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Medicaid Postpartum Survey
June 8, 2015
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of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938TBD . The time required to complete this information collection is estimated to average 30 minutes per response, including the time
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Prepared by Mathematica Policy Research
Frequently Used Fills
In the boxes below, please list fills that are repeated frequently in your questionnaire requirements. These
must come from a single source (whether from a preload or a question). The fills specified here do not
need to be specified in the fill condition box each time they appear in a question.
Fill
Source / Condition
First Used at Question #:
EXAMPLE 1: [PARENT]
Fill from Preload File: RespName
A2
EXAMPLE 2: [he / she]
he IF A5 = 1; she IF A5 = 2
E16
Prepared by Mathematica Policy Research
Version History:
Version Name/Notes
Date
Created/Revised
Revised by
40400 Appendix A Medicaid Postpartum CATI Survey (12-23-14 dab)
v1.docx
Dot formatted for Erin Panzarella
12/23/14
Dot B.
Medicaid postpartum CATI survey (3-2-15 sf).docx
Sheena formatted for So O’Neil
3/2/15
Sheena F.
EPMHP Medicaid Postpartum Survey CATI (3-10-15 ac).docx
Allie updated all fills/skips etc. to match new numbering system for
So O’Neil
3/10/15
Allie C
Appendix A1a - Medicaid Postpartum CATI Survey.docx
Sheena checked for formatting errors
6/11/15
Sheena F.
Prepared by Mathematica Policy Research
FRONT END SCREENER
ALL
FILL RESPONDENT PHONE NUMBER AND EXTENSION FROM PRELOAD
MakeDialPhone.
PHONE NUMBER DETAILS:
PHONE NUMBER= [PHONE NUMBER]
EXTENSION= [EXTENSION]
CODE ONE ONLY
AUTO DIAL .............................................................................................................. 1 CallDialer
MANUAL DIAL ......................................................................................................... 2 DialResult
QUICK EXIT ............................................................................................................. 3 Exit
RESPONDENT CALLING IN ................................................................................... 4 Hello1
MAKEDIALPHONE=1
CallDialer.
INTERVIEWER:
PLEASE CLICK ON THE BUTTON IN THE FIELD WITH THREE DOTS TO
MAKE THE CALL.
CALL OUTs
DialResult.
INTERVIEWER:
CODE RESULT OF DIALING
CODE ONE ONLY
SOMEONE ANSWERS............................................................................................ 1 Hello
NO ANSWER ........................................................................................................... 2 Exit
BUSY........................................................................................................................ 3 Exit
ANSWERING MACHINE ......................................................................................... 4 Verified
ANSWERING SERVICE .......................................................................................... 5 AnsService
PRIVACY MANAGER .............................................................................................. 6 Exit
PHONE/LINE PROBLEMS ...................................................................................... 7 PhoneProb
CHANGED TO NEW NUMBER ............................................................................... 8 PhoneNum
DIALRESULT=4
NAME FROM PRELOAD
Verified.
INTERVIEWER:
DID RECORDING VERIFY [NAME] AT THIS NUMBER?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
Prepared by Mathematica Policy Research
1
Finished
Finished
DIALRESULT=5
AnsService.
INTERVIEWER:
IS THIS THE ANSWERING SERVICE FOR [NAME]?
CODE ONE ONLY
YES, [NAME]’S ANSWERING SERVICE ................................................................ 1 Finished
NO, DEFINITELY NOT [NAME]’S ANSWERING SERVICE ................................... 2 Finished
DON’T KNOW, WOULDN’T SAY, NO NAME WAS GIVEN .................................... 3 AnsOther
ANSSERVICE=3
AnsOther.
INTERVIEWER:
PLEASE ENTER WHAT WAS SAID
___________________________________________________ (STRING 100)
Finished
DIALRESULT=7
PhoneProb.
INTERVIEWER:
CODE PHONE PROBLEM
CODE ONE ONLY
NOT IN SERVICE; DISCONNECTED; NOT WORKING ......................................... 1
TEMPORARILY NOT IN SERVICE ......................................................................... 2
CIRCUIT PROBLEMS; CIRCUITS OVERLOADED ................................................ 3
FAST BUSY; FAST RING; NO RING ...................................................................... 4
COMPUTER/FAX LINE............................................................................................ 5
PAGER ..................................................................................................................... 6
CELL PHONE .......................................................................................................... 7
OTHER PHONE DEVICE ........................................................................................ 8
Prepared by Mathematica Policy Research
2
Exit
Exit
Exit
Exit
Exit
Exit
Exit
Exit
DOCALLBACK = No
AUTOFILL INTNAME
MAKEDIALPHONE=1,2 (call-out) text = My name is [INTNAME] and I am calling from Mathematica Policy
Research on behalf of The Centers for Medicare & Medicaid Services. May I please speak with [FULL
NAME]?
MAKEDIALPHONE=4 (call-in) text = My name is [INTNAME]. Am I speaking with [FULL NAME]?]
Hello.
[Hello, my name is [INTNAME] and I am calling from Mathematica Policy Research
on behalf of The Centers for Medicare & Medicaid Services. May I please speak to
[FULL NAME]?]
[My name is [INTNAME]. Am I speaking with [FULLNAME]?]
CODE ONE ONLY
SPEAKING TO [FIRSTNAME] ................................................................................. 1
[FIRSTNAME] COMES TO THE PHONE ................................................................ 2
PERSON ASKS WHAT CALL IS ABOUT ................................................................ 3
NEED TO CALLBACK ............................................................................................. 4
[FIRSTNAME] HAS A HEALTH PROBLEM............................................................. 5
[FIRSTNAME] IS IN AN INSTITUTION.................................................................... 6
[FIRSTNAME] HAS MOVED .................................................................................... 7
[FIRSTNAME] DOES NOT SPEAK ENGLISH......................................................... 8
NEVER HEARD OF [FULLNAME]/WRONG NUMBER ........................................... 9
GO TO SampMemb
GO TO SampMemb
GO TO WhatAbout
GO TO Callback
GO TO HealthProb
GO TO Institution
GO TO KnowWhere
GO TO Lang
Status 530, GO TO
Thanks
HUNG UP DURING INTRODUCTION..................................................................... 10 Status 640, Exit
REFUSED ................................................................................................................ r Status 220, Exit
HELLO = 3
WhatAbout
[FIRSTNAME] should have received a letter from Mathematica Policy Research
about a survey of new moms for The Centers for Medicare & Medicaid. May I speak
with her now?
CODE ONE ONLY
[FIRSTNAME] COMES TO THE PHONE ................................................... 1
NEED TO CALLBACK ................................................................................ 2
[FIRSTNAME] HAS HEALTH PROBLEM/IS DECEASED.......................... 3
[FIRSTNAME] IS IN AN INSTITUTION....................................................... 4
[FIRSTNAME] MOVED ............................................................................... 5
[FIRSTNAME] DOES NOT SPEAK ENGLISH............................................ 6
HUNG UP DURING INTRODUCTION........................................................ 8
SUPERVISOR REVIEW ............................................................................. 9
REFUSED ................................................................................................... r
Prepared by Mathematica Policy Research
3
GO TO SampMemb
GO TO Callback
GO TO HealthProb
GO TO Institution
GO TO KnowWhere
GO TO Lang
Status 640, Exit
Status 380, Exit
Status 220, Exit
HELLO = 5 OR WHATABOUT = 3
HealthProb.
ENTER TYPE OF HEALTH PROBLEM.
CODE ONE ONLY
HEARING PROBLEM ............................................................................... 1
SPEECH PROBLEM ................................................................................. 2
PHYSICAL PROBLEM .............................................................................. 3
COGNITIVE PROBLEM ............................................................................ 4
IN A COMA ............................................................................................... 5
DECEASED .............................................................................................. 6
REFUSED .................................................................................................. r
GO TO AmpTTY
GO TO AmpTTY
GO TO CallLater
Status 410, GO TO Thanks
Status 410 GO TO Thanks
GO TO Deceased
Status 210, Exit
HEALTHPROB = 1 OR 2
FILL FIRSTNAME
AmpTTY.
I can get on a phone that will amplify my voice or [FIRSTNAME]’s voice, or we
could use a TTY service. Would either of these help her to complete the interview?
CODE ONE ONLY
YES - USE AMPLIFIER PHONE .............................................................. 1
YES - USE TTY CAPABILITY ................................................................... 2
NO ............................................................................................................. 0
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
GO TO RespAvail
GO TO RespAvail
Status 411, GO TO Thanks
GO TO Callback
Status 210, GO TO Thanks
AMPTTY = 1 or 2
FIRSTNAME
RespAvail.
Is [FIRSTNAME] available now?
YES ............................................................................................................. 1
NO ............................................................................................................... 0
GO TO Callback
PROGRAMMER
If AmpTTY = 1, GO TO AmpPhone. If AmpTTY = 2, GO TO CallTTY
Prepared by Mathematica Policy Research
4
AMPTTY = 1 AND RESPAVAIL = 1
AmpPhone.
Please hold while I get the amplifier phone.
INTERVIEWER:
SET UP AMPLIFIER/WEAK SPEECH EQUIPMENT AND ASK
GATEKEEPER TO CALL [FIRSTNAME] TO THE PHONE.
CODE ONE ONLY
[FIRSTNAME] COMES TO THE PHONE ...................................... 1
NEED TO CALLBACK ................................................................... 2
GO TO SampMemb
GO TO Callback
AMPTTY = 2 AND RESPAVAIL = 1
CallTTY.
I will call back in a few minutes after I have the help of the TTY operator.
CODE ONE ONLY
ARRANGE CALL WITH OPERATOR ....................................................... 1
UNSUCCESSFUL -- NEED TO CALLBACK ............................................ 2
GO TO SampMemb
GO TO Callback
HEALTHPROB = 3
FILL FIRSTNAME
CallLater.
Will [FIRSTNAME] be able to talk on the telephone if I call back in a week or two?
