Attachment J1: Redesigned 3Ps Pilot Test Report

J1. Redesigned 3Ps Pilot Test Report.docx

National Healthy Start Evaluation and Quality Assurance

Attachment J1: Redesigned 3Ps Pilot Test Report

OMB: 0915-0338

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ATTACHMENT J1


Development of and Pilot Test Results for the

redesigned preconception, pregnancy and parenting (3Ps) Information Form


I. Development of the redesigned preconception, pregnancy and parenting (3ps) information form

Overview

HRSA/MCHB’s Division of Healthy Start and Perinatal Services (DHSPS) convened the Healthy Start (HS) Collaborative Improvement and Innovation Network (CoIIN) to serve as an Expert Panel to promote implementation of standardized evidence-based approaches to core program elements on behalf of all HS grantees. The HS CoIIN includes all level 3 grantees (18), one level 1, and one level 2 grantees.


In Year 1, the HS CoIIN identified three priority areas for standardization: screening forms, data collection methods and reporting, and the case management/care coordination model. The HS CoIIN elected to begin with standardizing screening forms and data collection methods so as to begin to ensure comprehensive and consistent assessment of participants’ needs as well as to standardize data collection (including benchmarks) and reporting to support monitoring and evaluation.

The HS CoIIN identified indicators for risks and strengths for which all HS participants should be screened based on the literature and HS performance measures. Starting with benchmarks outlined in the funding opportunity announcement (FOA), the HS CoIIN identified factors for which 100% of HS CoIIN members already screened, and then identified factors ascertained as critical by 80% of HS CoIIN members. Guiding principles for screening form development were identified at the outset. The screening form(s) would:

  • Serve as the foundation for care coordination and case management.

  • Address comprehensive risks and strengths for each perinatal period.

  • Align with HS benchmarks.

  • Provide a minimum requirement that can be expanded by HS programs.

  • Adapt questions from standardized surveys and/or validated screening instruments when possible.


The first step was to assess screening forms and processes currently in place among HS CoIIN members’ programs. This initial process included reviewing screening forms from 80% of CoIIN members (n=16), and revealed significant variation across programs in length or comprehensiveness, format, inclusion of guidance depending upon participant response, and whether the form is completed by participant or staff, further reinforcing the need for standardization.


As the HS CoIIN engaged in this foundational work, two related initiatives were concurrently underway, including the development of a data dictionary that established definitions for each of the benchmarks required through the HS Grantee FOA released in 2014, and the release of a RFP for developing a data collection database for the National HS Evaluation based on the original, OMB-approved 3Ps Information Form. It was essential that the HS CoIIN screening forms enable the collection of data points that would inform benchmark reporting. Additionally, each HS program would be required to complete and submit program data through the 3Ps Information Form, which included questions abstracted from various standardized instruments (National Survey of Children’s Health [NSCH], Pregnancy Risk Assessment Monitoring System [PRAMS], and others). In order to address potential duplication of data collection, and reduce burden on staff and participants, every effort was made by the HS CoIIN to incorporate questions included in the original 3Ps Information Form into the screening forms. However, the distinction between questions designed for evaluation and those designed for case management/care coordination became increasingly apparent. Where evaluation takes a retrospective stance on the outcomes of a program (Army Public Health Center, n.d.), screening prospectively identifies risk factors and strengths of individual participants (Commission for Case Manager Certification, 2016).


Two CoIIN Workgroups were formed: the Screening Form Feedback Workgroup (Feedback Workgroup), comprised of four HS CoIIN members, and the Screening Form Implementation Workgroup (Implementation Workgroup), comprised of six HS CoIIN members to redesign the original 3Ps Information Form to include elements of the HS CoIIN screening forms. The Feedback Workgroup held eight virtual meetings between October 2015 and January 2016 to review HS CoIIN feedback, develop recommendations to the HS CoIIN, and prepare draft versions of the redesigned 3Ps Information Form. Their work focused on the “what” of the redesigned form: which questions to incorporate to address essential risk and protective factors? The Implementation Workgroup met five times, focusing on the “how” of the redesigned form: operationalizing pilot and implementation phases across the HS community. The Implementation Workgroup developed a robust implementation plan that included testing the redesigned 3Ps Information Form across programs representing a range of variables (e.g., grantee funding level, which staff conduct screening activities, whether the screening process occurs through a centralized or decentralized intake process, whether forms are completed on paper and/or electronically). Piloting the redesigned 3Ps Information Form was planned to take place June through August of 2016, with a September launch date.


Updated drafts of the redesigned 3Ps Information Form were released in January 2016 to the larger HS community and informal feedback were gathered. General emergent themes included concerns about the personal level of information asked of participants through the screening process, as well as the appropriateness of asking about broader participant needs which the HS program itself may not have the capacity to address. Feedback also emphasized a need to include questions addressing potentially unstable social determinants (such as income, food security, housing security, and transportation) throughout the form so that these issues are touched upon at each encounter. Grantee feedback also prompted the separation of preconception/ interconception, instead incorporating interconception screening into the parenting form.


In March 2016, the HS CoIIN worked with the HRSA/MCHB Office of Epidemiology and Research (OER) and the vendor developing the National HS Evaluation database to develop a mechanism to streamline data collection for multiple purposes to meet care coordination, program management, and evaluation needs. The Feedback Workgroup worked with the HS CoIIN to reach consensus on the version of the redesigned 3Ps Information Form that was submitted by OER to OMB as a Change Memo in May 2016 and pilot tested in July 2016.


Table 1: May 2016 Redesigned 3Ps Information Form Content

Screening Form

Number of Questions

Sections in Sequential Order

Demographic Intake Form

8

Date of Birth, Zip Code, Ethnicity, Race, Country of Origin, Language

Pregnancy History/Status

12

Current Pregnancy Status, Past Pregnancy Outcomes and Complications

Preconception

45

Demographics, Social Determinants, Neighborhood and Community, Medical Home/Access to Care/Health Insurance, Health and Healthy History, Mental Health, Substance Use, Personal Safety, Stress and Discrimination, Partner Involvement/Social Support, Reproductive Life Planning

Prenatal

59

Prenatal Care, Demographics, Social Determinants, Neighborhood and Community, Health and Health History, Mental Health, Substance Use, Personal Safety, Readiness for Motherhood, Stress and Discrimination, Social Support/Father Involvement, Reproductive Life Planning

Postpartum

53

Pregnancy Outcome, Infant Care, Sleep and Car Safety, Baby Insurance/Access to Care, Reproductive Life Planning, Demographics, Social Determinants, Neighborhood and Community, Medical Home / Access to Care/Health Insurance, Maternal Health, Mental Health, Substance Use, Personal Safety, Stress and Discrimination, Father Involvement/Social Support

Interconception/Parenting

53

Infant Care, Sleep and Car Safety, Baby Insurance/Access to Care, Reproductive Life Planning, Demographics, Social Determinants, Neighborhood and Community, Medical Home / Access to Care/Health Insurance, Maternal Health, Mental Health, Substance Use, Personal Safety, Stress and Discrimination, Father Involvement/Social Support

II. Pilot Test Report and Recommendations

Pilot Test Goals

By pilot testing the redesigned 3Ps Information Form, we hoped to gain information on the following:

  • To gauge usefulness of the forms to HS programs and participants.

    • Program participants’ understanding of the questions on the forms

  • To understand feasibility of using the forms.

    • Any questions that could be deleted or revised to improve clarity

    • The average time it takes to administer the forms

  • To identify training needs for implementation of the forms.



Conducting the Pilot Test

The pilot test period was implemented for one week, July 11-15, 2016. The week before the pilot started, a 2-hour web-based training was provided to the site participating in the pilot. The objectives of the training were to:

  • Provide background and overview of the forms

  • Provide guidance for piloting programs in administering forms and completion of the pilot program evaluation form

  • Establish follow-up check-in meeting times


During the week of the pilot, two one-hour office hours were provided for the site to ask questions if they ran into any challenges during the pilot process.


The pilot site was asked to document the start and end time for each form.  The time study documented the time it takes for the full utilization of the forms including asking and getting responses to the screening questions as well as the completion of the follow-up/referral sections. 


Additionally, the sites were also asked to document if there were questions that were unclear either to the staff that were conducting the screening with the participant or to the participant.  If there were specific questions they wanted to provide comment on, they were able to check off the question number (s) and provide qualitative information about the question. 

 

Pilot Test Sample

For the pilot test, we selected a Level 3 grantee with previous Healthy Start experience and that predominately serves the target population, African American and Hispanic/Latino participants.

The pilot site was asked to pilot the forms with up to 9 participants. The Demographic Intake and Pregnancy Status/History forms were piloted with all 9 participants.

