Other

7


Child

8


Sibling

9


Grandparent

10


Other Relative

11


Friend

12


Co-Worker

14


Caregiver

15


Teacher

16


Aunt

19


Uncle

20


Cousin

21


Other Non-Relative

22


Adoptive Mother

23


Adoptive Father

24


Social Mother

25


Social Father

26


Step Mother

27


Step Father

28


Step Brother

29


Step Sister

30


Adoptive Brother

31


Adoptive Sister

32


Grandmother

33


Grandfather

34



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


PIU22000/(OTHER_CONT_CELL). What is his/her cell phone number?

 

________________________________________


Label

Code

Go To

Does not have a cell phone

-1



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


PIU23000/(OTHER_CONT_HOME). What is his/her home phone number?

 

____________________________________________


Label

Code

Go To

Does not have a home phone/land line

-1



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


PIU24000/(OTHER_CONT_EMAIL). What is his/her email address?

 

___________________________________________


Label

Code

Go To

Does not have an email address

-1



SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)


PIU25000. 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. 

 

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

  • INSERT 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 5 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.

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