CODE ONE ONLY
YES/MAYBE – CALLBACK ...................................................................... 1
NO ............................................................................................................. 0
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
GO TO Callback
Status 419, GO TO Thanks
GO TO Callback
Status 210, Exit
(HELLO = 5 OR WHATABOUT = 3) AND (HEALTHPROB = 7)
Deceased.
I am very sorry to hear that she passed away. I am calling on behalf of The Centers
for Medicare & Medicaid Services. A letter explaining why we are calling was
recently sent to [FIRSTNAME]. When did she pass away?
Thank you. Please accept my condolences. Goodbye.
PROGRAMMER:
SELECT NUMBER OF FIELDS
| | |/| | |/| | | |
MONTH DAY
YEAR
1-12
1-31
2016-2017
|
GO TO Thanks, Status 440
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
Prepared by Mathematica Policy Research
5
GO TO Thanks, Status 440
GO TO Thanks, Status 440
HELLO = 6 OR WHATABOUT = 4
Institution.
INTERVIEWER: ENTER TYPE OF INSTITUTION.
CODE ONE ONLY
HOSPITAL ................................................................................................ 1
NURSING HOME ...................................................................................... 2
ASSISTED LIVING FACILITY ................................................................... 3
GROUP HOME ......................................................................................... 4
JAIL OR PRISON ...................................................................................... 5
GO TO HomeSoon
GO TO Capable
GO TO Capable
GO TO Capable
Status 421, GO TO Thanks
INSTITUTION = 1
FIRSTNAME
HomeSoon.
Do you expect [FIRSTNAME] to come home from the hospital within a week or
two?
CODE ONE ONLY
YES ARRANGE CALLBACK .................................................................... 1
NO ............................................................................................................. 0
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
GO TO Callback
GO TO Capable
GO TO Callback
Status 210, Exit
(HELLO = 6 OR WHATABOUT = 4) AND (INSTITUTION = 2 OR 3 OR 4 OR HOMESOON = 0)
FIRSTNAME = RESPONDENT’S FIRST NAME
Capable.
I am calling about a survey we would like to conduct with [FIRSTNAME]. A letter
explaining why we are calling was recently sent to her. Would she be able to
answer questions herself or would someone need to answer on her behalf?
CODE ONE ONLY
[FIRSTNAME] IS ABLE TO RESPOND .................................................... 1
[FIRSTNAME] IS UNABLE TO RESPOND............................................... 2
GO TO Facility
Status 410, GO TO Thanks
Hello = 6 OR WhatAbout = 4 OR Institution = 2, 3 or 4 OR HomeSoon = 2 OR Capable = 1 or DK
Facility.
What is the name of the [hospital/group home/assisted living facility]?
STRING (50)
NAME
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
Prepared by Mathematica Policy Research
6
GO TO Contact
GO TO Contact
GO TO Contact
Hello = 6 OR WhatAbout = 4 OR Institution = 2, 3 or 4 OR HomeSoon = 2 OR Capable = 1 or DK
Contact.
Do you have the name of the administrator or a contact person there?
STRING (20)
FIRST NAME
STRING (20)
MIDDLE INITIAL/NAME
STRING (20)
LAST NAME
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
GO TO FacAddr
GO TO FacAddr
GO TO FacAddr
Hello = 6 OR WhatAbout = 4 OR Institution = 2, 3 or 4 OR HomeSoon = 2 OR Capable = 1 or DK
FacAddr.
What is the address of the hospital/group home/assisted living facility?
STRING (25)
STREET
STRING (25)
CITY
STRING (25)
STATE
| | | | | |-| | | | |
ZIP CODE
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
GO TO FacPhone
GO TO FacPhone
GO TO FacPhone
Hello = 6 OR WhatAbout = 4 OR Institution = 2, 3 or 4 OR HomeSoon = 2 OR Capable = 1 or DK
FacPhone.
May I please have the telephone number of the hospital/group home/assisted living
facility?
| | | |-| | | |-| | | | |
Status 899, GO TO Thanks
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
Prepared by Mathematica Policy Research
7
Status 380, GO TO Thanks
Status 380, GO TO Thanks
HELLO = 7 OR WHATABOUT = 5
S2 = FIRSTNAME
KnowWhere. Do you or anyone there know how we can reach [FIRSTNAME]?
YES ........................................................................................................... 1
NO ............................................................................................................. 0
Status 530, GO TO Thanks
DON’T KNOW ........................................................................................... d
Status 530, GO TO Thanks
REFUSED .................................................................................................. r
Status 530, GO TO Thanks
KNOWWHERE = 1
NewPhone.
| | | |-| | | |-| | | | |
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
GO TO NewAddr
GO TO NewAddr
GO TO NewAddr
KNOWWHERE = 1
NewAddr.
May I please have her address?
(STRING 25)
STREET
(STRING 25)
CITY
(STRING 25)
STATE
| | | | | |-| | | | |
ZIP CODE
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
See programmer box
See programmer box
PROGRAMMER:
IF NEWPHONE = D OR R, STATUS 530, GO TO THANKS, ELSE: STATUS 899, GO TO THANKS
Prepared by Mathematica Policy Research
8
HELLO = 8 or WHATABOUT = 6
Lang.
CODE LANGUAGE NEEDED TO COMPLETE INTERVIEW IF KNOWN
CODE ONE ONLY
SPANISH .................................................................................................. 1
OTHER LANGUAGE SPECIFY _____________ (STRING 20) ............. 99
DON’T KNOW ........................................................................................... d
Status 401, GO TO Thanks
Status 400, GO TO Thanks
Status 400, GO TO Thanks
HELLO = 1 OR 2 OR WHATABOUT = 1 OR AMPHHONE = 1 OR CALLTTY = 1
SampMemb.
I work for Mathematica Policy Research. Recently you may have received a letter
saying that we would be calling to ask you to take part in a survey of new mothers.
The survey will take approximately 25 minutes, and we will send you a $25 gift card
in the mail after you complete the survey to thank you for your time.
PROBE IF NEEDED:
Mathematica Policy Research is a well-known nonpartisan
research firm with headquarters in Princeton, NJ. The
Centers for Medicare & Medicaid Services has contracted
with Mathematica to conduct this study.
PROBE IF NEEDED:
Your participation is completely voluntary, but very
important. All your answers will be kept private.
CODE ONE ONLY
BEGIN INTERVIEW .................................................................................. 1
GO TO SC1
DID NOT GET LETTER ............................................................................ 2
GO TO NoLetter
WANTS MORE INFORMATION ............................................................... 3
GO TO MoreInfo
NOT A GOOD TIME.................................................................................. 4
GO TO Callback
HUNG UP DURING INTRODUCTION...................................................... 5
Status 640, Exit
SUPERVISOR REVIEW ........................................................................... 6
Status 380, Exit
REFUSED .................................................................................................. r
Status 200, Exit
SAMPMEMB = 2 OR WHATABOUT = 7
FILL [PROGRAM] FROM SAMPLE FILE
NoLetter.
The letter explained that we are conducting a study to learn about the ways new
moms get information about their health and their babies’ health. Can we begin
now?
CODE ONE ONLY
BEGIN INTERVIEW .................................................................................. 1
GO TO SC1
WANTS ANOTHER LETTER .................................................................... 2
GO TO ReadLetter
NOT A GOOD TIME.................................................................................. 3
GO TO Callback
HUNG UP DURING INTRODUCTION...................................................... 4
Status 640, Exit
REFUSED .................................................................................................. r
Status 200, Exit
Prepared by Mathematica Policy Research
9
NOLETTER = 2
ReadLetter.
May I read the letter to you and then we can begin?
CODE ONE ONLY
YES, READ THE LETTER FROM HARD COPY ...................................... 1
GO TO Screener/Survey
NO, WANTS ANOTHER LETTER FIRST ................................................. 2
GO TO SendLetter
HUNG UP DURING INTRODUCTION...................................................... 3
Status 640, Exit
REFUSED .................................................................................................. r
Status 200, Exit
ReadLetter = 2
SendLetter.
Okay, I'll mail another letter and will call back in a few days
STREET
STRING (25)
CITY
STRING (25)
STATE
STRING (25)
| | | | | |-| | | | |
ZIP CODE
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
Status 831, GO TO Thanks
Status 831, GO TO Thanks
Status 200, Exit
SAMPMEMB = 3
MoreInfo.
We are interviewing women in four states to learn about the types of services and
information they get during pregnancy and after giving birth. Your answers will
help The Centers for Medicare & Medicaid Services learn the best ways to help
pregnant women and new moms get the information and services they need to
have healthy babies. Your participation is really important. Let’s get started.
CODE ONE ONLY
BEGIN INTERVIEW .................................................................................. 1
NOT A GOOD TIME.................................................................................. 2
HUNG UP DURING INTRODUCTION...................................................... 3
REFUSED .................................................................................................. r
Prepared by Mathematica Policy Research
10
GO TO SC1
GO TO Callback
Status 640, Exit
Status 200 Exit
DOCALLBACK = YES (CALL BACK TO SAMPLE MEMBER AFTER INITIAL CONTACT)
AUTOFILL INTVNAME
Hello2.
Hello, my name is [INTNAME]. I am calling from Mathematica Policy Research on
behalf of The Centers for Medicare & Medicaid Services. May I please speak to
[FULLNAME]?
CODE ONE ONLY
SPEAKING TO [FIRSTNAME] .................................................................. 1
[FIRSTNAME] COMES TO THE PHONE ................................................. 2
PERSON ASKS WHAT CALL IS ABOUT ................................................. 3
NEED TO CALLBACK .............................................................................. 4
NEVER HEARD OF [FULLNAME]/WRONG NUMBER ............................ 5
REFUSED .................................................................................................. r
GO TO SampMemb2
GO TO SampMemb2
GO TO WhatAbout2
GO TO Callback
GO TO PhoneCheck
Status 220, Exit
HELLO2 = 3
FIRSTNAME
WhatAbout2.
I'm calling to finish an interview we recently started with [FIRSTNAME]. Is she
available now?
