45.3 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Retrospective Pregnancy - Birth Cohort (CASI), Phase 2g

OMB Specification

Retrospective Pregnancy – Birth Cohort (CASI)

Event Category:	Time-Based
Event:	Birth, or 3M, or 6M
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, CAI
OMB Approved Modes:	In-Person, CAI; Web-Based, CAI
Estimated Administration Time:	11 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.
**Administer at Birth. If it was not administered at birth, then administered at 3M. If not administered at Birth & 3M, then administer at 6M.

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Retrospective Pregnancy – Birth Cohort (CASI)

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

TRAINING SCREENS 3

REPRODUCTIVE HISTORY 7

DRUGS, ALCOHOL AND CIGARETTE USE 14

FAMILY INCOME 22

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Retrospective Pregnancy – Birth Cohort (CASI)

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.

TRAINING SCREENS

(TIME_STAMP_TS_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PARTICIPANT ID (P_ID) OR RESPONDENT ID (R_P_ID) FOR PARENT/CAREGIVER.

• PRELOAD PARTICIPANT/RESPONDENT AGE

• FOR THIS SECTION, ALLOW PARTICIPANT/RESPONDENT TO PROGRESS THROUGH THE SECTION BY SELECTING “NEXT” EVEN IF THEY HAVE NOT SELECTED A RESPONSE TO THE QUESTION. 

 

 

CASI FORMATTING INSTRUCTIONS

• DISPLAY NCS CASI BANNER THROUGHOUT QUESTIONNAIRE.

• CONFIGURE QUESTIONNAIRE BASED ON CASI BEST PRACTICES AND GUIDELINES.

• DISPLAY ONE QUESTION/ITEM PER SCREEN THROUGHOUT.

• “NEXT” BUTTONS SHOULD BEGIN ON THE FIRST SCREEN AND SHOULD BE DISPLAYED AT THE BOTTOM RIGHTHAND CORNER OF THE SCREEN.

• “BACK” BUTTONS SHOULD BEGIN ON THE SECOND SCREEN AND SHOULD BE DISPLAYED AT THE BOTTOM LEFTHAND CORNER OF THE SCREEN.

• DISPLAY “LANGUAGE” AND “HELP” BUTTONS AT THE TOP OF EACH SCREEN.

• RESPONSE OPTIONS SHOULD BE DISPLAYED WITHIN THE ANSWER FIELD AND SHADED TO DISTINGUISH FROM OTHER FIELDS.

• ALL PARTICIPANT INSTRUCTIONS SHOULD BE DISPLAYED IN RED TEXT BETWEEN THE QUESTION FIELD AND ANSWER FIELD.

• USE FONT CALIBRI, SIZE 18, BOLD FOR ALL QUESTIONS, INSTRUCTIONS, AND ANSWERS

• EACH SCREEN SHOULD CONTAIN AT MINIMUM A QUESTION BOX AND AN ANSWER BOXES.  IF INDICATED, PLACE AN INSTRUCTIONS BOX BETWEEN THE QUESTION BOX AND ANSWER BOX.

• ANSWER BOXES SHOULD BE SHADED LIGHT PURPLE.

• “BACK” AND “NEXT” BUTTONS SHOULD HAVE A BLACK LINE BORDER AND BE LOCATED AT THE BOTTOM LEFT AND BOTTOM RIGHT (RESPECTIVELY) OF THE SCREEN.

• “HELP” BUTTON WITH BLACK LINE BORDER LOCATED AT TOP LEFT OF SCREEN.

• LANGUAGE TOGGLE “ENGLISH/ESPANOL” WITH BLACK LINE BORDER LOCATED AT TOP RIGHT OF SCREEN.

• EACH NEW ITEM NUMBER TRIGGERS A NEW SCREEN

TS01000/(TRAINING_1). Now we want to teach you how to use this computer.  The interviewer will be here to answer any questions you have.  The computer will ask you a series of questions.  Some people may consider some of the following questions to be personal. You will be able to answer these on your own in complete privacy.  Like all other questions that you have answered today, your responses will be kept confidential.  If you are not sure about an answer, choose the best option.  Answer each question by selecting your response on the screen.  After you answer a question, go to the next question by touching the button marked NEXT in the lower right-hand corner of the screen.  Try touching that button now to move on.