Depending on the participants’ perinatal stage, the grantee pilot tested appropriate perinatal phase forms (e.g., Preconception, Prenatal, Postpartum, and Interconception/Parenting). We asked to have each perinatal phase form piloted with at least one participant, up to the 9 limit.


Within the pilot site, case management staff selected to administer the forms were assembled to identify women who met the criteria for each of the four (4) specific perinatal periods. Scheduled intake appointments during the pilot test week were reviewed to determine if a sufficient number of new case enrollments were available to meet the objectives of the pilot process. A process map was created linking the scheduled intake to specific staff members for the pilot period July 11-15, 2016. A few backup intakes were also identified for each of the four (4) perinatal periods in case of cancellations.


Pilot Test Results

The pilot evaluation survey remained open through July 22, 2016. The pilot site was asked to review the forms with their staff and submit a collective review. The grantee rated the forms on five dimensions:



Evaluation Domain

Description of Domain

Relevance/importance to Healthy Start grantee and participants’ needs

Significance of the Social Determinants Participant Profile to address Healthy Start participant needs.

Technical quality

Soundness of form framework and questions

Clarity of form

Organized, clear, concise, comprehensive

Diversity

Ability to address the diversity of the HS grantees’ populations, and culture

Length of form

Time it would take to administer form with

Participant


Each section of the evaluation survey for each form began with this evaluation domain table. Each domain for each form was summarized by the mean, median and range of scores from a Likert scale: 1-5: 1 being totally disagree and 5 being completely agree. 


Demographic Intake Form

Evaluation Domains

N=11

Evaluation Domain

Mean

Median

Range

Relevance/importance to Healthy Start grantee and participants’ needs

3.9

4

3-5

Technical quality

3.9

4

3-5

Clarity of form

4

4

3-5

Diversity

4.1

4

3-5

Length of form

4.1

4

3-5


Demographic Intake Form

Time Study

N=10

Total Estimated Annualized Burden of Hours

Published in Federal Register, Public Comment Request

25 minutes

Pilot Test Raw Time Range

1-30 minutes

Pilot Test Median Time

4.6 minutes

Pilot Test Mean Time

3.5 minutes

The demographic intake form scored well in all domains, and no substantive issues were identified within each domain that would require any changes. The demographic form median and mean time stamp was well below the estimated burden to complete, by 20 and 22 minutes respectively.


Pregnancy History/Status Form

Evaluation Domains

N=11

Evaluation Domain

Mean

Median

Range

Relevance/importance to Healthy Start grantee and participants’ needs

3.8

4

2-5

Technical quality

3.9

4

3-5

Clarity of form

3.9

4

2-5

Diversity

3.8

4

2-5

Length of form

3.7

4

2-5


Pregnancy History/Status Form

Time Study

N=10

Total Estimated Annualized Burden of Hours

Published in Federal Register, Public Comment Request

42 minutes

Pilot Test Raw Time Range

1-25minutes

Pilot Test Median Time

6.3 minutes

Pilot Test Mean Time

4.5 minutes

The pregnancy history/status form scored well in all domains. There was some qualitative feedback on the technical quality and clarity of the form. This feedback was reviewed along with the feedback on specific questions. The pregnancy status/history form median and mean time stamp was well below the estimated burden to complete, by 36 and 38 minutes respectively.


Preconception Form

Evaluation Domains

N=11

Evaluation Domain

Mean

Median

Range

Relevance/importance to Healthy Start grantee and participants’ needs

2.9

3

1-5

Technical quality

3.4

3

2-5

Clarity of form

3.6

3

2-5

Diversity

3.3

3

1-5

Length of form

3.3

3

1-5




 

Preconception Form

Time Study

N=5

Total Estimated Annualized Burden of Hours

Published in Federal Register, Public Comment Request

90 minutes

Pilot Test Raw Time Range

25-60 minutes

Pilot Test Median Time

51 minutes

Pilot Test Mean Time

45 minutes

The preconception form scored well in all domains, except for the relevance or importance to Program participants’ needs. There was some qualitative feedback on the relevance, clarity, and length of the form. This feedback was reviewed along with the feedback on specific questions. The preconception form median and mean time stamp was well below the estimated burden to complete, by 39 and 45 minutes respectively.


Prenatal Form

Evaluation Domains

N=11

Evaluation Domain

Mean

Median

Range

Relevance/importance to Healthy Start grantee and participants’ needs

3.9

4

3-5

Technical quality

3.8

4

2-5

Clarity of form

3.8

4

2-5

Diversity

4.1

4

3-5

Length of form

3.3

3

1-5


Prenatal Form

Time Study

N=10

Total Estimated Annualized Burden of Hours

Published in Federal Register, Public Comment Request

120 minutes

Pilot Test Raw Time Range

32-88 minutes

Pilot Test Median Time

56 minutes

Pilot Test Mean Time

47 minutes

The prenatal form scored well in all domains. There was some qualitative feedback on the relevance and clarity of the form. This feedback was reviewed along with the feedback on specific questions. The prenatal form median and mean time stamp was well below the estimated burden to complete, by 64 and 73 minutes respectively.


Postpartum Form

Evaluation Domains

N=11

Evaluation Domain

Mean

Median

Range

Relevance/importance to Healthy Start grantee and participants’ needs

4.1

4

3-5

Technical quality

4

4

3-5

Clarity of form

3.9

4

2-5

Diversity

4.1

4

3-5

Length of form

3

3

1-5


Postpartum Form

Time Study

N=10

Total Estimated Annualized Burden of Hours

Published in Federal Register, Public Comment Request

108 minutes

Pilot Test Raw Time Range

18-120 minutes

Pilot Test Median Time

52 minutes

Pilot Test Mean Time

43 minutes

The postpartum form scored well in all domains, and no substantive issues were identified within each domain that would require any changes. The postpartum form median and mean time stamp was well below the estimated burden to complete, by 56 and 65 minutes respectively.


Parenting/Interconception Form

Evaluation Domains

N=11

Evaluation Domain

Mean

Median

Range

Relevance/importance to Healthy Start grantee and participants’ needs

3.9

4

2-5

Technical quality

3.7

4

2-5

Clarity of form

3.7

4

2-5

Diversity

4

4

3-5

Length of form

2.7

2

1-5




Interconception/Parenting Form

Time Study

N=10

Total Estimated Annualized Burden of Hours

Published in Federal Register, Public Comment Request

120 minutes

Pilot Test Raw Time Range

24-112 minutes

Pilot Test Median Time

61minutes

Pilot Test Mean Time

52 minutes

The interconception/parenting form scored well in all domains, except for the length of form. There was some qualitative feedback on the clarity and length of the form. This feedback was reviewed along with the feedback on specific questions. The parenting form median and mean time stamp was well below the estimated burden to complete, by 59 and 68 minutes respectively.


The Feedback Workgroup met four times between July 25-August 19, 2016, to review comments from the pilot testing results and public comment period feedback to identify emergent themes throughout the comments, and reach consensus on a final set of forms for the redesigned 3Ps Information Form. These are described below in more detail.



Recommended Changes to the Redesigned 3Ps Information Form Based on Pilot Test

General highlights of recommended changes are included below. Notations reflect the actual changes made to the revised forms. Several recommended changes cut across all four perinatal forms. For many questions recommended for deletion, the information is captured in other questions. When all the deletions and additions are accounted for, there was a net reduction, shortening the forms by 11 core questions. Detailed documentation of changes to each revised form is included in Appendix A.


  1. Deletions

We recommend the following deletions to streamline the forms, and reducing redundancy:

  • From each of the four perinatal forms (Preconception, Prenatal, Postpartum, Interconception/Parenting):

    • “On average, how many hours per day are you in the same room or vehicle with another person who is smoking?”

    • “How often do you have transportation to or from your medical appointments?”

    • “How often has it been very hard to get by on your family’s income…?”

    • Medical home questions: delete “Is there one person or more than one person?” (But change responses to “Do you have one or more persons you think of as your personal doctor or nurse?” to include ‘Yes, one person”, “Yes, more than one person” etc.)

    • “Is there a place that you usually go for care…?” “What kind of place do you go to most often…” captures usual source of care.

    • “Have you ever had a case with Child Protective Services”? But keep “Do you currently have an open case …?” Delete both questions from Preconception Form.

    • “There are people I can count on in this neighborhood or community”, as that information is captured through other questions in the Neighborhood and Community sections.

    • Delete the question about how the participant handles life events in the Stress and Discrimination section.

    • Streamline Reproductive Life Planning sections, while maintaining mechanism for capturing the existence of a reproductive life plan.