CODE ONE ONLY
[FIRSTNAME] COMES TO THE PHONE ................................................. 1
NEED TO CALLBACK .............................................................................. 2
SUPERVISOR REVIEW ........................................................................... 3
REFUSED .................................................................................................. r
GO TO Sampemb2
GO TO Callback
Status 380, Exit
Status 220, Exit
HELLO2 = 1 OR 2 OR WHATABOUT2 = 1
SampMemb2. Hello, my name is [INTNAME].] I'm calling to finish the interview we started
recently. We will send you a gift card for $25 to thank you for participating. I’m
calling to see if this is a good time to finish the interview.
As a reminder, your participation is completely voluntary, but very important. All
your answers will be kept private. Let’s continue the interview.
CODE ONE ONLY
CONTINUE INTERVIEW .......................................................................... 1
GO TO SC1
NOT A GOOD TIME.................................................................................. 2
GO TO Callback
SUPERVISOR REVIEW ........................................................................... 3
Status 380, Exit
REFUSED .................................................................................................. r
Status 200, Exit
Prepared by Mathematica Policy Research
11
HELLO2=5
PHONE
PhoneCheck2.
I'm sorry, I must have misdialed. I thought I dialed [PHONE]. Is that the
number I've reached?
CODE ONE ONLY
RIGHT NUMBER, NO SUCH PERSON ................................................... 1
GO TO WrongNumber2
WRONG CONNECTION/MISDIAL ........................................................... 2
Status 530, Exit
SUPERVISOR REVIEW REQUIRED ....................................................... 3
Status 380, Exit
REFUSED TO CONFIRM NUMBER ........................................................ 4
Status 380
PHONECHECK = 1
AUTOFILL INTVNAME
WrongNumber2.
I'm [INTNAME] from Mathematica Policy Research. My information was that
we’d recently spoken to someone at your number and we were supposed to
call back to interview [FULLNAME]. There must have been some mistake.
Thank you for your help. I'll turn this over to my supervisor.
CONTINUE ............................................................................................... 1
Status 380
HELLO = 9 OR HEALTHPROB = 1 OR 2 AND or AMPTTY = 1
Thanks.
Thank you very much for your time.
CONTINUE ............................................................................................... 1
Exit
HELLO = 4 OR WHATABOUT = 4 OR AMPTTY= d OR RESPAVAIL=0 OR MOREINFO=2 (ALL CALL
BACKS)
CallBack.
When would be a good time to callback?
INTERVIEWER:
Prepared by Mathematica Policy Research
MAKE AN APPOINTMENT. (PROGRAMMER: STATUS 810).
12
PARENT GUARDIAN CONSENT/CALLBACK
SC4 = 2 OR SC5 = 2
AUTOFILL INTNAME
S1 = FULLNAME
Hello P/G.
Hello, my name is [INTNAME]. I am calling from Mathematica Policy Research on
behalf of The Centers for Medicare & Medicaid Services. May I please speak to
[FULLNAME]’s parent or guardian?
CODE ONE ONLY
SPEAKING TO PARENT/GUARDIAN ...................................................... 1
PARENT/GUARDIAN COMES TO THE PHONE ..................................... 2
PERSON ASKS WHAT CALL IS ABOUT ................................................. 3
NEED TO CALLBACK .............................................................................. 4
[FIRSTNAME] HAS A HEALTH PROBLEM.............................................. 5
[FIRSTNAME] IS IN AN INSTITUTION..................................................... 6
[FIRSTNAME] HAS MOVED ..................................................................... 7
[FIRSTNAME] DOES NOT SPEAK ENGLISH.......................................... 8
HUNG UP DURING INTRODUCTION.................................................... 10
REFUSED .................................................................................................. r
GO TO SC5
GO TO SC5
GO TO Whatabout P/G
GO TO Callback P/G
GO TO HealthProb P/G
GO TO HomeSoon P/G
GO TO KnowWhere P/G
GO TO Lang P/G
Status 640, Exit
Status 210, Exit
HELL0 P/G = 3
S2 = FIRSTNAME
WhatAbout P/G.
[FIRSTNAME] has been selected to take part in a brief survey of new moms.
Because she is under 18 years of age, I’m calling to ask her parent or guardian
to give permission for her to take part in the survey. May I speak with her
parent or guardian now?
CODE ONE ONLY
PARENT/GUARDIAN COMES TO THE PHONE ..................................... 1
GO TO SC5
NEED TO CALLBACK .............................................................................. 2
GO TO Callback
PARENT/GUARDIAN HAS HEALTH PROBLEM/IS DECEASED ............ 3
GO TO HealthProb P/G
PARENT/GUARDIAN IS IN AN INSTITUTION ......................................... 4
GO TO HomeSoon P/G
PARENT/GUARDIAN MOVED ................................................................. 5
GO TO KnowWhere P/G
PARENT/GUARDIAN DOES NOT SPEAK ENGLISH .............................. 6
GO TO Lang P/G
HUNG UP DURING INTRODUCTION...................................................... 7
Status 640, Exit
SUPERVISOR REVIEW ........................................................................... 8
Status 380, Exit
REFUSED .................................................................................................. r
Status 210, Exit
Prepared by Mathematica Policy Research
13
HELLO P/G = 5 OR WHATABOUT P/G = 3
HealthProb P/G.
ENTER TYPE OF HEALTH PROBLEM.
CODE ONE ONLY
HEARING PROBLEM ............................................................................... 1
GO TO AmpTTY P/G
SPEECH PROBLEM ................................................................................. 2
GO TO AmpTTY P/G
PHYSICAL PROBLEM .............................................................................. 3
GO TO CallLater
COGNITIVE PROBLEM/ IN A COMA ....................................................... 4
Status 211, Exit
DECEASED .............................................................................................. 5
GO TO Deceased
REFUSED .................................................................................................. r
Status 211, Exit
HEALTHPROB P/G = 1 OR 2
AmpTTY P/G. I can get on a phone that will amplify my voice or her parent or guardian’s voice, or
we could use a TTY service. Would either of these help me to speak with the parent
or guardian?
CODE ONE ONLY
YES - USE AMPLIFIER PHONE .............................................................. 1
GO TO RespAvail P/G
YES - USE TTY CAPABILITY ................................................................... 2
GO TO RespAvail P/G
NO ............................................................................................................. 0
Status 211; Exit
DON’T KNOW ........................................................................................... d
GO TO Callback
REFUSED .................................................................................................. r
Status 211; Exit
AMPTTY P/G = 1 or 2
RespAvail P/G.
Is the parent or guardian available now?
YES ........................................................................................................... 1
NO ............................................................................................................. 0
GO TO Callback
PROGRAMMER:
If AmpTTY = 1, GoTo AmpPhone, else GO TO CallTTY
AMPTTY P/G = 1 AND RESPAVAIL P/G = 1
AmpPhone.
Please hold while I get the amplifier phone.
INTERVIEWER:
SET UP AMPLIFIER/WEAK SPEECH EQUIPMENT AND ASK
GATEKEEPER TO CALL [FIRSTNAME] TO THE PHONE.
CODE ONE ONLY
[FIRSTNAME] COMES TO THE PHONE ................................................. 1
GO TO SC5
NEED TO CALLBACK .............................................................................. 2
GO TO Callback
Prepared by Mathematica Policy Research
14
AMPTTY P/G = 2 AND RESPAVAIL = 1
CallTTY P/G.
I will call back in a few minutes after I have the help of the TTY operator.
CODE ONE ONLY
ARRANGE CALL WITH OPERATOR ....................................................... 1
GO TO SC5
UNSUCCESSFUL -- NEED TO CALLBACK ............................................ 2
GO TO Callback
HEALTHPROB P/G = 3
CallLater P/G.
Will [FIRSTNAME]’s parent or guardian be able to talk on the telephone if I call
back in a week or two?
YES/MAYBE – CALLBACK ...................................................................... 1
NO ............................................................................................................. 0
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
GO TO Callback
Status 211, Exit
GO TO Callback
GO TO End 4
HELLO P/G = 5 AND HEALTHPROB P/G= 6
Deceased P/G.
I am very sorry to hear that. When did that happen?
Thank you. Please accept my condolences. Goodbye.
| | |/| | |/| | | | |
Status 211
MONTH DAY
YEAR
1-12
1-31
2000 - 2017
DON’T KNOW ........................................................................................... d
Status 380 Sup Rev
REFUSED .................................................................................................. r
Status 380 Sup Rev
HELLO P/G = 6 OR WHATABOUT P/G= 4
S2 = FIRSTNAME
HomeSoon P/G.
Do you expect [FIRSTNAME]’s parent or guardian to come home within a week
or two?
YES ARRANGE CALLBACK .................................................................... 1
NO ............................................................................................................. 0
[FIRSTNAME] UNABLE TO RESPOND OVER THE TELEPHONE......... 3
Prepared by Mathematica Policy Research
15
GO TO Callback
Status 211, Exit
Status 211, Exit
HELLO P/G = 7 OR WHATABOUT P/G = 5
S2 = FIRSTNAME
KnowWhere P/G.
Do you or anyone there know how we can reach [FIRSTNAME]’s parent or
guardian?
YES ........................................................................................................... 1
NO ............................................................................................................. 0
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
Status 211, Exit
Status 211, Exit
Status 211, Exit
KNOWWHERE P/G = 1
NewPhone P/G.
|
|
|
|-|
|
|
|-|
|
|
|
|
Exit
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
Exit
Exit
HELLO P/G = 8 OR WHATABOUT P/G = 6:
Lang P/G.
CODE LANGUAGE NEEDED TO COMPLETE INTERVIEW IF KNOWN
CODE ONE ONLY
SPANISH .................................................................................................. 1
OTHER (SPECIFY) ___________________ (STRING (100)) ............... 99
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
Continue in Spanish
Status 211, Exit
Status 211, Exit
Status 211, Exit
ALL
FILL SAMPLE MEMBER FULL NAME
SC1.
Before we start, I need to make sure that I’ve reached the right person. Am I speaking with
[FILL SAMPLE MEMBER FULL NAME]?