PARTICIPANT INSTRUCTIONS

• Select/touch the box beside your answer.

• Then select/touch the NEXT button to go to the next page.

• Select/touch the BACK button to go back to the previous page.

• Press the HELP button to get helpful tips for completing the questions.

SOURCE

New

TS02000/(TRAINING_2). If you want to go back and change your answer to an earlier question, touch the button marked BACK in the lower left-hand corner of the screen.  Touch the BACK button now to return to the last screen.  Then touch the NEXT button to return to this screen and again to move on.

SOURCE

New

TS03000/(TRAINING_3). These first questions are practice questions and are not part of the study.  These practice questions will help you learn how to use the computer. 

 

If you want to change your answer to a multiple choice question, you may simply select another option.

 

What is your favorite season of the year?

Label	Code	Go To
Spring	1
Summer	2
Fall	3
Winter	4

SOURCE

New

TS04000/(TRAINING_4). Another type of question requires a number response. Answer by pressing the number buttons on the keypad.

 

If a question asks you to enter a number on the keypad, and you would like to change your answer after you have already entered a number, you can select the “CLEAR” button to erase the answer and enter your new response. 

 

Answer the following question.  Then try selecting “CLEAR” and entering your answer again.

 

 

How many hours did you sleep last night?

 

|___|___|

HOURS

SOURCE

New

TS05000/(TRAINING_5). If you skip a question for any reason, the computer will say you didn't answer the question and will ask whether you really meant to answer, would rather not answer, or don't know the answer.  If you choose, "I really meant to answer," the screen will go back so you can answer the question.” 

PROGRAMMER INSTRUCTIONS

• INSERT SCREENSHOT OF REDO SCREEN

SOURCE

New

TS06000/(TRAINING_6). Sometimes you will be asked a question that refers to a particular time period such as the last 30 days.  Be sure to think only about the specific time period asked in that question.  

SOURCE

New

TS07000/(TRAINING_7). If you answer a question with a response that is not valid, a message will appear on the screen.  For example, the question below asks about your activities during the last 90 days.  If your response was greater than 90, the following message would appear. 

 

On how many days in the past 90 did you ride the bus?

 

|___|___|

NUMBER OF DAYS

PROGRAMMER INSTRUCTIONS

• INSERT SCREENSHOT OF HARD EDIT: The number of days must be between 0 and 90.  Please enter the number of days.

 

SOURCE

New

TS08000/(TRAINING_9). If there is anything that you do not understand, or if you have any problems during the interview, please ask the interviewer to help you.  If you are ready to begin the interview, press the NEXT button now.

SOURCE

New

(TIME_STAMP_TS_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

REPRODUCTIVE HISTORY

(TIME_STAMP_RH_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

 

INSTRUCTIONS FOR HARD EDITS

• HARD EDITS SHOULD BE PROGRAMMED AS POP-UP SCREENS.

RH00100. DISPLAY IN QUESTION FIELD: You did not select an answer to the question on the previous page {INSERT QUESTION BOX TEXT FROM PREVIOUS QUESTION}.  Would you like to go back to the previous page and answer the question?

PROGRAMMER INSTRUCTIONS

INSTRUCTIONS FOR REDO/RF/DK SCREENS:

• CASI VARIABLE ANSWER OPTIONS SHOWN TO THE PARTICIPANT DO NOT INCLUDE “REFUSED” OR “DON’T KNOW.”

• IF A PARTICIPANT ATTEMPTS TO MOVE ON TO THE NEXT ITEM (BY SELECTING THE “NEXT” BUTTON AT THE BOTTOM RIGHT OF SCREEN) WITHOUT ENTERING A VALID ANSWER, DISPLAY CASI REDO SCREEN.

• CASI REDO SCREENS FOLLOW THE FOLLOWING FORMAT:

Label	Code	Go To
Yes, I would like to go back and answer the question	1
No, I do not want to answer that question	2
No, I do not know the answer to that question	3

PROGRAMMER INSTRUCTIONS

• IF = 1, ROUTE RESPONDENT BACK TO PREVIOUS SCREEN.