  • The revised forms also reflect revisions to and/or deletions of medically or clinically-oriented items based on pilot test feedback. These include deletion of some questions about immunizations and medications. Appendix A details these recommendations.

  • From the Pregnancy History/Status Form

    • “Including this pregnancy, how many times have you been pregnant…?”,

    • “How many of your children were delivered vaginally?”,

    • “Were any babies born with medical conditions…?”

    • What were they diagnosed with?”

    • How much weight did you during your last pregnancy?

  • From the Prenatal Form

    • Are you currently receiving prenatal care? We recommend keeping questions about how many weeks or months pregnant when they had first prenatal care visit and if they have had any difficulty getting prenatal care which provide that information.



  1. Additions:

For informing/reminding staff and participants about the purpose of including the selected questions, and to provide instruction to staff on administering the forms, we recommend adding the following text at the beginning of each form:


The questions and answer choices were selected based on the available evidence about factors that may impact a woman’s health or pregnancy outcomes. The information provided by the participant through this screening form will help Healthy Start identify each participant’s unique needs and ensure that she is connected to the appropriate support services.


Please read the questions to the participant. Do not read the responses to the participant unless the instructions tell you to do so.


Recommendations for specific additions include the following:

  • To the Demographic Intake Form:

    • Add address, contact information, and emergency contact information.

  • To each of the four perinatal forms:

    • “What is the zip code where you live?” include in the Social Determinants section of each perinatal screening form. The Implementation Work Group recognized this item as one that could change between visits, and should be tracked over time.

    • “How many people are supported by this income?” inserted after the income question in the Social Determinants of Health section.

    • “Do you keep guns in your home?” Based on AAP1 and ACOG2 recommendations, and in light of the current social climate, the Implementation Work Group felt it prudent to include this question.


  1. Text Revisions

During the pilot test, a few items caused confusion across the pilot test participants. In order to improve the clarity of the items on the forms and ensure that all possible response options are included, we recommend implementing the following revisions to question text:

  • Change “baby’s father” or “child’s father” to “partner or father of baby “ or “partner or father of child“

  • Change “year” to “12 months” in all questions to improve clarity

  • Other minor revision recommendations are documented in Appendix A.


  1. Reordering, Reformatting and Other Minor Revisions

Review of pilot testing feedback by the Health Start CoIIN Implementation Work Group highlighted several areas where formatting could improve flow and clarity. Recommendations for improvements are outlined below, and reflected in the updated versions:

  • Across all forms:

    • Indent sub-questions to help differentiate.

    • Include more explicit instructions to the person administering the form for each question.

    • Provide more transition statements between sections or questions to improve flow.

    • Update skip patterns

    • Update and ensure alignment and consistency of Follow Up boxes across forms

    • Revise some section headers, including deleting “Demographics” sections

  • Re-format Postpartum and Parenting/Interconception Forms to capture information on multiples as well as single babies.


We recommend two substantial changes to the Interconception/Parenting Form. The initial form lacked a mechanism for identifying mothers who may have experienced the death of their infant after the Postpartum Form was completed. We inserted a question, modified from National Children’s Health Survey QA1 asking about the child’s health. This provides a means of identification and forgoing asking the mother the range of questions that follow regarding child health status, safety, and insurance information through an embedded skip pattern. The next question asks the participant if she is pregnant, addressing another issue – that a participant could be in the parenting phase with a young child and also be pregnant. If a woman in the parenting phase is also pregnant, an embedded skip pattern directs the staff to ask questions about her partner’s or the father of the baby’s involvement (if the baby is alive), and then to the Prenatal Screening Form.


Conclusion

In summary, the pretest provided important feedback about the clarity, flow and timing of the questions on the Healthy Start redesigned 3Ps Information Form. The suggestions outlined above would improve respondent comprehension and ease of staff administration of the six forms. Table 2 below shows the final content of the forms submitted for OMB final review as a result of pilot testing recommendations.



Table 2: August 2016 3Ps Information Form Content

Screening Tool

Number of Questions

Sections in Sequential Order

Demographic Intake tool

10

Date of Birth, Address, Contact Info, Emergency Contact, Education, Ethnicity, Race, Country of Origin, Language

Pregnancy History/Status

9

Current Pregnancy Status, Summary of Past Pregnancy Outcomes and Complications

Preconception

43

Social Determinants, Neighborhood and Community, Medical Home/Access to Care/Health Insurance, Health and Healthy History, Mental Health, Substance Use, Personal Safety, Stress and Discrimination, Social Support/Partner Involvement, Reproductive Life Planning

Prenatal

50

Readiness for Motherhood/Prenatal Care, Social Determinants, Neighborhood and Community, Health and Health History, Mental Health, Substance Use, Personal Safety, Stress and Discrimination, Social Support/Father or Partner Involvement, Reproductive Life Planning

Postpartum

49

Pregnancy Outcome, Infant Care, Infant Safety, Baby Insurance/Access to Care/Medical Home, Reproductive Life Planning, Social Determinants, Neighborhood and Community, Medical Home / Access to Care/Health Insurance, Maternal Health, Mental Health, Substance Use, Personal Safety, Stress and Discrimination, Social Support/ Father or Partner Involvement

Interconception/Parenting

58

Child Insurance/Access to Care/Medical Home, Reproductive Life Planning, Social Determinants, Neighborhood and Community, Medical Home/Access to Care/Health Insurance, Maternal Health, Mental Health, Substance Use, Personal Safety, Stress and Discrimination, Social Support/ Father or Partner Involvement




APPENDIX A:

Documentation of Changes to the Redesigned Preconception, Pregnancy and Parenting (3Ps) Information Form


The following sections outline the questions that were changed, and the changes that were made to those questions, by specific form. Sections Headers are included to help organize the information. Changes to section headers are explicitly noted.


For Pregnancy History/Status, Preconception, Prenatal, Postpartum and Interconception/Parenting Forms, the following text was inserted at the beginning of the forms:


The questions and answer choices were selected based on the available evidence about factors that may impact a woman’s health or pregnancy outcomes. The information provided by the participant through this screening tool will help Healthy Start identify each participant’s unique needs and ensure that she is connected to the appropriate support services.


Please read the questions to the participant. Do not read the responses to the participant unless the instructions tell you to do so.


DEMOGRAPHIC INTAKE SCREENING FORM

2

Deleted

“What is your zip code?”

Inserted zip code question into the each of the individual perinatal screening forms

Add


2. What is your address:

Add


3. What is the best way to contact you?

Add


4. Emergency Contact info:

7

What is your race?

  • Asian (i.e. Chinese, Thai, Pakistani, Korean, etc.)

  • Native Hawaiian 

  • Other Pacific Islander (i.e. Samoan, Guamanian, Polynesia, etc.)

  • Black/ African American

  • American Indian/ Alaska native

  • White

  • Some other race

  • More than one race

  • Declined to answer

What is your race?

(One or more categories may be selected)

____White

____Black or African American

____American Indian or Alaska Native

____Asian Indian

____Chinese

____Filipino

____Japanese

____Korean

____Vietnamese

____Other Asian

____Native Hawaiian

____Guamanian or Chamorro

____Samoan

____Other Pacific Islander







PREGNANCY HISTORY/STATUS SCREENING FORM

1.2

Delete:

Including this pregnancy, how many times have you been pregnant in your life?


3

Changed format of documenting types of pregnancies

Type of Pregnancy Outcome

Number

Date of Most Recent

Live birth


__/__/____

Miscarriage



Ectopic or tubal pregnancy



Abortion



Fetal death/stillbirth


__/__/____

3. Revised format:

4

Delete:

How many of your children were delivered vaginally (naturally)?


5

Delete:

How many of your children were delivered by Cesarean delivery (C-section)?

_______children. IF NONE, ENTER “0” AND go to question 6.1

  • Declined to answer

Add:

4. Did you ever have a baby by cesarean delivery or C-section (when a doctor cuts through the mother’s belly to bring out the baby)?

  • Yes

  • No

  • Don’t Know

  • Declined to answer

9 & 9.1

Delete:

9. Were any of your babies diagnosed with any medical conditions at birth?

9.1 What were they diagnosed with?


10

Changed:

Did any of your babies stay in the hospital after you came home?

Select one only.

  • Yes

  • No

  • Declined to answer

Revision:

8. Did any of your babies stay in the hospital after you came home?

Select one only.

  • Yes, Please specify reason:____________________

  • No

  • Declined to answer

11

Delete: How much weight in pounds did you gain during your last pregnancy?







PRECONCEPTION SCREENING FORM

Section Header

Delete: Demographics

Merged questions with those under Social Determinants of Health Section Header

After Q3


Add:

4. How many people are supported by this income?

STAFF: Enter number of people.