CODE ONE ONLY
YES ........................................................................................................... 1
YES, NAME NOW CHANGED .................................................................. 2
NO ............................................................................................................. 0
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
Prepared by Mathematica Policy Research
16
GO TO SC2
NOT ELIGIBLE
NOT ELIGIBLE
STATUS 200, EXIT
IF SC1 = YES, NAME NOW CHANGED
SC1a. What is your new name?
RECORD NEW NAME
(STRING 400)
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
ALL
FILL DOB FROM PRELOAD
SC2.
What is your date of birth?
PROGRAMMER:
DISPLAY DOB AS INTERVIEWER NOTE
PROGRAMMER:
ALLOW RESPONDENT INFO TO BE ENTERED/REVISED IN INFO
SCREEN. FIRST, HAVE INTERVIEWER INDICATE WHETHER THE
MOTHER’S DOB IS CORRECT; THEN, IF IT IS INCORRECT, ALLOW DOB
TO BE REVISED.
INTERVIEWER:
COMPARE RESPONSE WITH DOB DISPLAYED.
DOB CORRECT ........................................................................................ 1
DOB INCORRECT .................................................................................... 2
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
Prepared by Mathematica Policy Research
17
GO TO SC3
GO TO SC3
IF SC2 = DK, RF
SC2a. How old were you on your last birthday?
| | | YEARS (14–50)
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
ALL
FILL DATES
SC3.
Did you have a baby between [CURRENT DATE MINUS 7 MONTHS] and [CURRENT DATE
MINUS 4 MONTHS]?
YES ........................................................................................................... 1
NO ............................................................................................................. 0
MISCARRIAGE/BABY DIED/WAS STILLBORN ...................................... 2
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
NOT ELIGIBLE
NOT ELIGIBLE
NOT ELIGIBLE
STATUS 200, EXIT
SC2A < 18 YEARS OLD
SC4.
Because you are less than 18 years of age, I need to get permission from your parent or
guardian before I can interview you. May I please speak to a parent or guardian for a
moment?
YES ........................................................................................................... 1
NOT AVAILABLE NOW ............................................................................ 2
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
Prepared by Mathematica Policy Research
18
GO TO CALLBACK
GO TO END 14
GO TO END 14
SPEAKING TO PARENT/GUARDIAN
SC4=1
INTERVIEWER NAME; FIRST NAME
SC5.
Hello, I’m [INTNAME]. [FIRSTNAME] would like to take part in a brief survey of new moms
that we are conducting on behalf of the Centers for Medicare and Medicaid Services. The
survey will take 25 minutes. To thank her for taking part, we will send her a gift card for
$25. Because she is under the age of 18, I need a parent or guardian’s permission to
interview her. Do you give permission for [FIRSTNAME] to take part in this study?
YES ........................................................................................................... 1
PARENT CANNOT COME TO PHONE.................................................... 2
PARENT REFUSES PERMISSION ........................................................... r
GO TO CALLBACK
Status 210, Exit
SC5=1
FIRST NAME
SC6.
Thanks very much. May I please speak with [FIRSTNAME] again to begin the interview?
YES ........................................................................................................... 1
NO, SHE’S NOT HERE/NO LONGER HERE ........................................... 0
Prepared by Mathematica Policy Research
19
GO TO SC7
GO TO CALLBACK
ALL
IF SC3 <18 FILL [Your parent/guardian gave permission for you to take part in the survey, so let’s
continue.]
SC7.
[Your parent/guardian gave permission for you to take part in the survey, so let’s
continue.] Thank you for answering those questions. Now I’ll explain the survey and then
ask for your consent to take part. The Centers for Medicare & Medicaid Services has
contracted with Mathematica to conduct this survey. We are conducting this survey with
women who recently had a baby. During the interview, I will ask you about your
experiences as a new mom as well as your experiences during your most recent
pregnancy.
Taking part in the survey is voluntary. If any of the questions seem too personal or you
don’t feel like answering them, you can let me know and we will skip those questions.
Your name and survey answers will be kept private and used only for the purpose of the
study unless required by law. We may combine your survey answers with information we
get about you from your state Medicaid agency, which you may know as [FILL STATE
MEDICAID NAME]. Risks to taking part in the survey include possible disclosure of your
name, your answers to survey questions, and linked medical information, which we have
taken steps to avoid. Although there are no direct benefits to you or your baby from taking
part in the study, the information you provide may help other women and their babies in
the future. We will send you a $25 gift card in the mail after you complete the survey.
PROBE IF NEEDED: If you wish to speak to a researcher about the study, I can give you
the contact information for So O’Neil, the principal investigator. She
can be reached at 617-301-8975.
PROBE IF NEEDED: If you want to speak to someone about your rights as a participant in
the survey, I can give you the contact information for the New
England Institutional Review Board. They can be reached at 617-2433924.
Do you consent to take part in this survey?
YES ........................................................................................................... 1
NO ............................................................................................................. 0
SC7=1
FILL DATES
SC8.
Now I’m going to ask you some questions about your recent pregnancy. How many babies
did you give birth to between [CURRENT DATE MINUS 7 MONTHS] and [CURRENT DATE
MINUS 4 MONTHS]?
|
|
| BABIES (1–6)
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
Prepared by Mathematica Policy Research
20
SC7= 1 (R CONSENTS)
SC9.
IF ONE BABY: What is your baby’s name?
IF MORE THAN ONE BABY: What are the names of your babies?
PROBE IF NEEDED:
his or her name.
You can provide your baby’s initials if you do not wish to provide
ENTER NAME OR INITIALS FOR ALL BABIES
___________________________________________________ (STRING 400)
IFSC8> 1 (IF MORE THAN ONE BABY, PROGRAM AUTOMATICALLY SELECTS ONE)
FILL SELECTED CHILD’S NAME
SC10. We realize that [CHILD] was part of a multiple birth. For the purposes of this survey, we
would like you to answer all of the questions we ask about [CHILD] and your recent
pregnancy with [CHILD].
SC7=1 (R CONSENTS)
FILL CHILD’S NAME
SC11. Is [CHILD] male or female?
MALE......................................................................................................... 1
FEMALE .................................................................................................... 2
DON’T KNOW ........................................................................................... d
REFUSED .................................................................................................. r
SC7=1 (R CONSENTS)
FILL CHILD’S NAME
SC12. What is [CHILD]’s date of birth?
|
|
|/|
|
MONTH DAY
(1–12) (1–31)
|/|
|
|
|
|
YEAR
(2016–2017)
DON’T KNOW ........................................................................................... d
REFUSED ................................................................................................. r
Prepared by Mathematica Policy Research
21
A. TEXT4BABY ENROLLMENT AND USE OF SERVICES
First, I’d like to ask you a few questions about cell phones and your use of social media.
ALL
A0.
Do you have a cell phone?
CODE ONE ONLY
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
GO TO A1
DON’T KNOW .......................................................................................................... d
GO TO A1
REFUSED ................................................................................................................ r
GO TO A1
A0 = YES
A0a.
Some cell phones are called “smartphones” because of certain features they have. Is your
cell phone a smartphone, such as an iPhone or Android, or are you not sure?
CODE ONE ONLY
YES, SMARTPHONE............................................................................................... 1
NO, NOT A SMARTPHONE .................................................................................... 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
A1.
Before today, did you ever hear of Text4baby?
If no, PROBE: Text4baby sends free text messages to pregnant women and new mothers
on their cell phones about having a healthy pregnancy and baby. Have you heard of
Text4baby?
CODE ONE ONLY
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
GO TO SECTION D
DON’T KNOW ....................................................................................................... d
GO TO SECTION D
REFUSED ............................................................................................................. r
GO TO SECTION D
Prepared by Mathematica Policy Research
22
IF A1 = YES (HEARD OF TEXT4BABY)
A2.
Have you ever signed up to receive free Text4baby messages on your cell phone?
INTERVIEWER:
CODE YES IF R SAYS SOMEONE ELSE SIGNED HER UP.
CODE YES IF R WAS SIGNED UP IN THE PAST BUT IS NOT
CURRENTLY SIGNED UP.
YES ........................................................................................................................ 1
NO .......................................................................................................................... 0 GO TO A10
DON’T KNOW ........................................................................................................ d GO TO SECTION D
REFUSED .............................................................................................................. r
GO TO SECTION D
IF A2 = YES (EVER SIGNED UP FOR TEXT4BABY)
A3.
How did you sign up for Text4baby? Did you send a text message on your cell phone, sign
up on the Internet, or sign up some other way?
CODE ONE ONLY
CELL PHONE ........................................................................................................ 1
INTERNET ............................................................................................................. 2
SOMEONE ELSE SIGNED ME UP ....................................................................... 3
OTHER (SPECIFY) ................................................................................................ 99
_____________________________________________ (STRING 200)
DON’T KNOW ........................................................................................................ d
REFUSED .............................................................................................................. r
IF OTHER SPECIFY (99): How did you sign up for Text4baby?
Prepared by Mathematica Policy Research
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IF A2 = YES (EVER SIGNED UP FOR TEXT4BABY)
A4.
Did you sign up to get Text4baby messages in English or in Spanish?
CODE ONE ONLY
ENGLISH ............................................................................................................... 1
SPANISH ............................................................................................................... 2
DON’T KNOW ........................................................................................................ d
REFUSED .............................................................................................................. r
IF A2 = 1 AND (A3 = 1 or 2)
A5.
How easy or hard was it to sign up for Text4baby? Would you say it was…
CODE ONE ONLY
Very easy, ............................................................................................................. 1
Somewhat easy, ................................................................................................... 2
Somewhat hard, or ............................................................................................... 3
Very hard? ............................................................................................................ 4
DON’T KNOW ........................................................................................................ d
REFUSED .............................................................................................................. r
IF A2 = YES (EVER SIGNED UP FOR TEXT4BABY)
FILL CHILD’S NAME
A6.
Did you sign up for Text4baby while you were pregnant with [CHILD]?