• IF = 2, SET ANSWER TO PREVIOUS QUESTION AS = -1 (“REFUSED”).

• IF = 3, SET ANSWER TO PREVIOUS QUESTION AS = -2 (“DON’T KNOW”).

INTERVIEWER INSTRUCTIONS

• LAUNCH CASI MODULE AND THEN SET UP PARTICIPANT SO THEY ARE SITTING DOWN IN FRONT OF THE COMPUTER SCREEN.

• AFTER CASI HAS STARTED, TURN THE TABLET TOWARDS THE PARTICIPANT AND ASSIST WITH PRACTICE QUESTIONS IF NEEDED.

• EXPLAIN CASI SAQ TO PARTICIPANT AND DEMONSTRATE HOW PARTICIPANT CAN RESPOND TO ITEMS USING THE COMPUTER.

RH01000/(SETUP_INT). These next questions may be somewhat sensitive.  Like all of the other questions that you have answered today, your response will be kept confidential.  If you are not sure about an answer, please provide your best estimate.  If you would like you can listen to the questions using headphones and enter your information directly into the computer.  You can also listen to the questions without headphones or read the questions without sound.

Which would you prefer?  Would you like to:

Label	Code	Go To
Listen to the questions on your own using headphones	1
Listen to the questions on your own without headphones	2
Read the questions on your own without sound	3

SOURCE

National Children’s Study, Legacy Phase (T1) 

PROGRAMMER INSTRUCTIONS

• IF SETUP_INT = 1 OR 2, PLAY APPROPRIATE .WAV FILES FOR THE REMAINING QUESTIONS.

RH02000/(TRY_PREG). I’ll begin by asking about your most recent pregnancy.  Thinking about your most recent pregnancy, were you trying to become pregnant?

Label	Code	Go To
Yes	1
No	2	PREVENT_PREG
REFUSED	-1	PREVENT_PREG
DON'T KNOW	-2	PREVENT_PREG

SOURCE

National Survey of Family Growth

Legacy: National Children’s Study, Legacy Phase (T1) 

Current: National Children’s Study Vanguard Phase (PV1 SAQ) 

RH03000/(MONTHS_TRY_PREG). For about how many months were you trying to become pregnant? 

 

|___|___|

MONTHS

PARTICIPANT INSTRUCTIONS

• If 1 month or less, enter 1.

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

SOURCE

Pregnancy Risk Assessment Monitoring System (PRAMS) (modified)

Legacy: National Children’s Study, Legacy Phase (T1) 

Current: National Children’s Study Vanguard Phase (PV1 SAQ) 

RH04000/(PREVENT_PREG). When you became pregnant, were you doing something to prevent pregnancy when you became pregnant?

Label	Code	Go To
Yes	1
No	2	WANT_BABY
REFUSED	-1	WANT_BABY
DON'T KNOW	-2	WANT_BABY

SOURCE

National Children’s Study, Legacy Phase (T1) (modified)

RH05000/(PREG_BC_TYPE). When you became pregnant, which of hte following methods were you using to prevent pregnancy?  You may select more than one answer.

Label	Code	Go To
Birth control pills	1
Condoms	2
Depo-Provera/shots/injections	3
Natural family planning	4
Diaphragm/cap/shield	5
Foam/jelly/cream/insert	6
Female condom/vaginal pouch	7
Patch/Norplant/Nuva ring	8
TODAY® sponge	9
IUD/Coil/Loop	10
Plan B/“Morning After” pill	11
Withdrawal/pulling out	12
Some other method	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Legacy Phase (T1) (modified)

PROGRAMMER INSTRUCTIONS

• IF PREG_BC_TYPE = -5, OR ANY COMBINATION OF 1 THROUGH 12 AND -5, GO TO PREG_BC_TYPE_OTH

• IF PREG_BC_TYPE = -1 OR -2, DO NOT ALLOW SELECTION OF ANY OTHER RESPONSE AND GO TO WANT_BABY.