_____ Adults age 18 or older

_____ Children age 18 or younger

  • Don’t know

  • Declined to answer

4

Delete:

How often has it been very hard to get by on your family’s income, by this I mean to pay for food or housing?


5

Delete:

How often do you have transportation to or from your medical appointments?


After Q 6


Add:

6. What is the Zip Code where you live?

8

Delete:

How do you feel about your current housing situation--do you feel very stable and secure, fairly stable and secure, just somewhat stable and secure, fairly unstable and insecure, or very unstable and insecure

Insert:

8. Do you have any housing concerns?

Select one only.

  • Yes (Go to question 18)

  • No (Go to question 18)

  • Don’t know (Go to question 18)

  • Declined to answer

9

Delete: response option: “Ineligible”

Add response option: “Not applicable”

10

Delete:

Have you ever had a case with Child Protective Services?


Section Header

NEIGHBORHOOD AND COMMUNITY SECTION

11.3

Delete:

There are people I can count on in this neighborhood or community.


Section Header

MEDICAL HOME / ACCESS TO CARE / HEALTH INSURANCE

15

Change:

Do you have one or more persons you think of as your personal doctor or nurse?

  • Yes

  • No

  • Don’t know

  • Declined to answer

Revision:

Do you have one or more persons you think of as your personal doctor or nurse?

  • Yes, one person

  • Yes, more than one person

  • No

  • Don’t know

  • Declined to answer

15.1

Delete:

Is there one person or more than one person


16.1

Change:

What kind of place do you go to most often when you are sick or you need advice about your health?

  • Doctor’s Office

  • Hospital Emergency Room

  • Hospital Outpatient Department

  • Clinic or Health Center

  • Retail Store Clinic or “Minute Clinic”

  • School (Nurse’s Office, Athletic Trainer’s Office)

  • Does Not Go To One Place Most Often

  • Some other place (Go to question 16.2)

Revision:

15. What kind of place do you go to most often when you are sick or you need advice about your health?

  • Doctor’s Office

  • Hospital Emergency Room

  • Hospital Outpatient Department

  • Clinic or Health Center

  • Retail Store Clinic or “Minute Clinic”

  • School (Nurse’s Office, Athletic Trainer’s Office)

  • Some other place


16.2

Delete:

Please identify the usual place of care:– not a place for care


22

Delete: “Gestational Diabetes” as a possible health issue for preconception form

Delete: superscript “2” after PKU question.


22.1

Delete:

If participant currently has any of the above conditions, ask: Have you been seen in the emergency room or hospitalized for any of these conditions within the past 6 months?


22.2

Delete:

Please tell me which condition or conditions you were seen for in the past 6 months.

Insert:

22. Please tell me which condition or conditions you were seen for by a healthcare provider in the past 6 months.”

24, 24.2, 24.3

Delete:

24. Are you taking any prescription medications?


Are you taking these medications as prescribed?


Please specify which medications:

Add:

24.1. Does your provider know all the medications that you are taking? Please tell me for prescribed as well as over the counter medications.

  • Yes

  • No

  • Not taking any medications

  • Don’t know

  • Declined to answer

27 & 28

Changed order of these 2 questions, and

Revision:

28. When was the last time you were tested for sexually transmitted diseases or sexually transmitted infections? Add ‘Don’t know” and “Declined to Answer”

29. Have you ever been diagnosed with any of the following infectious diseases?

Follow Up Box

Provided information/education about:

  • Keeping a healthy weight such as through diet and exercise

  • Health risks during pregnancy

  • Getting vaccines

  • Getting flu shot

  • Travel advisory

  • Sexually transmitted infections

  • Keeping teeth healthy

Provided information/education about:

  • Keeping a healthy weight such as through diet and exercise

  • Importance of vitamins/folic acid

  • Getting vaccines

  • Getting flu shot

  • Travel advisory

  • Sexually transmitted infections

  • Keeping teeth healthy

  • Health risks during pregnancy

Section Header

MENTAL HEALTH

32

Change:

Over the past two weeks, how often have you experienced any of the following?

NOTE: Circle the number that matches the participant’s answer, and add the answers for both together to get the final score. If the final score is more than 3, further assessment is needed.

Revision: Added response options to the question:

32. Over the past two weeks, how often have you experienced any of the following? Would you say never, several days, more than half the days, or nearly every day?

NOTE: Enter the number that matches the participant’s answer in the last column, and add the answers for both together to get the final score. If the final score is more than 3, further assessment is needed.

Section Header

SUBSTANCE USE

35

Change:

In the past year, how often have you used the following?

Revision:

33. In the past 12 months, how often have you used the following?



Delete:

On average, about how many hours per day are you in the same room or vehicle with another person who is smoking?


Section Header

PERSONAL SAFETY

Add


Add:

36. Do you keep guns at home?

 https://brightfutures.aap.org/Bright%20Futures%20Documents/15-Infancy.pdf​ (p. 268 )

Follow Up Box

  • Provided information/ education about what to do if you have or someone you know has a partner that hurts them physically


Provided information/ education about

  • what to do if you have or someone you know has a partner that hurts them physically

  • gun safety

Section Header

STRESS AND DISCRIMINATION

38& 38.2

Change:

38. Stem: The next set of questions asks you about how other people have treated you. In your day-to-day life, how often have any of the following things happened to you?

38.2 You receive poorer service than other people at restaurants or stores.

Revision:

38. Add possible responses to question:

Stem: The next set of questions asks you about how other people have treated you. In your day-to-day life, how often have any of the following things happened to you? Would you say almost every day, at least once a week, a few times a year, less than once a year, or never?


38.2 You receive poorer service than other people at restaurants, stores, or social services.

40

Delete:

The following statements are about the way you handle life events.


Section Header

PARTNER INVOLVEMENT/SOCIAL SUPPORT

41.3

To help with daily chores if you were sick

Added “to” to stem, and modified response options by removing “to” from each.

40.3 Help with daily chores?

40.4 Help you if you were sick?

Section Header

REPRODUCTIVE LIFE PLANNING

43

Delete:

“…at any time in your future”

Revised:

42. Do you plan to have any children?

43.2

In question stem, change “year: to “12 months”

Revised:

42.2 Would you like to become pregnant in the next 12 months?

43.3

Delete:

How long would you like to wait until you or your partner become pregnant?

Revised:

42.3 How long would you like to wait until you become pregnant?

44

Change:

Are you currently using any form of contraception or birth control to either prevent pregnancy or prevent sexually transmitted infections?

43. Add response:

“Don’t know”

44.1

Delete:

What kind of birth control are you or your husband or partner using now to keep from getting pregnant or to prevent sexually transmitted diseases?


45 & 45.1

Delete:

What family planning method do you plan to use to avoid pregnancy?


How sure are you that you will be able to use this method without any problems- not at all confident, somewhat confident, or very confident?


Follow Up Box

Provided information/education about family planning or birth control

Change:

Provided information/education about birth control or family planning/birth spacing.



PRENATAL SCREENING FORM

Section Header

Change

Prenatal Care

Readiness for Motherhood/Prenatal Care

After Q 2

Insert from Readiness for Motherhood section Q45-48, Delete: Q 49)

4-5

Delete:

4. Are you currently receiving prenatal care?

5. When was your last prenatal care visit?


7

Delete:

Do you have one or more persons you think of as your personal doctor or nurse?

  • Yes

  • No

  • Don’t know

  • Declined to answer


Changed response options to include “yes, one person” and “Yes, more than one person”, as in Q 7.1

9. Do you have one or more persons you think of as your personal doctor or nurse?

  • Yes, one person

  • Yes, more than one person

  • No

  • Don’t know

  • Declined to answer

7.1

Delete:

Is there one person or more than one person?

  • Yes, one person

  • Yes, more than one person

  • No

  • Don’t know

  • Declined to answer


8.1

Change:

What kind of place do you go to most often when you sick or you need advice about your health? Is it a doctor’s office, emergency room, hospital outpatient department, clinic or some other place?

  • Doctor’s Office

  • Hospital Emergency Room

  • Hospital Outpatient Department

  • Clinic or Health Center

  • Retail Store Clinic or “Minute Clinic”

  • School (Nurse’s Office, Athletic Trainer’s Office)

  •  Does Not Go To One Place Most Often

  • Some other place (Go to question 10.2)

Revised:

9.1 What kind of place do you go to most often when you sick or you need advice about your health? Is it a doctor’s office, emergency room, hospital outpatient department, clinic or some other place?