YES ........................................................................................................................ 1
NO .......................................................................................................................... 0
GO TO A6B
DON’T KNOW ........................................................................................................ d
GO TO A7
REFUSED .............................................................................................................. r
GO TO A7
Prepared by Mathematica Policy Research
24
IF A6 = YES (SIGNED UP FOR TEXT4BABY WHILE PREGNANT)
A6a.
About how many months pregnant were you when you signed up for Text4baby?
PROBE:
Your best estimate is fine.
CODE ONE ONLY
3 months or less, .................................................................................................. 1
GO TO A7
4 to 6 months, or .................................................................................................. 2
GO TO A7
7 to 9 months? ...................................................................................................... 3
GO TO A7
DON’T KNOW ........................................................................................................ d
GO TO A7
REFUSED .............................................................................................................. r
GO TO A7
IF A6 = NO (NOT PREGNANT WITH CHILD WHEN SIGNED UP FOR TEXT4BABY)
FILL CHILD’S NAME
A6b.
About how old was [CHILD] in months when you signed up for Text4baby?
PROBE:
Your best estimate is fine.
CODE ONE ONLY
3 months or less, .................................................................................................... 1
4 to 6 months, or .................................................................................................... 2
7 to 9 months? ........................................................................................................ 3
SIGNED UP DURING PREVIOUS PREGNANCY .................................................. 4
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
25
IF A1 = YES (HEARD OF TEXT4BABY)
A7.
How did you hear about Text4baby?
CODE ALL THAT APPLY
A HEALTH CARE PROVIDER (FOR EXAMPLE, DOCTOR OR MIDWIFE)........... 1
A FRIEND OR FAMILY MEMBER ........................................................................... 2
A BILLBOARD, FLYER, NEWSPAPER, OR MAGAZINE ....................................... 3
ON TV OR RADIO ................................................................................................... 4
ON THE INTERNET................................................................................................. 5
SOMETHING I RECEIVED IN THE MAIL................................................................ 6
WIC .......................................................................................................................... 7
MEDICAID, ALSO KNOWN AS [STATE NAME] ..................................................... 8
FROM SOME OTHER SOURCE? (SPECIFY) ....................................................... 99
________________________________________________________ (STRING 200)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
PROGRAMMER BOX
IF A2 = 0 (DID NOT SIGN UP) GO TO A10
Prepared by Mathematica Policy Research
26
IF A2 = YES
A8.
When you decided to sign up for Text4baby, how important were these reasons . . .
INTERVIEWER:
[READ EACH REASON, THEN ASK FOR EACH]: Was that very
important, somewhat important, or not important?
PROGRAMMER:
ROTATE ORDER OF QUESTIONS
CODE ONE RESPONSE PER ROW
VERY
SOMEWHAT
NOT
IMPORTANT IMPORTANT IMPORTANT
DK
REF
a.
Getting Text4baby messages is free? ....
1
2
3
d
r
b.
Getting Text4baby messages is
convenient? ............................................
1
2
3
d
r
c.
Your doctor or midwife suggested you
sign up? ..................................................
1
2
3
d
r
d.
A friend or family member suggested
you sign up? ...........................................
1
2
3
d
r
e.
You wanted to get tips about having a
healthy baby? .........................................
1
2
3
d
r
f.
You wanted to get phone numbers to
call for information about specific health
topics? ....................................................
1
2
3
d
r
g.
You thought the reminders about
prenatal care and other appointments
would be helpful? ....................................
1
2
3
d
r
IF A2 = YES
A9.
Were there other important reasons why you decided to sign up for Text4baby?
RECORD VERBATIM
(STRING 400)
OTHER REASONS
NO OTHER REASON .............................................................................................. 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
27
IF A2 = NO (HEARD OF TEXT4BABY BUT NEVER SIGNED UP)
A10.
Why did you decide not to sign up for Text4baby? Was it because . . .
INTERVIEWER:
[READ EACH REASON FIRST. FOR EACH “YES,” ASK]: How important
was this in your decision not to sign up? Was it very important,
somewhat important, or not important?
PROGRAMMER:
ROTATE ORDER OF QUESTIONS
REASON?
YES
NO
CODE ONE RESPONSE FOR EACH YES
VERY
SOMEWHAT
NOT
IMPORTANT IMPORTANT IMPORTANT
DK
REF
a.
Your cell phone has no text
messaging capability?.....................
1
0
1
2
3
d
r
b.
You don’t know how to use text
messaging? ....................................
1
0
1
2
3
d
r
c.
You don’t like text messaging? .......
1
0
1
2
3
d
r
d.
You have other sources of
information about having a healthy
pregnancy? .....................................
1
0
1
2
3
d
r
e.
A friend or family member advised
you not to sign up? .........................
1
0
1
2
3
d
r
f.
Your doctor, midwife, or another
health care provider advised you not
to sign up? ......................................
1
0
1
2
3
d
r
g.
Text4baby messages are not
available in your preferred
language? .......................................
1
0
1
2
3
d
r
IF ALL RESPONSES A10_A THROUGH A10_g= NO
A10a. What were the other reasons why you decided not to sign up for Text4baby?
RECORD VERBATIM
(STRING 400)
OTHER REASONS
NO OTHER REASON .............................................................................................. 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
28
IF ONE OR MORE RESPONSES A10_A THROUGH A10_G = YES
A10b. Were there any other reasons why you decided not to sign up for Text4baby?
RECORD VERBATIM
(STRING 400)
OTHER REASONS
NO OTHER REASON .............................................................................................. 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
IF A2 = YES (EVER SIGNED UP FOR TEXT4BABY)
A11.
I am going to read a list of special Text4baby features that some women use to get more
personalized service. For each item, tell me if you ever used the feature.
INTERVIEWER: [READ EACH TOPIC FIRST. THEN FOR EACH “YES” RESPONSE TO
“EVER USED,” ASK]: Was [FOR A AND B: the information you got in
response] [FOR C: the feature] very useful, somewhat useful, or not
useful?
PROGRAMMER: ROTATE ORDER OF QUESTIONS
EVER USED?
YES
NO
VERY
USEFUL
SOMEWHAT
USEFUL
NOT
USEFUL
DK
REF
Have you ever responded to any
questions that Text4baby sent you? ......
1
0
1
2
3
d
r
Have you ever clicked on a web link
in one of the Text4baby messages to
get more information on a topic? ...........
1
0
1
2
3
d
r
Have you ever used the Text4baby
appointment reminders to get text
updates about the dates and times of
your doctor’s appointments? ..................
1
0
1
2
3
d
r
TOPICS
a.
b.
c.
USEFUL OR NOT USEFUL?
Prepared by Mathematica Policy Research
29
IF A2 = YES (EVER SIGNED UP FOR TEXT4BABY)
A12.
Text4baby sends some text messages that include a phone number to call if you want
more information on topics like smoking, drug use, breastfeeding, installing car seats, or
getting health care. Did you ever save any of the phone numbers to call at a later time?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
IF A2 = YES (EVER SIGNED UP FOR TEXT4BABY)
A13.
Did you ever call one of the phone numbers included in a message?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
GO TO A15
DON’T KNOW .......................................................................................................... d
GO TO A15
REFUSED ................................................................................................................ r
GO TO A15
Prepared by Mathematica Policy Research
30
IF A13 = YES
A14.
Thinking about the messages with phone numbers, have you ever called one of these
phone numbers about...
INTERVIEWER:
[READ EACH TOPIC FIRST. THEN FOR EACH “YES” RESPONSE TO
“EVER CALLED,” ASK]: WAS THE INFORMATION YOU GOT USEFUL OR
NOT USEFUL?
PROGRAMMER: ROTATE ORDER OF QUESTIONS
EVER CALLED?
USEFUL OR NOT USEFUL?
YES
NO
USEFUL
NOT
USEFUL
DK
REF
a.
Finding a doctor or midwife? ........
1
0
1
2
d
r
b.
Quitting smoking? ........................
1
0
1
2
d
r
c.
Getting information about alcohol
or drug use? .................................
1
0
1
2
d
r
d.
Getting health coverage from
Medicaid? You may also call this
[STATE PROGRAM NAME]. ........
1
0
1
2
d
r
e.
Getting information about WIC? ...
1
0
1
2
d
r
f.
Getting information about
breastfeeding? .............................
1
0
1
2
d
r
g.
Finding child care? .......................
1
0
1
2
d
r
h.
Getting help if you feel down or
depressed? ..................................
1
0
1
2
d
r
i.
Getting information about safe
sleep positions for your baby? .....
1
0
1
2
d
r
j.
Getting help if you or someone
you know has a partner that hurts
them physically or mentally? ........
1
0
1
2
d
r
k.
Some other topic I haven’t
mentioned? (SPECIFY)................
1
0
1
2
d
r
_______________ (STRING 400)
IF OTHER SPECIFY (99): What other topic did you call about?
Prepared by Mathematica Policy Research
31
IF A2 = YES (EVER SIGNED UP FOR TEXT4BABY)
A15.
The next questions are about your current experience with Text4baby. Are you currently
receiving messages from Text4baby?
YES .......................................................................................................................... 1
GO TO B1
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
GO TO B1
REFUSED ................................................................................................................ r
GO TO B1
IF A15 = 0
A16.
Why are you not currently getting any Text4baby messages? Is it because...
CODE ALL THAT APPLY
Your cell phone was lost or stolen, ...................................................................... 1
A friend or relative borrowed your cell phone, .................................................. 2
You didn’t have enough money to continue cell phone service, ..................... 3
You were somewhere with no cell phone service, ............................................. 4
You texted STOP to stop receiving messages, or .............................................. 5
Some other reason? (SPECIFY) .......................................................................... 99
_______________________________________________________ (STRING 400)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
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GO TO B2
B. DISENROLLMENT
IF A15 = YES, DK, R OR A16 ≠ 5 (NOT CURRENTLY GETTING MESSAGES; THE REASON IS FOR
SOME OTHER REASON THAN TEXTING STOP)
B1.