• OTHERWISE, GO TO WANT_BABY.

RH06000/(PREG_BC_TYPE_OTH). Specify other method: _______________________________________

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

SOURCE

National Children’s Study, Legacy Phase (T1) (modified)

RH07000/(WANT_BABY). Many women have mixed feelings about pregnancy before and just after they become pregnant.  When you became pregnant, did you yourself actually want to have a baby at some time?

Label	Code	Go To
Yes	1
No	2	AGE_FIRST_PERIOD
REFUSED	-1	AGE_FIRST_PERIOD
DON'T KNOW	-2	AGE_FIRST_PERIOD

SOURCE

National Survey of Family Growth (modified)

Legacy: National Children’s Study, Legacy Phase (T1) (modified)

Current: National Children’s Study Vanguard Phase (PV1 SAQ) (modified)

RH08000/(PREG_TIMING). So would you say you became pregnant too soon, at about the right time, or later than you wanted?

Label	Code	Go To
Too soon	1
Right time	2
Later	3
Didn’t care	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Survey of Family Growth Item EG-17

Legacy: National Children’s Study, Legacy Phase (T1) 

RH09000/(AGE_FIRST_PERIOD). These next questions are about your reproductive history.  I’ll begin by asking about your periods or menstrual cycle.

How old were you when you had your first menstrual period?

 

|___|___|

AGE

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

SOURCE

Pregnancy Risk Assessment Monitoring System (PRAMS) (modified)

Legacy: National Children’s Study, Legacy Phase (T1)

RH10000/(PREG_BEFORE). These next questions are about any previous pregnancies you may have had.

Before your pregnancy with {C_FNAME/the baby/the babies}, have you ever been pregnant?  Please include live births, miscarriages, stillbirths, ectopic pregnancies, abortions and pregnancy terminations.

Label	Code	Go To
Yes	1
No	2	TIME_STAMP_RH_ET
REFUSED	-1	TIME_STAMP_RH_ET
DON'T KNOW	-2	TIME_STAMP_RH_ET

SOURCE

Avon Longitudinal Study of Parents and Children Having a Baby Questionnaire (modified)

Legacy: National Children’s Study, Legacy Phase (T1) (modified)

Current: National Children’s Study Vanguard Phase (PV1 SAQ) (modified)

RH11000/(AGE_FIRST_PREG). How old were you when you became pregnant for the first time?

 

|___|___|

AGE

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

SOURCE

Pregnancy Risk Assessment Monitoring System (PRAMS) (modified)

Legacy: National Children’s Study, Legacy Phase (T1) 

Current: National Children’s Study Vanguard Phase (PV1 SAQ) 

PROGRAMMER INSTRUCTIONS

• DISPLAY HARD EDIT IF AGE_FIRST_PREG < AGE_FIRST_PERIOD.

RH12000/(NUMBER_PREGNANCIES). Not including your most recent pregnancy, how many times have you been pregnant?

 

|___|___|

NUMBER OF PREGNANCIES

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

SOURCE

National Children’s Study, Legacy Phase (T1) (modified)

Current: National Children’s Study Vanguard Phase (PV1 SAQ) (modified)

RH13000/(PREV_MISCARRY). Did any of your previous pregnancies end in a miscarriages or stillbirth?

Label	Code	Go To
Yes	1
No	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Avon Longitudinal Study of Parents and Children Having a Baby Questionnaire (modified)

Legacy: National Children’s Study, Legacy Phase (T1) (modified)

Current: National Children’s Study Vanguard Phase (PV1 SAQ) 

RH14000/(PREV_LIVE_BIRTH). How many of your previous pregnancies resulted in a live birth?

 

l___l___l

NUMBER 

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

SOURCE

National Children’s Study, Legacy Phase (T1) 

RH15000/(LIVE_3_WEEKS). Were any of your live-born babies born more than 3 weeks early?

Label	Code	Go To
Yes	1
No	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Avon Longitudinal Study of Parents and Children Having a Baby Questionnaire (modified)

Legacy: National Children’s Study, Legacy Phase (T1) 

RH16000/(LESS_FIVE_LBS). Did any of your full-term babies, who were born at 37 weeks or later, weigh less than 5lb 8oz or 2500 grams at birth?