  • Doctor’s Office

  • Hospital Emergency Room

  • Hospital Outpatient Department

  • Clinic or Health Center

  • Retail Store Clinic or “Minute Clinic”

  • School (Nurse’s Office, Athletic Trainer’s Office)

  • Some other place

8.2

Delete:

Please identify the usual place of care:

  • Friend/Relative

  • Mexico/Other Locations Out Of Us

  • Other ______________________


Section Header

Change

Demographics

Social Determinants of Health

After Q12


Add:

14. How many people are supported by this income?

STAFF: Enter number of people.

_____ Adults age 18 or older

_____ Children age 18 or younger

  • Don’t know

  • Declined to answer

13-14

Delete:

13. How often has it been very hard to get by on your family’s income, by this I mean to pay for food or housing?

14. How often do you have transportation to or from your medical appointments?


After Q15


Insert

16. “What is the Zip Code where you live?”

16

In the stem, change “Do you own as place…?”

17. “Do you own a place…?”

17

Delete:

How do you feel about your current housing situation--do you feel very stable and secure, fairly stable and secure, just somewhat stable and secure, fairly unstable and insecure, or very unstable and insecure?

Add:

18. Do you have any housing concerns?

  • Yes (Go to question 18)

  • No (Go to question 18)

  • Don’t know (Go to question 18)

  • Declined to answer

18

Delete: response choice: “Ineligible”

19. Add response choice: “Not applicable”

19

Delete:

Have you ever had a case with Child Protective Services?


Section Header

NEIGHBORHOOD AND COMMUNITY

20.3

Delete:

There are people I can count on in this neighborhood or community.


Section Header

HEALTH AND HEALTH HISTORY

27

Move: Question about Gestational Diabetes so that it falls right after the question about Diabetes


27.1

Delete:

Have you been seen in the emergency room or hospitalized for any of these conditions within the last 6 months?


27.2

Delete:

Which condition or conditions were you seen for in the past 6 months

Add:

Please tell me which condition or conditions you were seen for by a healthcare provider in the past 6 months.

29

Delete:

29. Are you taking any prescription medications?


29.2

Delete:

Are you taking these medications as prescribed?

Add:

Does your provider know all the medications that you are taking? Please tell me for prescribed as well as over the counter medications.

29.3

Delete:

Please specify which medications:


31, 32, 33

Delete:

31. How long ago did you last have a flu vaccination? Would you say less than six months ago, six months to a year ago, more than a year ago, or never?

32. Have you received a Tdap (tetanus, diphtheria, pertussis) and/or Hepatitis B shot since you became pregnant?


33. Have you been tested for Hepatitis C since you became pregnant?


34-35

Changed order of these 2 questions:

34. Have you ever been diagnosed with any of the following:

35. When was the last time you were tested for sexually transmitted diseases or sexually transmitted infections?

Revision:

23. When was the last time you were tested for sexually transmitted diseases or sexually transmitted infections? Add ‘Don’t know” and “Declined to Answer”

34. Have you ever been diagnosed with any of the following infectious diseases?

Follow Up Box

Provided information/education about:

  • Keeping a healthy pregnancy weight including how much weight to gain during pregnancy

  • Nutrition

  • Exercise

  • Getting vaccines

  • Getting flu shot

  • Travel advisory

  • Sexually transmitted infections

  • Keeping teeth healthy

  • Health risks during pregnancy

  • Seat belt use during pregnancy

Provided information/education about:

  • Keeping a healthy pregnancy weight including how much weight to gain during pregnancy

  • Nutrition

  • Exercise

  • Importance of taking prenatal vitamins/ folic acid vitamin

  • Getting vaccines

  • Getting flu shot

  • Travel advisory

  • Sexually transmitted infections

  • Keeping teeth healthy

  • Health risks during pregnancy

  • Seat belt use during pregnancy

Section Header

MENTAL HEALTH

38

Change:

Over the past two weeks, how often have you experienced any of the following?

NOTE: Circle the number that matches the participant’s answer, and add the answers for both together to get the final score. If the final score is more than 3, further assessment is needed.

Revised: Added response options to the question:

37. Over the past two weeks, how often have you experienced any of the following? Would you say never, several days, more than half the days, or nearly every day?

NOTE: Enter the number that matches the participant’s answer in the last column, and add the answers for both together to get the final score. If the final score is more than 3, further assessment is needed.

Section Header

SUBSTANCE USE

39

Change:

In the past year, how often have you used the following?


Revision:

38. In the past 12 months, how often have you used the following?

42

Delete:

On average, about how many hours per day are you in the same room or vehicle with another person who is smoking?


43

Change:

Which of the following statements would you say best describes your alcohol consumption, INCLUDING beer and wine coolers? Please read the following responses out loud.

Revision:

41. Which of the following statements would you say best describes your current alcohol use, INCLUDING beer and wine coolers?

Section Header

PERSONAL SAFETY

44

Change:

We are concerned about the safety of all participants. Please answer the following questions so that we can help you if needed.

Revision:

42. We are concerned about the safety of all participants. Please answer the following questions about experiences that you may have had during the last 12 months so that we can help you if needed.

Insert


Add:

43. Do you keep guns at home?

 https://brightfutures.aap.org/Bright%20Futures%20Documents/15-Infancy.pdf​ (p. 268)

Follow Up Box

Change:

Provided information/ education about what to do if you have or someone you know has a partner that hurts them physically

Revision:

Provided information/ education about:

  • What to do if you have or someone you know has a partner that hurts them physically

  • Gun safety

Section Header

STRESS AND DISCRIMINATION

51

Change:

Stem: The next set of questions asks you about how other people have treated you. In your day-to-day life, how often have any of the following things happened to you?



You receive poorer service than other people at restaurants or stores.

Revision: Added to stem:

45. The next set of questions asks you about how other people have treated you. In your day-to-day life, how often have any of the following things happened to you? Would you say almost every day, at least once a week, a few times a year, less than once a year, or never?


45.2You receive poorer service than other people at restaurants, stores, or social services.

53

Delete:

The following statements are about the way you handle life events.


Section Header

Social Support / Father Involvement

SOCIAL SUPPORT / FATHER OR PARTNER INVOLVEMENT

54

Delete:

54.3 To help with daily chores if you were sick

Revision:

47. Added “to” to stem, and modified response options by removing “to” from each.

47.3 Help with daily chores?

47.4 Help you if you were sick?

55

Change:

What is your baby’s father’s role in your life?

  • Partner is deceased 

  • Partner is incarcerated

  • Assists with housework and/or runs errands (ex: grocery shopping)

  • Attends prenatal appointments and/or childbirth classes

  • Provides emotional support

  • Provides financial support

  • Partner plays no role / is not involved

  • Other (please specify):_____________________

  • Declined to answer (Go to question

Revision:

48.1 What is your partner’s or the father of your baby’s role in your life?

Select all that apply.

  • Partner or father of baby is deceased 

  • Partner or father of baby is incarcerated

  • Assists with housework and/or runs errands (ex: grocery shopping)

  • Attends prenatal appointments and/or childbirth classes

  • Provides emotional support

  • Provides financial support

  • Partner or father of baby plays no role / is not involved

  • Other (please specify): ________

  • Declined to answer

55.1

Modify and move ahead of old Q 55.

Change:

Would you describe father of this baby as:

Revision:

48. Would you describe your partner or the father of this baby as:

Select only one.

  • Involved in my pregnancy and supportive of me

  • Involved but not supportive of me

  • Aware that I’m pregnant but not involved

  • Not aware that I’m pregnant

Staff: DO NOT READ OUT LOUD:

  • Declined to answer

56 & 57

Delete:

56. Is there someone you can count on to help you during this pregnancy and with your new baby

57. Who do you count on for support?


Section Header

REPRODUCTIVE LIFE PLANNING

59

Delete:

What family planning method(s) do you plan to use until you or your partner are ready to become pregnant again?

49. Do you and your partner have a method of birth control that you plan to use until you are ready to become pregnant again?

  • Yes

  • No

  • Don’t know

  • Declined to answer

Follow Up Box

Delete:

  • Provided information/education about family planning or birth control

  • Provided information/education about birth control or family planning/birth spacing









POSTPARTUM: DESIGN CHANGED TO CAPTURE SINGLETON OR MULTIPLE BIRTHS


Please remember that Baby 1 should be the baby that was born 1st.

Baby 2 should be the baby that was born 2nd. Baby 3 should be the baby that was born 3rd. And Baby 4 should be the baby that was born 4th. This applies to all questions regarding the children.

___________________________________

Responses are laid out in table format to capture info for all babies if there is more than one.

Section Header

PREGNANCY OUTCOME

1

Change:

Please tell me what the outcome was of your pregnancy.

Revision: note responses are changed.