Have you ever texted STOP to stop receiving Text4baby messages?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0 GO TO SECTION C
DON’T KNOW .......................................................................................................... d GO TO SECTION C
REFUSED ................................................................................................................ r
GO TO SECTION C
IF B1 = Yes (EVER TEXTED STOP TO STOP RECEIVING MESSAGES) OR a16_5 = 1
B2.
Why did you want to stop receiving Text4baby messages? Was it because...
CODE ALL THAT APPLY
You didn’t have time to read the messages? ...................................................... 1
There were too many messages? ........................................................................ 2
You didn’t find the messages useful? ................................................................. 3
You had enough information from other sources? ............................................ 4
You do not like text messaging? Or..................................................................... 5
Another reason? (SPECIFY) ................................................................................. 99
______________________________________________________ (STRING 400)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
IF OTHER SPECIFY (99): Why did you want to stop receiving Text4baby messages?
IF B1 = YES (EVER TEXTED STOP TO STOP RECEIVING MESSAGES)
B3.
Were you pregnant with [CHILD] when you decided to stop receiving Text4baby
messages?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0 GO TO B3B
DON’T KNOW .......................................................................................................... d GO TO B3B
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
33
GO TO B3B
IF B3 = YES (PREGNANT WITH CHILD WHEN DECIDED TO STOP RECEIVING MESSAGES)
B3a.
About how many months pregnant were you when you decided to stop receiving
Text4baby messages?0
|
| MONTHS (1–9)
DON’T KNOW .......................................................................................................... d
GO TO C1
REFUSED ................................................................................................................ r
GO TO C1
IF B3 = NO, DK, RF (NOT PREGNANT WITH CHILD WHEN DECIDED TO STOP RECEIVING
MESSAGES)
FILL CHILD’S NAME
B3b.
About how old was [CHILD] in months when you decided to stop receiving Text4baby
messages?
INTERVIEWER:
|
|
IF RESPONDENT SAYS LESS THAN 1 MONTH
OLD, CODE 1.
| MONTHS (1–12)
STOPPED RECEIVING MESSAGES DURING A PREVIOUS PREGNANCY ....... n
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
34
C. SATISFACTION WITH TEXT4BABY
IF A2 = YES (EVER SIGNED UP FOR TEXT4BABY)
C1.
In general, thinking about all of the Text4baby messages that you ever received, do you
agree or disagree with the following statements?
FOR EACH STATEMENT: Do you agree, or disagree?
CODE ONE PER ROW
AGREE
DISAGREE
DK
REF
a. You learned something from them ...............
1
2
d
r
b. You trusted them ..........................................
1
2
d
r
c.
They were interesting ...................................
1
2
d
r
d. They were annoying .....................................
1
2
d
r
IF A2 = YES (EVER SIGNED UP FOR TEXT4BABY)
C2.
Thinking about your overall experience since you first signed up for Text4baby, which
statement best describes your feelings about the number of Text4baby messages you
receive?
CODE ONE ONLY
Text4baby sends too many messages, .............................................................. 1
Text4baby does not send enough messages, or ................................................ 2
I am happy with the number of Text4baby messages I receive ........................ 3
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
IF A2 = YES (EVER SIGNED UP FOR TEXT4BABY)
C3.
Would you recommend the Text4baby program to a friend or family member?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
35
D. PREGNANCY HISTORY
The next questions are about your health.
ALL
D1.
How many times have you been pregnant?
|
|
| NUMBER OF TIMES PREGNANT (1–20)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
SOFT CHECK: IF GT 10; I just wanted to confirm that I’ve recorded correctly that you’ve been
pregnant [FILL TIMES] times. Is that correct?
ALL
D2.
Were all the babies from your pregnancies born alive?
YES .......................................................................................................................... 1
GO TO D4
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
GO TO E1
REFUSED ................................................................................................................ r
GO TO E1
IF D2 = NO (ALL BABIES FROM PREGNANCIES NOT BORN ALIVE)
FILL NUMBER OF PREGNANCIES FROM D1
D3.
How many babies from your [FILL NUMBER PREGNENCIES] pregnancies were born alive?
|
|
| NUMBER OF LIVE BIRTHS (1–10)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
D2=1
D4.
Did any of these babies die before their first birthday?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
PROGRAMMER BOX
IF D2 =0 OR D4 =1 display: I’m very sorry for your loss. Please accept my condolences.
INTERVIEWER, IF NEEDED, OFFER GRIEF COUNSELING REFERRAL. If you would like, I can offer
you a phone number where you can talk with somebody about your loss.
Prepared by Mathematica Policy Research
36
E. MOST RECENT PREGNANCY
The next questions are about your most recent pregnancy with [CHILD].
ALL
FILL CHILD’S NAME
E1.
About how many weeks pregnant were you when [CHILD] was born?
INTERVIEWER: ONLY CODE MONTHS IF RESPONDENT ANSWERS IN MONTHS
|
|
| WEEKS (20–42)
|
| MONTHS (5–9)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
SOFT CHECK: IF WEEKS LT 32 OR GT 42, OR MONTHS EQ 5 OR 6: I just wanted to confirm that I
recorded correctly that you were [X WEEKS/X MONTHS] pregnant when [CHILD] was born. Is that
correct?
ALL
FILL CHILD’S NAME
E2.
How much did you weigh just before you got pregnant with [CHILD]? Your best estimate is
fine.
|
|
|
| POUNDS (085–500)
|
|
|
| KILOS (038–227)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
SOFT CHECK: IF POUNDS GT 300; I just wanted to confirm that I recorded correctly that you
weighed [X POUNDS] before you got pregnant with [CHILD]. Is that correct?
Prepared by Mathematica Policy Research
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ALL
FILL CHILD’S NAME
E3.
How much weight did you gain during your pregnancy with [CHILD]? Your best estimate is
fine.
|
|
|
| POUNDS (0–100)
|
|
| KILOS (0–45)
LOST WEIGHT DURING PREGNANCY ................................................................. 1
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
SOFT CHECK: IF POUNDS LT 10 OR GT 50: I just wanted to confirm that I recorded correctly that
you gained [X POUNDS/X KILOS) during your pregnancy with [CHILD]. Is that correct?
The next questions are about [CHILD].
ALL
FILL CHILD’S NAME; FILL HE/SHE BASED ON CHILD’S GENDER
E4.
How much did [CHILD] weigh when [he/she] was born?
INTERVIEWER:
IF RESPONDENT GIVES A RESPONSE WITH A FRACTION OF AN
OUNCE, PLEASE ASK HER TO ROUND TO THE NEAREST OUNCE.
ENTER 1 TO ENTER POUNDS AND OUNCES ..................................................... 1
GO TO E5
ENTER 2 TO ENTER GRAMS ................................................................................ 2
GO TO E5
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
|
|
| POUNDS (1–16)
|
|
| OUNCES (0–16)
|
|
|
|
| GRAMS (500–7260)
SOFT CHECK: IF POUNDS LT 5 OR GT 12 OR IF GRAMS LT 2250 OR GT 5450; I just wanted to
confirm that I recorded correctly that [CHILD] weighed [X POUNDS AND X OUNCES/X GRAMS]
when [he/she] was born. Is that correct?
Prepared by Mathematica Policy Research
38
IF E4 = DON’T KNOW, REFUSED
FILL CHILD’S NAME
E4a.
Was [CHILD]’s birth weight . . .
PROBE:
8 lbs. 12. oz. is about 4000 grams; 5 lbs. 8 oz. is about 2500 grams; and 3 lbs.
8 oz. is about 1500 grams.
CODE ONE ONLY
8 lbs. 13 oz. or more,.............................................................................................. 1
5 lbs. 9 oz. to 8 lbs. 12 oz., .................................................................................... 2
3 lbs. 8 oz. and 5 lbs. 8 oz., or ............................................................................... 3
Less than 3 lbs. 8 oz.? ........................................................................................... 4
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
FILL CHILD’S NAME
E5.
How was [CHILD] delivered?
PROBE IF NECESSARY:
Did you have a vaginal delivery or a cesarean section (Csection)?
CODE ONE ONLY
VAGINALLY ............................................................................................................. 1
GO TO E7
CESAREAN DELIVER (C-SECTION)...................................................................... 2
DON’T KNOW .......................................................................................................... d
GO TO E7
REFUSED ................................................................................................................ r
GO TO E7
Prepared by Mathematica Policy Research
39
IF E5 = 2 (C-SECTION)
E6.
What were the reasons you had a cesarean section (C-section)?
CODE ALL THAT APPLY
HAD A C-SECTION BEFORE ................................................................................. 1
THE BABY WAS IN THE WRONG POSITION ........................................................ 2
DOCTOR WAS WORRIED THAT THE BABY WAS TOO BIG ............................... 3
HAD A MEDICAL CONDITION THAT MADE GOING INTO LABOR
DANGEROUS .......................................................................................................... 4
DOCTOR OR NURSE TRIED TO INDUCE LABOR BUT IT DIDN’T
WORK ...................................................................................................................... 5
LABOR WAS TAKING TOO LONG ......................................................................... 6
THE FETAL MONITOR SHOWED THAT THE BABY WAS HAVING
PROBLEMS DURING LABOR ................................................................................. 7
WANTED TO SCHEDULE DELIVERY .................................................................... 8
DIDN’T WANT TO HAVE THE BABY VAGINALLY ................................................. 9
DOCTOR OR NURSE SUGGESTED DELIVERY BY C-SECTION ........................ 10
SOME OTHER REASON (SPECIFY) ...................................................................... 99
___________________________________________________ (STRING 400)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
IF OTHER SPECIFY (99): Why did you have a cesarean section (C-section)?
ALL
FILL CHILD’S NAME
E7.
Did your doctor, nurse, or other health care worker try to induce your labor (start your
contractions using medicine) with [CHILD]?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0 GO TO E9
DON’T KNOW .......................................................................................................... d GO TO E9
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
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GO TO E9
IF E7 = YES (DOCTOR, NURSE, HEALTH CARE WORKER TRIED TO INDUCE LABOR)
E8.