Label	Code	Go To
Yes	1
No	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Avon Longitudinal Study of Parents and Children Having a Baby Questionnaire (modified)

Legacy: National Children’s Study, Legacy Phase (T1) 

RH17000/(TWINS_MULT). Have you ever had twins, triplets, or other multiple births?

Label	Code	Go To
Yes	1
No	2	TIME_STAMP_RH_ET
REFUSED	-1	TIME_STAMP_RH_ET
DON'T KNOW	-2	TIME_STAMP_RH_ET

SOURCE

National Children’s Study, Legacy Phase (T1) 

RH18000/(FERTILITY_DRUGS). Thinking about when you had twins, triplets, or other multiple births, were fertility drugs or treatments used to help you conceive that time?

Label	Code	Go To
Yes	1
No	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Legacy Phase (T1) 

(TIME_STAMP_RH_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

DRUGS, ALCOHOL AND CIGARETTE USE

(TIME_STAMP_DAA_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

DAA01000/(SMOKE_CIG_PREG). The next questions are about your use of cigarettes just before and during your most recent pregnancy.

In the 3 months before you became pregnant, did you smoke any cigarettes?

Label	Code	Go To
Yes	1
No	2	SMOKE_FIRST3_PREG
REFUSED	-1	SMOKE_FIRST3_PREG
DON'T KNOW	-2	SMOKE_FIRST3_PREG

SOURCE

National Children’s Study, Legacy Phase (T1) (modified)

Current: National Children’s Study Vanguard Phase (PV1 SAQ) 

DAA02000/(SMOKE_FREQ). Did you smoke cigarettes:

Label	Code	Go To
Every day	1
5 or 6 days a week	2
2-4 days a week	3
Once a week	4
1-3 days a month	5
Less than once a month	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Legacy Phase (T1) (modified)

Current: National Children’s Study Vanguard Phase (PV1 SAQ) 

DAA03000/(SMOKE_PER_DAY). On days that you smoked, how many cigarettes did you smoke per day?

 

|___|___|

NUMBER PER DAY

PARTICIPANT INSTRUCTIONS

• If you smoked 1 cigarette or less each day, please enter “1.”

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

SOURCE

National Health and Nutrition Examination Study 2005-2006 (modified)

Legacy: National Children’s Study, Legacy Phase (T1) (modified)

Current: National Children’s Study Vanguard Phase (PV1 SAQ) 

DAA04000/(SMOKE_FIRST3_PREG). In the first 3 months after you became pregnant, did you smoke any cigarettes?

Label	Code	Go To
Yes	1
No	2	SMOKE_LAST3_PREG
REFUSED	-1	SMOKE_LAST3_PREG
DON'T KNOW	-2	SMOKE_LAST3_PREG

SOURCE

New

DAA05000/(FIRST_3SMOKE_FREQ). During that period, did you smoke cigarettes...

Label	Code	Go To
Every day	1
5 or 6 days a week	2
2-4 days a week	3
Once a week	4
1-3 days a month	5
Less than once a month	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

New

DAA06000/(SMOKE3_PER_DAY). On days that you smoked, how many cigarettes did you smoke per day? 

 

|___|___|

NUMBER PER DAY

PARTICIPANT INSTRUCTIONS

• If you smoked 1 cigarette or less each day, please enter “01.”

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

SOURCE

National Health and Nutrition Examination Study 2005-2006 (modified)

DAA07000/(SMOKE_LAST3_PREG). In the last 3 months of your pregnancy, did you smoke any cigarettes?

Label	Code	Go To
Yes	1
No	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

New

PROGRAMMER INSTRUCTIONS

• IF SMOKE_LAST3_PREG = 2, -1 OR -2, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING SMOKE_LAST3_PER_DAY.

• OTHERWISE, GO TO SMOKE_LAST3_FREQ.