1. Please tell me the outcome of your pregnancy.

  • Live birth - single baby (Go to question 1.1)

  • Live birth - multiples (twins, triplets, etc.) Please indicate __________(Go to question 1.1)

  • Miscarriage (Go to question 14)

  • Ectopic or tubal pregnancy (Go to question 14)

  • Abortion (Go to question 14)

  • Fetal death/stillbirth (Go to question 1.1)

  • Declined to answer (Go to question 14)

Insert after Q1.1


Staff Instructions:

If the outcome of the pregnancy was a miscarriage, tubal or ectopic pregnancy, abortion, or fetal death or stillbirth, staff need to be cognizant of the sensitivity of the mother, and potentially delay completing this screening form until a more appropriate time.

1.3

Delete:

1.3 Was your labor induced?

Add:

1.3 Was your baby/were your babies born vaginally or by C-section?

1.4.1

Delete:

1.4.1 If baby was delivered by C-section: What were the reasons you had a cesarean section (C-section)? Was it because…


Section Header

INFANT CARE

2.1

How many days, weeks or months did you breastfeed or pump breast milk for your child?

Add response option: Still/Currently breastfeeding

Section Header

Change

SAFE SLEEP & CAR SAFETY

INFANT SAFETY

6

In the past 2 weeks, how often has your new baby slept alone in his or her own crib or bed?

Added to stem:

In the past 2 weeks, how often has your new baby/have your new babies slept alone in his or her/their own crib or bed? Would you say always, often, sometimes, rarely, or never?

7

Change:

STAFF: PLEASE READ OUT LOUD and ask participant to say “no” if it doesn't usually apply to her child or “yes” if it does.

Please tell us how your new child most often slept in the past 2 weeks.

Sleeping Location

Yes

No

In a crib, bassinet, or pack and play



On a twin or larger mattress or bed



On a couch, sofa, or armchair



In an infant car seat or swing



With a blanket



With toys, cushions, or pillows, including nursing pillows



With crib bumper pads (mesh or non-mesh



In a sleeping sack or wearable blanket





Revision:

7. Please tell us how your new baby most often slept in the past 2 weeks.

STAFF: PLEASE READ each sleeping location to participant and select a response for each sleeping location for each baby.

Sleeping Location

Baby 1

Baby 2

In a crib, bassinet, or pack and play



On a twin or larger mattress or bed



On a couch, sofa, or armchair



In an infant car seat or swing



With a blanket



With toys, cushions, or pillows, including nursing pillows



With crib bumper pads (mesh or non-mesh



In a sleeping sack or wearable blanket





Insert


Moved from Substance Use Section:

9. On average, how many hours per day is your baby/are your babies in the same room or vehicle with another person who is smoking?

Please enter number of hours baby is in the same room or vehicle with another person who is smoking, or select one response only for each baby.




Follow up box:

Provided information/education about:

  • Safe sleep positions, safe sleep environment

  • Car seat safety (installation, placement in car, rear facing, checking weight and height limits)

Provided information/education about:

  • Safe sleep positions, safe sleep environment

  • Car seat safety (installation, placement in car, rear facing, checking weight and height limits)

  • Effects of tobacco exposure on infant

Section Header

Change

BABY INSURANCE / ACCESS TO CARE

BABY INSURANCE / ACCESS TO CARE/MEDICAL HOME

9

Do you have one or more persons you think of as your baby’s personal doctor or nurse?

  • Yes (Go to question 9.1)

  • No (Go to question 10)

  • Don’t know (Go to question 10)

  • Declined to answer (Go to question 10)

10. Do you have one or more persons you think of as your baby’s/babies’ personal doctor or nurse?

  • Yes, one person

  • Yes, more than one person

  • No

  • Don’t know

  • Declined to answer

9.1

Delete:

9.1 Is there one person or more than one person?



10.1

Change:

What kind of place does your baby go to most often when he/she is sick or you need advice about his/her health? Is it a doctor’s office, emergency room, hospital outpatient department, clinic or some other place?

  • Doctor’s Office

  • Hospital Emergency Room

  • Hospital Outpatient Department

  • Clinic or Health Center

  • Retail Store Clinic or “Minute Clinic”

  • School (Nurse’s Office, Athletic Trainer’s Office)

  •  Does Not Go To One Place Most Often

  • Some other place (Go to question 10.2)

Revision:

11. What kind of place does your baby go to most often when he/she is sick or you need advice about his/her health? Is it a doctor’s office, emergency room, hospital outpatient department, clinic or some other place?

  • Doctor’s Office

  • Hospital Emergency Room

  • Hospital Outpatient Department

  • Clinic or Health Center

  • Retail Store Clinic or “Minute Clinic”

  • School (Nurse’s Office, Athletic Trainer’s Office)

  • Some other place

10.2

Delete:

10.2 Please identify the usual place of care:

  • Friend/Relative

  • Mexico/Other Locations Out Of Us

  • Other ______________________



Section Header

REPRODUCTIVE LIFE PLANNING

13

Change:

Do you plan to have any children at any time in your future?

Revision:

14. Do you plan to have any more children?

13.2

Change:

Would you like to become pregnant in the next year?

Revision:

14.2 Would you like to become pregnant in the next 12 months?

13.3

Change:

How long would you like to wait until you or your partner becomes pregnant?

Revision: Delete: “…or your partner…”

14.3 How long would you like to wait until you become pregnant?

14

Remove:

“currently” from the stem

Revision:

15. Are you using any form of contraception or birth control to either prevent pregnancy or prevent sexually transmitted infections?

14.1

Delete:

14.1. What kind of birth control are you or your husband or partner using now to keep from getting pregnant or to prevent sexually transmitted diseases?



15 & 15.1

Delete:

15. What family planning method do you plan to use to avoid pregnancy?

15.1. How sure are you that you will be able to use this method without any problems- not at all confident, somewhat confident, or very confident?



Follow up Box

Change:

Provided information/education about family planning or birth control

Revision:

Provided information/education about birth control or family planning/birth spacing.

Section Header

Change

Demographics

Social Determinants of Health

Insert



Insert:

19. How many people are supported by this income?

STAFF: Enter number of people.

_____ Adults age 18 or older

_____ Children age 18 or younger


  • Don’t know

Declined to answer

19-20

Delete:

19. How often has it been very hard to get by on your family’s income, by this I mean to pay for food or housing?

20. How often do you have transportation to or from your medical appointments?



23

Delete:

How do you feel about your current housing situation--do you feel very stable and secure, fairly stable and secure, just somewhat stable and secure, fairly unstable and insecure, or very unstable and insecure?

Add:

22. Do you have any housing concerns?

  • Yes (Go to question 18)

  • No (Go to question 18)

  • Don’t know (Go to question 18)

  • Declined to answer

24

Delete: response option: “Ineligible”

23. Add response option: “Not Applicable”

25

Delete:

25. Have you ever had a case with Child Protective Services?



Section Header

NEIGHBORHOOD AND COMMUNITY

26.3

Delete:

There are people I can count on in this neighborhood or community.



Section Header

MEDICAL HOME / ACCESS TO CARE/HEALTH INSURANCE

30

Change:

Do you have one or more persons you think of as your personal doctor or nurse?

  • Yes

  • No

  • Don’t know

  • Declined to answer



Revision:

Changed response options to include “yes, one person” and “Yes, more than one person”

29. Do you have one or more persons you think of as your personal doctor or nurse?

  • Yes, one person

  • Yes, more than one person

  • No

  • Don’t know

  • Declined to answer

30.1

Delete:

Is there one person or more than one person?



31

Delete:

What kind of place do you go to most often when you are sick or you need advice about your health? Is it a doctor’s office, emergency room, hospital outpatient department, clinic or some other place?

  • Doctor’s Office

  • Hospital Emergency Room

  • Hospital Outpatient Department

  • Clinic or Health Center

  • Retail Store Clinic or “Minute Clinic”

  • School (Nurse’s Office, Athletic Trainer’s Office)

  •  Does Not Go To One Place Most Often

  • Some other place (Go to question 10.2)

Revision:

30. What kind of place do you go to most often when you sick or you need advice about your health? Is it a doctor’s office, emergency room, hospital outpatient department, clinic or some other place?

  • Doctor’s Office

  • Hospital Emergency Room

  • Hospital Outpatient Department

  • Clinic or Health Center

  • Retail Store Clinic or “Minute Clinic”

  • School (Nurse’s Office, Athletic Trainer’s Office)

  • Some other place

33

Change:

33. Since your child was born, have you had a postpartum checkup for yourself? A postpartum checkup is the regular checkup a woman has 4-6 weeks after she gives birth.

Revision:

32. Since your child was /children were born, have you had a postpartum visit for yourself? A postpartum visit is the regular checkup a woman has 4-6 weeks after she gives birth.

33.1

Change:

When?