Why did your doctor, nurse, or other health care worker try to induce your labor (start your
contractions using medicine)?
CODE ALL THAT APPLY
MY WATER BROKE (AND THERE WAS A FEAR OF INFECTION) ...................... 1
I WAS PAST MY DUE DATE ................................................................................... 2
MY HEALTH CARE PROVIDER WORRIED ABOUT THE SIZE OF THE BABY ... 3
MY BABY WAS NOT DOING WELL AND NEEDED TO BE BORN........................ 4
I HAD A HEALTH PROBLEM AND NEEDED TO DELIVER THE BABY ................ 5
I WANTED TO SCHEDULE MY DELIVERY............................................................ 6
I WANTED TO GIVE BIRTH WITH A SPECIFIC HEALTH CARE PROVIDER ...... 7
SOME OTHER REASON? ....................................................................................... 99
_______________________________________________________(STRING 400)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
IF OTHER SPECIFY (99): Why did your doctor, nurse, or other health care worker try to induce
your labor?
ALL
FILL CHILD’S NAME
E9.
During your pregnancy with [CHILD], did a doctor, nurse, or other health care worker try to
keep your new baby from being born too early by giving you a series of weekly shots of a
medicine called Progesterone, Gestiva, or 17P (17-alpha-Hydroxyprogesterone)?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
41
F. HEALTH CARE ACCESS AND UTILIZATION
ALL
FILL CHILD’S NAME
F1.
Thinking back to when you were pregnant with [CHILD], how many weeks or months
pregnant were you when you had your first visit for prenatal care?
Do not count a visit that was only for a pregnancy test or only for WIC (the Special
Supplemental Nutrition Program for Women, Infants, and Children).
PROBE:
You may answer in weeks, months, or trimesters.
ENTER WEEKS ....................................................................................................... 1
ENTER MONTHS .................................................................................................... 2
ENTER TRIMESTERS ............................................................................................. 3
DIDN’T RECEIVE ANY PRENATAL CARE ............................................................. 4
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
|
|
| NUMBER OF WEEKS (1–42)
|
| NUMBER OF MONTHS (1–9)
IF RESPONDENT GIVES TRIMESTER RESPONSE:
CODE ONE ONLY
1ST TRIMESTER, WEEKS UNSPECIFIED ............................................................ 55
2ND TRIMESTER, WEEKS UNSPECIFIED ............................................................ 66
3RD TRIMESTER, WEEKS UNSPECIFIED ............................................................ 77
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
42
IF F1WEEKS <28 OR F1MONTHS < 7 OR (F1TRIMESTER = 1 OR 2) OR F1 = DK, R
(RECEIVED FIRST PRENATAL CHECKUP BEFORE 28 WEEKS OR 7 MONTHS PREGNANT)
F2.
After your first prenatal care visit, how often did you have a prenatal checkup before you
were 7 months, or 28 weeks, pregnant? Was it…
CODE ONE ONLY
At least once a week, ............................................................................................. 1
At least once every two weeks, ............................................................................ 2
At least once every four weeks, or ....................................................................... 3
More than four weeks between visits? ................................................................ 4
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
IF F1WEEKS < 36 OR F1MONTHS < 8 OR (F1TRIMESTER = 1 OR 2 OR 3) OR F1 = DK,
REF(RECEIVED FIRST PRENATAL CHECKUP BEFORE 36 WEEKS OR 8 MONTHS PREGNANT)
F3.
How often did you have a prenatal checkup when you were 7 and 8 months, or 28 to 36
weeks, pregnant? Was it…
CODE ONE ONLY
At least once a week, ............................................................................................. 1
At least once every two weeks, ............................................................................ 2
At least once every four weeks, or ....................................................................... 3
More than four weeks between visits? ................................................................ 4
BABY WAS BORN BETWEEN 28 AND 36 WEEKS ............................................... 5
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
43
F1 ≠ 4 or f3≠5 (BABY BORN BETWEEN 28 AND 36 WEEKS)
FILL CHILD’S NAME
F4.
How often did you have a prenatal checkup when you were 9 months, or 36 to 40 weeks,
pregnant, or until [CHILD] was born? Was it…
CODE ONE ONLY
At least once a week, ............................................................................................. 1
At least once every two weeks, ............................................................................ 2
At least once every four weeks, or ....................................................................... 3
More than four weeks between visits? ................................................................ 4
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
FILL CHILD’S NAME
F5.
Since [CHILD] was born, have you had a postpartum checkup for yourself? A postpartum
checkup is the regular checkup a woman has about 6 weeks after she gives birth.
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
FILL CHILD’S NAME
F6.
At any time during your pregnancy with [CHILD] or after delivery, did a doctor, nurse, or
other health care worker talk with you about “baby blues” or postpartum depression?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
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ALL
FILL CHILD’S NAME
F7.
Since [CHILD] was born, has a doctor, nurse, or other health care worker told you that you
had depression?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
FILL CHILD’S NAME
F8.
Doctors or nurses may ask their patients about their health-related behaviors during
prenatal checkups. At any time during your pregnancy with [CHILD] or after delivery, did a
doctor, nurse, or other health care worker ask you about your …
CODE ONE PER ROW
YES
NO
DK
R
a. Drug and alcohol use? ..............................................................
1
0
d
r
b. Smoking? ...................................................................................
1
0
d
r
c.
Diet and exercise? .....................................................................
1
0
d
r
d. Sexual behaviors? .....................................................................
1
0
d
r
e. Abuse toward yourself or another member of your family?.......
1
0
d
r
ALL
F9.
A personal doctor or nurse is a health professional who knows you well and is familiar
with your health history. This can be a general doctor, a specialist doctor, a nurse
practitioner, or a physician’s assistant. Do you have one or more persons you think of as
your personal doctor or nurse?
INTERVIEWER:
[IF RESPONDENT SAYS YES, ASK]: Is there one person or more
than one person that you think of as your personal doctor or
nurse?
YES, ONE PERSON ................................................................................................ 1
YES, MORE THAN ONE PERSON ......................................................................... 2
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
45
ALL
F10.
Is there a place you usually go for a check-up?
INTERVIEWER:
[IF RESPONDENT SAYS YES, ASK]: Is that one place or more than one
place?
YES, ONE PLACE ................................................................................................... 1
YES, THERE IS MORE THAN ONE PLACE ........................................................... 2
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
F11.
During 12 months before you became pregnant with [CHILD], did you see a doctor, nurse,
or other health care worker for preventive medical care, such as a physical or well visit
checkup?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
F12.
During the past 12 months, did you GO TO a dentist or dental hygienist for preventive
dental care, such as a checkup or dental cleaning?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
F13.
During the past 12 months, have you had a flu shot?
PROBE:
A flu shot is a shot you get to prevent you from getting the flu. It’s
usually given in the fall and protects against influenza for the flu
season.
PROBE:
IF R SAYS SHE TOOK A LIQUID OR PILL, CODE YES.
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
46
ALL
FILL CHILD’S NAME; FILL HIS/HER BASED ON CHILD’S GENDER
F14.
Since [his/her] birth, how many times did [CHILD] see a doctor, nurse, or other health care
provider for preventive medical care such as a physical exam or well-child checkup?
|
|
| TIMES
(0–20)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
FILL CHILD’S NAME
F15.
Has [CHILD] been given any vaccines or shots yet? Please do not include the shots given
when your baby was born.
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
GO TO F16
DON’T KNOW .......................................................................................................... d
GO TO F16
REFUSED ................................................................................................................ r
GO TO F16
IF F15 = YES (CHILD HAS HAD ANY VACCINES OR SHOTS)
FILL CHILD’S NAME; FILL HE/SHE BASED ON CHILD’S GENDER
F15a.
When was the last time [CHILD] received any vaccines or shots? You can tell me the
month and year, or you can tell me how old your baby was the last time [he/she] received a
shot. Your best estimate is fine.
ENTER MONTH AND YEAR ................................................................................... 1
ENTER AGE ............................................................................................................ 2
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
IF MONTH AND YEAR:
| | | / | | | | | ENTER DATE
(MONTH)
(YEAR)
(1–12)
(2016–2017)
IF AGE:
| | | MONTHS
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
47
ALL
FILL CHILD’S NAME; FILL HE/SHE BASED ON CHILD’S GENDER
F16.
Has [CHILD] gotten [his/her] first tooth yet?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
GO TO SECTION G
DON’T KNOW .......................................................................................................... d
GO TO SECTION G
REFUSED ................................................................................................................ r
GO TO SECTION G
IF F16 = YES (CHILD HAS GOTTEN FIRST TOOTH)
FILL CHILD’S NAME; FILL HE/SHE BASED ON CHILD’S GENDER
F16a.
Since [CHILD] was born, have you taken [him/her] to see a dentist for preventive dental
care, such as a checkup or dental cleaning?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
48
G. PREGNANCY AND POSTPARTUM BEHAVIORS
Next I’m going to ask you about some things you may have done while you were pregnant or after
[CHILD] was born.
ALL
FILL CHILD’S NAME
G1.
During your pregnancy with [CHILD], how many times a week did you take a multivitamin,
prenatal vitamin, or folic acid vitamin?
INTERVIEWER: IF R SAYS “EVERY DAY OF THE WEEK”, CODE 7.
IF R SAYS “NEVER”, CODE 0.
|
| DAYS (0 – 7)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
FILL CHILD’S NAME; FILL HE/SHE BASED ON CHILD’S GENDER
G2.
How do you typically lay [CHILD] down to sleep? Would you say, on [his/her] . . .
CODE ONE ONLY
Side, ......................................................................................................................... 1
Back, or ................................................................................................................... 2
Stomach? ................................................................................................................ 3
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
FILL CHILD’S NAME
G3.
In a typical week, how often does someone in your household look at or read books with
[CHILD]? Would you say...