DAA08000/(SMOKE_LAST3_FREQ). Did you smoke cigarettes:

Label	Code	Go To
Every day	1
5 or 6 days a week	2
2-4 days a week	3
Once a week	4
1-3 days a month	5
Less than once a month	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

New

DAA09000/(SMOKE_LAST3_PER_DAY). On days that you smoked, how many cigarettes did you smoke per day? 

 

|___|___|

NUMBER PER DAY

PARTICIPANT INSTRUCTIONS

• If you smoked 1 cigarette or less each day, please enter “01.”

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

SOURCE

National Health and Nutrition Examination Study 2005-2006 (modified)

PROGRAMMER INSTRUCTIONS

• IF SMOKE_CIG_PREG, SMOKE_FIRST3_PREG, AND SMOKE_LAST3_PREG # 1, GO TO CURRENTLY_SMOKE.

• OTHERWISE, GO TO QUIT_SMOKE_AID.

DAA10000/(QUIT_SMOKE_AID). During your pregnancy, did you take any of the following drugs to help you stop smoking?

Label	Code	Go To
Nicotine Patch	1
Nicotine Gum	2
Zyban	3
REFUSED	-1
DON'T KNOW	-2
Did not take any drugs to help you stop smoking	-7

SOURCE

New

DAA11000/(CURRENTLY_SMOKE). Currently, do you smoke cigarettes?

Label	Code	Go To
Yes	1
No	2	DRINK_3BEFORE_PREG
REFUSED	-1	DRINK_3BEFORE_PREG
DON'T KNOW	-2	DRINK_3BEFORE_PREG

SOURCE

National Children’s Study, Legacy Phase (T1, T3) (modified)

Current: National Children’s Study Vanguard Phase (PV1 SAQ)

DAA12000/(CURRENT_SMOKE_FREQ). Do you smoke cigarettes:

Label	Code	Go To
Every day	1
5 or 6 days a week	2
2-4 days a week	3
Once a week	4
1-3 days a month	5
Less than once a month	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Legacy Phase (T1, T3) (modified)

Current: National Children’s Study Vanguard Phase (PV1 SAQ) 

DAA13000/(CURRENT_SMOKE_PER_DAY). On days that you smoke, how many cigarettes do you smoke per day?

 

|___|___|

NUMBER PER DAY

 

PARTICIPANT INSTRUCTIONS

• If you smoke 1 cigarette or less each day, please enter “1.”

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

SOURCE

National Health and Nutrition Examination Study 2005-2006 (modified)

Legacy: National Children’s Study, Legacy Phase (T1, T3) (modified)

Current: National Children’s Study Vanguard Phase (PV1 SAQ) 

DAA14000/(DRINK_3BEFORE_PREG). In the first 3 months of your pregnancy, how often did you drink alcoholic beverages including wine, beer, drinks containing hard liquor, wine coolers, hard lemonade, or hard cider?

Label	Code	Go To
5 or more times a week	1
2-4 times a week	2
Once a week	3
1-3 times a month	4
Less than once a month	5
Never	6	DRINK_3AFTER_PREG
REFUSED	-1	DRINK_3AFTER_PREG
DON'T KNOW	-2	DRINK_3AFTER_PREG

SOURCE

National Children’s Study, Legacy Phase (T1) 

Current: National Children’s Study Vanguard Phase (PV1 SAQ) 

DAA15000/(DRINK_3BEFORE_NUM). In the first 3 months of your pregnancy, on days that you drank alcoholic beverages, how many drinks did you have per day? If you had one drink or less, please enter “1.”

 

|___|___|

NUMBER OF DRINKS

INTERVIEWER INSTRUCTIONS

• READ IF NECESSARY: One drink is 12 ounces of beer, one 5-ounce glass of wine, or 1-1/2 ounces of hard liquor.

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

SOURCE

National Children’s Study, Legacy Phase (T1) 

Current: National Children’s Study Vanguard Phase (PV1 SAQ) 

DAA16000/(DRINK_3BEFORE_BINGE). In the first 3 months of your pregnancy, how often did you have 5 or more drinks within a couple of hours?