Revision:

32.1 When did you have your postpartum visit?

33.2

33.2 Do you have one scheduled?

  • Yes: Please indicate when________________

  • No

  • Declined to answer

Revision:

32.2 Do you have one scheduled?

  • Yes: Please indicate date of scheduled appointment: ___ / __ / ____ (month/day/year)

  • No

  • Declined to answer

Section

Header

MENTAL HEALTH

40

Change:

Over the past two weeks, how often have you experienced any of the following?


NOTE: Circle the number that matches the participant’s answer, and add the answers for both together to get the final score. If the final score is more than 3, further assessment is needed.

Revision: Added possible responses to question stem:


39. Over the past two weeks, how often have you experienced any of the following, would you say never, several days, more than half the days, or nearly every day?


NOTE: Enter the number that matches the participant’s answer in the last column, and add the answers for both together to get the final score.

Section Header

SUBSTANCE USE

41

Change:

In the past year, how often have you used the following?


Revision:

40. In the past 12 months, how often have you used the following?

43

Delete:

On average, about how many hours per day are you in the same room or vehicle with another person who is smoking?


44

Moved to Infant Safety Section

#9

Section Header

PERSONAL SAFETY

45

Change:

We are concerned about the safety of all participants. Please answer the following questions so that we can help you if needed.

Revision:

43. We are concerned about the safety of all participants. Please answer the following questions about experiences that you may have had during the past twelve months so that we can help you if needed.


Insert


Add:

44. Do you keep guns at home?

 https://brightfutures.aap.org/Bright%20Futures%20Documents/15-Infancy.pdf​ (p. 268)

Follow up Box

Change:

Provided information / education about what to do if you have or someone you know has a partner that hurts them physically


Revision:

Provided information / education about:

  • What to do if you have or someone you know has a partner that hurts them physically

  • Gun safety

Section Header

STRESS AND DISCRIMINATION

47 & 47.2

Change:

The next set of questions asks you about how other people have treated you. In your day-to-day life, how often have any of the following things happened to you?

You receive poorer service than other people at restaurants or stores.

Revision:

46. The next set of questions asks you about how other people have treated you. In your day-to-day life, how often have any of the following things happened to you? Would you say almost every day, at least once a week, a few times a year, less than once a year, or never?

46.2You receive poorer service than other people at restaurants, stores, or social services.

49

Delete:

The following statements are about the way you handle life events


Section Header

Father Involvement / Social Support

Social Support / Father or Partner Involvement

50.3

Delete:

To help with daily chores if you were sick?

Revision:

Added “to” to stem, and modified response options by removing “to” from each.

48.3 Help with daily chores?

48.4 Help you if you were sick?

51

Change:

What is the baby’s father’s role in your life?

  • Baby’s father is deceased w

  • Baby’s father is incarcerated

  • Cares for baby (feeding, bathing, etc.)

  • Assists with housework and/or runs errands (ex: grocery shopping)

  • Attends medical appointments

  • Provides emotional support

  • Provides financial support

  • Baby’s father plays no role/is not involved

  • Other (please specify):________________

  • Declined to answer

Revision:

49.1 What is your partner’s or the father of your baby’s /babies’ role in your life?

  • Partner or father of baby/babies is deceased

  • Partner or father of baby/babies is incarcerated

  • Cares for baby/babies (feeding, bathing, etc.)

  • Assists with housework and/or runs errands (ex: grocery shopping)

  • Attends medical appointments

  • Provides emotional support

  • Provides financial support

  • Partner or father of baby/babies plays no role/is not involved

  • Other (please specify):________________

  • Declined to answer

51.1

Change:

51.1 Would you describe the father of this baby as

Revision:

49. Would you describe your partner or the father of your baby/babies as:

  • Involved in my pregnancy and supportive of me

  • Involved but not supportive of me

  • Aware that I’m pregnant but not involved

  • Not aware that I’m pregnant

Staff: DO NOT READ OUT LOUD:

  • Declined to answer

52 & 53

Delete:

52. Is there someone you can count on to help you with your baby?

53. Who do you count on for support?






PARENTING/INTERCONCEPTION SCREENING FORM

Please remember that Child 1 should be the child that was born 1st.

Child 2 should be the child that was born 2nd. Child 3 should be the child that was born 3rd. And Child 4 should be the child that was born 4th. This applies to all questions regarding the children.

Section Header

Change

Child Health and Safety

Child Health Status

1

Change:

1. What is the date of birth of your youngest child? ________________

Revision:

1. When was the last time you gave birth? __ / __ / ____

Add



1.1 How would you describe this child’s health? [NCHS QA1- modified]

Excellent

Very Good

Good

Fair

Poor

Child is deceased.

Child 1







Child 2







Etc.









2.1

Change:

How many days, weeks or months did you breastfeed or pump breast milk for your child?

_______ Number of days OR weeks OR months (please write in the number provided by the participant and circle days, weeks or months)

  • Don’t know

  • Declined to answer

Added:

2.1 “still/currently breastfeeding” as a response option

3

Change format:

3. Please indicate the number of days you or a family member read to your child during the past week. Reading includes books with words or pictures but not books read by an audio tape, record, CD, or computer.

STAFF: Record the total number of days, from 0 days (no days) to 7 days (everyday).

____0 DAYS ____1 DAY____2 DAYS____3 DAYS____4 DAYS____5 DAYS____6 DAYS____7 DAYS

  • Don’t know

Revision:

3. Please tell me the number of times you or a family member read to your child during the past week. Reading includes books with words or pictures but not books read by an audio tape, record, CD, or computer.

STAFF: Record the total number of days, from 0 days (no days) to 7 days (everyday).

Times per week (Record the number)

Don’t know

Declined to answer

Child 1




Child 2






Section Header

Safe Sleep

Child Safety

7

Change:

Please tell us how your new child most often slept in the past 2 weeks.

STAFF: PLEASE READ the choices out loud and ask participant to say “no” if it doesn't usually apply to her child or “yes” if it does.

Sleeping Location

Yes

No

In a crib, bassinet, or pack and play



On a twin or larger mattress or bed



On a couch, sofa, or armchair



In an infant car seat or swing



With a blanket



With toys, cushions, or pillows, including nursing pillows



With crib bumper pads (mesh or non-mesh



In a sleeping sack or wearable blanket





Revision:

Please tell us how your child most often slept in the past 2 weeks.


STAFF: PLEASE READ each sleeping location to participant and select a response for each sleeping location for each child.

Sleeping Location

Child 1

Child 2

ETC. Child 3

Child 4

In a crib, bassinet, or pack and play





On a twin or larger mattress or bed





On a couch, sofa, or armchair





In an infant car seat or swing





With a blanket





With toys, cushions, or pillows, including nursing pillows





With crib bumper pads (mesh or non-mesh





In a sleeping sack or wearable blanket







Add /Move

Move Q 44 : to Infant Safety Section



10. On average, how many hours per day is your child/are your children in the same room or vehicle with another person who is smoking?

Add



Add:

11. Do you keep guns at home?

 https://brightfutures.aap.org/Bright%20Futures%20Documents/15-Infancy.pdf​ (p. 268)

Follow Up Box

Change:

Provided information/education about:

  • Safe sleep positions

  • Car seat safety (installation, placement in car, rear facing, checking weight and height limits)

  • Lead poisoning

Revision:

Provided information/education about:

  • Safe sleep positions

  • Car seat safety (installation, placement in car, rear facing, checking weight and height limits)

  • Lead poisoning

  • Effects of tobacco exposure

  • Gun Safety

Section Header

CHILD INSURANCE / ACCESS TO CARE / MEDICAL HOME

10

Change:

Do you have one or more persons you think of as your child’s personal doctor or nurse?

  • Yes

  • No

  • Don’t know

  • Declined to answer



Revision:

12.

Changed response options to include “yes, one person” and “Yes, more than one person”,

9. Do you have one or more persons you think of as your child’s personal doctor or nurse?

  • Yes, one person

  • Yes, more than one person

  • No

  • Don’t know

  • Declined to answer

10.1

Delete:

10.1 Is there one person or more than one person?



11.1

Change:

11.1 What kind of place does your child go to most often when he/she is sick or you need advice about his/her health? Is it a doctor’s office, emergency room, hospital outpatient department, clinic or some other place?

  • Doctor’s Office

  • Hospital Emergency Room

  • Hospital Outpatient Department

  • Clinic or Health Center

  • Retail Store Clinic or “Minute Clinic”

  • School (Nurse’s Office, Athletic Trainer’s Office)

  • Does Not Go To One Place Most Often

  • Some other place (Go to question 11.2

Revision:

13. What kind of place does your child go to most often when he or she is sick or you need advice about his or her health? Is it a doctor’s office, emergency room, hospital outpatient department, clinic or some other place?

  • Doctor’s Office

  • Hospital Emergency Room

  • Hospital Outpatient Department

  • Clinic or Health Center

  • Retail Store Clinic or “Minute Clinic”

  • School (Nurse’s Office, Athletic Trainer’s Office)

  • Some other place

11.2

Delete:

Please identify the usual place of care:

  • Friend/Relative

  • Mexico/Other Locations Out Of Us

Other ______________________



13.1

Did your child receive vaccines during this visit?

15.1 Did your child receive age-appropriate vaccines during this visit?

Section Header

REPRODUCTIVE LIFE PLANNING

Insert


Add:

16. Are you pregnant now?

Select one only.

  • Yes (Go to questions 58 and 58.1, ) then complete Prenatal Screening Form

  • No (Go to question 17)

  • Don’t know (Go to question 17)

  • Declined to answer (Go to question 16)

14

Change:

Do you plan to have any children at any time in your future?

Revision:

17. Do you plan to have any more children?

14.2

Change:

Would you like to become pregnant in the next year?

Revision:

17.2. Would you like to become pregnant in the next 12 months?

14.3

Change:

How long would you like to wait until you or your partner becomes pregnant?

Revision:

17.3 How long would you like to wait until you become pregnant?

15.1

Delete:

What kind of birth control are you or your husband or partner using now to keep from getting pregnant or to prevent sexually transmitted diseases?


16

Delete:

What family planning method do you plan to use to avoid pregnancy?


16.1

Delete:

How sure are you that you will be able to use this method without any problems- not at all confident, somewhat confident, or very confident?


Section Header

Change

DEMOGRAPHICS

SOCIAL DETERMINANTS OF HEALTH

Insert


21. Inserted: After income question (Q19), How many people are supported by this income?

STAFF: Enter number of people.

_____ Adults age 18 or older

_____ Children age 18 or younger

  • Don’t know

  • Declined to answer

20

Delete:

How often has it been very hard to get by on your family’s income, by this I mean to pay for food or housing?


Section Header

Delete:

SOCIAL DETERMINANTS OF HEALTH

21

Delete:

How often do you have transportation to or from your medical appointments?


24

Delete:

How do you feel about your current housing situation--do you feel very stable and secure, fairly stable and secure, just somewhat stable and secure, fairly unstable and insecure, or very unstable and insecure?

Add:

23. Do you have any housing concerns?

  • Yes (Go to question 23.1)

  • No (Go to question 24)

  • Don’t know (Go to question 24)

  • Declined to answer (Go to question 24)

25

Delete: “Ineligible” as a response option

26. Add “Not applicable” as a response option

26

Delete:

Have you ever had a case with Child Protective Services?


Section Header

NEIGHBORHOOD AND COMMUNITY

27.3

Delete:

There are people I can count on in this neighborhood or community.


Section Header

MEDICAL HOME / ACCESS TO CARE

31

Change:

Do you have one or more persons you think of as your personal doctor or nurse?

  • Yes

  • No

  • Don’t know

  • Declined to answer


Modify to incorporate responses from 31.1

Revision:

Do you have one or more persons you think of as your personal doctor or nurse?

  • Yes, one person

  • Yes, more than one person

  • No

  • Don’t know

  • Declined to answer

31.1

Delete:

Is there one person or more than one person?


32

Delete:

Is there a place that you USUALLY go for care when you are sick or need advice about your health?


38.1

Change:

Approximately how many weeks postpartum did you have your postpartum checkup?

_______________Weeks

Revision:

39.1. Approximately how many weeks postpartum did you have your postpartum checkup?

_______________Number of Weeks

39

Delete:

superscript “1” after Autoimmune disease label

Revision:

40. Move question about gestational diabetes so that if comes immediately after Diabetes question

39.1

Delete:

Have you been seen in the emergency room or hospitalized for any of these conditions within the last 6 months?


39.2

Change:

Please tell me which condition or conditions you have been seen for in the emergency room hospital within the past 6 months.

Revision:

40.1. Please tell me which condition or conditions you have been seen for by a health care provider in the past 6 months.

41.1

Delete:

Ask participant specifically about each medication

Add explanation:

42. Are you taking any of the following medications? We are asking about these medications because they are known to have an impact on the fetus.

41.2

Delete:

Are you taking these medications as prescribed?



Add:

43. Does your provider know all the medications that you are taking? Please tell me for prescribed as well as over the counter medications.

  • Yes

  • No

  • Don’t know

  • Declined to answer

41.3

Delete:;

Please specify which medications:


45& 46

Changed order of these 2 questions

Revision:

47. When was the last time you were tested for sexually transmitted diseases or sexually transmitted infections? Add ‘Don’t know” and “Declined to Answer”

48. Have you ever been diagnosed with any of the following infectious diseases?

Section Header

MENTAL HEALTH

48

Change:

NOTE: Circle the number that matches the participant’s answer, and add the answers for both together to get the final score. If the final score is more than 3, further assessment is needed.

Added response options to the question:

48. Over the past two weeks, how often have you experienced any of the following? Would you say never, several days, more than half the days, or nearly every day?

NOTE: Enter the number that matches the participant’s answer in the last column, and add the answers for both together to get the final score. If the final score is more than 3, further assessment is needed.

Section Header

SUBSTANCE USE

49

Change:

In the past year, how often have you used the following?

Revision:

51. In the past 12 months, how often have you used the following?

51

Delete:

On average, about how many hours per day are you in the same room or vehicle with another person who is smoking?


52

Move:

On average, about how many hours a day is your child in the same room or vehicle with someone who is smoking?

Moved to Q10:

On average, how many hours per day is your child/are your children in the same room or vehicle with another person who is smoking?

Section Header

PERSONAL SAFETY

53

Change:

We are concerned about the safety of all participants. Please answer the following questions so that we can help you if needed.

Added:

51. We are concerned about the safety of all participants. Please answer the following questions about experiences that you may have had during the past twelve months so that we can help you if needed.

55 & 55.2

Stem: The next set of questions asks you about how other people have treated you. In your day-to-day life, how often have any of the following things happened to you?

55.2You receive poorer service than other people at restaurants or stores.

Added:

55. Added possible responses to question:

Stem: The next set of questions asks you about how other people have treated you. In your day-to-day life, how often have any of the following things happened to you? Would you say almost every day, at least once a week, a few times a year, less than once a year, or never?


55.2 You receive poorer service than other people at restaurants, stores, or social services.

57

Delete:

The following statements are about the way you handle life events.


Section Header

SOCIAL SUPPORT / FATHER INVOLVEMENT

SOCIAL SUPPORT / FATHER OR PARTNER INVOLVEMENT

58.3

Delete:

To help with daily chores if you were sick

57. Added “to” to stem, and modified response options by removing “to” from each.

Modified question 58.3 to 2 separate questions:

57.3 Help with daily chores?

57.4 Help you if you were sick?

59 & 59.1

Change:

59. What is the baby’s father’s role in your life?

  • Baby’s father is deceased w

  • Baby’s father is incarcerated

  • Cares for baby (feeding, bathing, etc.)

  • Assists with housework and/or runs errands (ex: grocery shopping)

  • Attends medical appointments

  • Provides emotional support

  • Provides financial support

  • Baby’s father plays no role/is not involved

  • Other (please specify):________________

  • Declined to answer

Added:

STAFF: Please ask the next two questions only if baby is alive.



58. Would you describe your partner or the father of your child as:

STAFF: Please read responses to participant, and select only one response.

  • Involved and supportive of me and my child

  • Involved but not supportive of me or my child

  • Not involved

Staff: DO NOT READ OUT LOUD:

  • Declined to answer

59.1

Would you describe the father of your child as:

  • Involved and supportive of me and my child

  • Involved but not supportive of me or my child

  • Not involved

  • Declined to answer

58.1 What is your partner’s or the father of your baby’s /babies’ role in your life?

  • Partner or father of baby/babies is deceased

  • Partner or father of baby/babies is incarcerated

  • Cares for baby/babies (feeding, bathing, etc.)

  • Assists with housework and/or runs errands (ex: grocery shopping)

  • Attends medical appointments

  • Provides emotional support

  • Provides financial support

  • Partner or father of baby/babies plays no role/is not involved

  • Other (please specify):________________

  • Declined to answer

60

Delete:

Is there someone you can count on to help you with your child?



61

Delete:

Who do you count on for support?







2 https://www.acog.org/-/media/Statements-of-Policy/Public/2014GunViolenceAndSafety.pdf?dmc=1&ts=20160823T1409574528

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AuthorKatie Morrison
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