Label	Code	Go To
Never	1
About once a month	2
About once a week	3
About once a day	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Pregnancy Risk Assessment Monitoring Survey (Modified)

Legacy: National Children’s Study, Legacy Phase (T1) 

Current: National Children’s Study Vanguard Phase (PV1 SAQ)

DAA17000/(DRINK_3AFTER_PREG). In the first 3 months after you became pregnant, how often did you drink alcoholic beverages including wine, beer, drinks containing hard liquor, wine coolers, hard lemonade, or hard cider?

Label	Code	Go To
5 or more times a week	1
2-4 times a week	2
Once a week	3
1-3 times a month	4
Less than once a month	5
Never	6	DRINK_LAST3_PREG
REFUSED	-1	DRINK_LAST3_PREG
DON'T KNOW	-2	DRINK_LAST3_PREG

SOURCE

New

DAA18000/(DRINK_3AFTER_NUM). In the first 3 months after you became pregnant, on days that you drank alcoholic beverages, how many drinks did you have per day?  If you had one drink or less, please enter “1.” 

 

|___|___|

NUMBER OF DRINKS

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

SOURCE

New

DAA19000/(DRINK_3AFTER_BINGE). In the first 3 months after you became pregnant, how often did you have 5 or more drinks within a couple of hours?

Label	Code	Go To
Never	1
About once a month	2
About once a week	3
About once a day	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

New

DAA20000/(DRINK_LAST3_PREG). In the last 3 months of your pregnancy, how often did you drink alcoholic beverages including wine, beer, drinks containing hard liquor, wine coolers, hard lemonade, or hard cider?

Label	Code	Go To
5 or more times a week	1
2-4 times a week	2
Once a week	3
1-3 times a month	4
Less than once a month	5
Never	6	TIME_STAMP_DAA_ET
REFUSED	-1	TIME_STAMP_DAA_ET
DON'T KNOW	-2	TIME_STAMP_DAA_ET

SOURCE

New

DAA21000/(DRINK_LAST3_NUM). In the last 3 months of your pregnancy, on days that you drank alcoholic beverages, how many drinks did you have per day?  If you had one drink or less, please enter “1.” 

 

|___|___|

NUMBER OF DRINKS

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

SOURCE

New

DAA22000/(DRINK_LAST3_BINGE). In the last 3 months of your pregnancy, how often did you have 5 or more drinks within a couple of hours?

Label	Code	Go To
Never	1
About once a month	2
About once a week	3
About once a day	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

New

(TIME_STAMP_DAA_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

FAMILY INCOME

(TIME_STAMP_FI_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

FI01000/(INC_TOTAL_NUM). Family income is important in analyzing the data we collect and is often used in scientific studies to compare groups of people who are similar.  Please remember that all the data you provide is confidential.

During your pregnancy, how many people, including yourself, were supported by your total combined family income?

 

|___|___|

NUMBER

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

SOURCE

National Children’s Study, Legacy Phase (T1) (modified)

Current: National Children’s Study Vanguard Phase (PV1) 

PROGRAMMER INSTRUCTIONS

• IF INC_TOTAL_NUM = 1, GO TO INCOME_TEN.

• IF INC_TOTAL_NUM > 1, GO TO INC_TOTAL_CHILD.

FI02000/(INC_TOTAL_CHILD). When you got pregnant, how many of those people were children?  Please include anyone under 18 years or anyone older than 18 years and in high school.

 

|___|___|

NUMBER

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

SOURCE

National Children’s Study Vanguard Phase (PV1) 

FI03000/(INCOME_TEN). Of these income groups, which category best represents your combined family income during {LAST CALENDAR YEAR}?

Label	Code	Go To
Less than $4,999	1
$5,000-$9,999	2
$10,000-$19,999	3
$20,000-$29,999	4
$30,000-$39,999	5
$40,000-$49,999	6
$50,000-$74,999	7
$75,000-$99,999	8
$100,000-$199,000	9
$200,000 or more	10
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Legacy Phase (T1) (modified)

Current: National Children’s Study Vanguard Phase (PV1) 

PROGRAMMER INSTRUCTIONS

• PRELOAD AND DISPLAY LAST CALENDAR YEAR.

(TIME_STAMP_FI_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 11 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.