CODE ONE ONLY
Never, ...................................................................................................................... 1
1 to 2 times a week,................................................................................................ 2
3 to 6 times a week, or ........................................................................................... 3
Everyday? ............................................................................................................... 3
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
49
ALL
FILL CHILD’S NAME
G4.
In a typical week, how often does someone in your household tell stories, say nursery
rhymes, or sing children's songs with [CHILD])? Would you say...
CODE ONE ONLY
Never, ...................................................................................................................... 1
1 to 2 times a week,................................................................................................ 2
3 to 6 times a week, or ........................................................................................... 3
Everyday? ............................................................................................................... 3
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
G5.
Are you currently breastfeeding exclusively, breastfeeding and bottle feeding formula, or
bottle feeding formula only?
INTERVIEWER:
IF RESPONDENT SAYS “BOTTLE FEED BREAST MILK” CODE AS 1
CODE ONE ONLY
BREASTFEEDING EXCLUSIVELY ......................................................................... 1
GO TO G7
BREASTFEEDING AND BOTTLE FEEDING FORMULA ....................................... 2
GO TO G7
BOTTLE FEEDING FORMULA ONLY..................................................................... 3
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
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IF G5 = 3 (BOTTLEFEEDING FORMULA ONLY)
FILL CHILD’S NAME
G6.
Did you ever breastfeed or pump breast milk to feed [CHILD] after delivery, even for a
short period of time?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
GO TO G8
DON’T KNOW .......................................................................................................... d
GO TO G8
REFUSED ................................................................................................................ r
GO TO G8
G5 = 1 or 2) or (G6 = 1)
EXCLUSIVELY BREASTFEEDING OR BREASTFEEDING AND BOTTLE FEEDING FORMULA OR
BREASTFED FOR A SHORT TIME
FILL CHILD’S NAME
G7.
How many weeks or months did you breastfeed or pump milk to feed [CHILD]? Your best
estimate is fine.
|
|
| WEEKS (1–52 WEEKS)
|
|
| MONTHS (1–12 MONTHS)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
G8.
Are you or your husband or partner doing anything now to keep from getting pregnant?
PROBE:
Some things people do to keep from getting pregnant include not having
sex at certain times [natural family planning or rhythm] or withdrawal, and
using birth control methods such as the pill, condoms, vaginal ring, IUD,
having their tubes tied, or their partner having a vasectomy.
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
GO TO G9
DON’T KNOW .......................................................................................................... d
GO TO G9
REFUSED ................................................................................................................ r
GO TO G9
Prepared by Mathematica Policy Research
51
IF G8 = YES (CURRENTLY DOING SOMETHING TO KEEP FROM GETTING PREGNANT)
G8a.
What kind of birth control are you or your husband or partner using now to keep from
getting pregnant?
CODE ALL THAT APPLY
TUBES TIED OR CLOSED (FEMALE STERILIZATION), ....................................... 1
VASECTOMY (MALE STERILIZATION) ................................................................. 2
PILL .......................................................................................................................... 3
CONDOMS .............................................................................................................. 4
INJECTION ONCE EVERY THREE MONTHS (DEPO-PROVERA) ....................... 5
CONTRACEPTIVE IMPLANT (IMPLANON)............................................................ 6
CONTRACEPTIVE PATCH (ORTHO EVRA) .......................................................... 7
DIAPHRAGM, CERVICAL CAP, OR SPONGE ....................................................... 8
CERVICAL VAGINAL RING (NUVARING) .............................................................. 9
IUD (INCLUDING MIRENA) ..................................................................................... 10
RHYTHM METHOD OR NATURAL FAMILY PLANNING ....................................... 11
OTHER ..................................................................................................................... 12
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Now I’m going to ask you some questions about smoking.
ALL
G9.
Have you smoked any cigarettes in the past 2 years?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
GO TO G10
DON’T KNOW .......................................................................................................... d
GO TO G10
REFUSED ................................................................................................................ r
GO TO G10
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52
IF G9 = YES (SMOKED ANY CIGARETTES IN PAST 2 YEARS)
FILL CHILD’S NAME
G9a.
Did you quit smoking at any time during your pregnancy with [CHILD]?
CODE ONE ONLY
YES .......................................................................................................................... 1
NO, BUT I CUT BACK ............................................................................................. 2
NO ............................................................................................................................ 3
DIDN’T SMOKE DURING PREGNANCY WITH [CHILD] ........................................ 4
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
IF G9 = YES AND G9A≠ 4
SMOKED ANY CIGARETTES IN PAST 2 YEARS AND DIDN’T QUIT DURING PREGNANCY
FILL CHILD’S NAME
G9b.
In the last 3 months of your pregnancy with [CHILD], how many cigarettes or packs did
you smoke on an average day?
INTERVIEWER:
ENTER “0” IF RESPONDENT DID NOT SMOKE.
ENTER “1” IF RESPONDENT SMOKED LESS THAN 1 CIGARETTE A DAY.
PROBE:
|
|
A pack has 20 cigarettes
| NUMBER (0–60) AND CODE
CODE ONE ONLY
CIGARETTES .......................................................................................................... 1
PACKS ..................................................................................................................... 2
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
SOFT CHECK: IF PACKS GT 4; I just want to confirm that I recorded correctly that you smoked [X]
packs of cigarettes in the last 3 months of your pregnancy with [CHILD]. Is that correct?
Prepared by Mathematica Policy Research
53
ALL
FILL CHILD’S NAME
G10.
When you were pregnant with [CHILD], about how many hours a day, on average, were
you in the same room or vehicle with another person who was smoking? Your best
estimate is fine.
PROBE:
[IF RESPONDENT SAYS 2 OR 3, ASK]: “Would you say 2 or 3?”
INTERVIEWER:
IF RESPONDENT SAYS NEVER, CODE 0 HOURS
IF RESPONDENT SAYS LESS THAN 1 HOUR A DAY, CODE 1 HOUR
|
|
| HOURS (00–24)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
SOFT CHECK: IF HOURS GT 8; I just want to confirm that I recorded correctly that you were in the
same room or vehicle with another person who was smoking for [X HOURS] per day, on average,
when you were pregnant with [CHILD]. Is that correct?
ALL
FILL CHILD’S NAME
G11.
About how many hours per day on average is [CHILD] in the same room or vehicle with
someone who is smoking? Your best estimate is fine.
PROBE:
[IF RESPONDENT SAYS 2 OR 3, ASK]: “Would you say 2 or 3?”
INTERVIEWER:
IF RESPONDENT SAYS NEVER, CODE 0 HOURS
IF RESPONDENT SAYS LESS THAN 1 HOUR A DAY, CODE 1 HOUR
|
|
| HOURS (00–24)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
SOFT CHECK: IF HOURS GT 8; I just want to confirm that I recorded correctly that you [CHILD] is
in the same room or vehicle with another person who is smoking for [X HOURS] per day, on
average. Is that correct?
Prepared by Mathematica Policy Research
54
ALL
G12.
Have you had any alcoholic drinks in the past 2 years?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
GO TO H1
DON’T KNOW .......................................................................................................... d
GO TO H1
REFUSED ................................................................................................................ r
GO TO H1
IF G12 = YES (HAD ANY ALCOHOLIC DRINKS IN PAST 2 YEARS)
FILL CHILD’S NAME
G12a. While you were pregnant with [CHILD], about how many alcoholic drinks did you have in
an average week? Would you say . . .
PROMPT IF NEEDED, “in an average week.” STOP WHEN RESPONDENT
INDICATES NUMBER OF DRINKS.
CODE ONE ONLY
Less than 1 drink in an average week,................................................................. 1
1 to 3 drinks in an average week, ......................................................................... 2
4 to 6 drinks in an average week, or .................................................................... 3
7 or more drinks in an average week? ................................................................. 4
RESPONDENT DID NOT CONSUME ALCOHOL WHILE PREGNANT ................. 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
IF G12 = YES (HAD ANY ALCOHOLIC DRINKS IN PAST 2 YEARS)
FILL CHILD’S NAME
G12b. Since you had [CHILD], about how many alcoholic drinks have you had in an average
week? Would you say . . .
PROMPT IF NEEDED, “in an average week.” STOP WHEN RESPONDENT
INDICATES NUMBER OF DRINKS.
CODE ONE ONLY
Less than 1 drink in an average week,................................................................. 1
1 to 3 drinks in an average week, ......................................................................... 2
4 to 6 drinks in an average week, or .................................................................... 3
7 or more drinks in an average week? ................................................................. 4
RESPONDENT DID NOT CONSUME ALCOHOL SINCE BIRTH OF BABY .......... 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
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55
H. HEALTH KNOWLEDGE
ALL
FILL CHILD’S NAME; FILL HE/SHE BASED ON CHILD’S GENDER
H1.
Have you ever gotten information about taking care of yourself during pregnancy, or
taking care of [CHILD] after [he/she] was born from the any of the following sources?
INTERVIEWER: IF R SAYS SHE GOT INFORMATION BUT DIDN’T ASK FOR IT, CODE YES.
CODE ONE PER ROW
YES
NO
DK
REF
a. A doctor or midwife? .........................................
1
0
d
r
b. Your partner or spouse? ...................................
1
0
d
r
c.
A parent? ..........................................................
1
0
d
r
d. A friend? ...........................................................
1
0
d
r
e. Books or magazines? .......................................
1
0
d
r
f.
Online sources or cell phone apps? .................
1
0
d
r
g. Another source (SPECIFY) ..............................
1
0
d
r
______________________(STRING 400)
IF OTHER SPECIFY (99): From what other source have you ever gotten information about taking
care of yourself during pregnancy or about taking care of [CHILD] after [he/she] was born?
IF MORE THAN 1 RESPONSE = YES IN H1
FILL CHILD’S NAME; IF A2 = YES (EVER SIGNED UP FOR TEXT4BABY), DISPLAY TEXT FOR
TEXT4BABY AND DISPLAY TEXT4BABY IN LIST OF SOURCES
H2.
Now, thinking about all of the sources of information you just mentioned [as well as
Text4baby], which one helped you the most during your pregnancy and the first few
months of [CHILD]’s life? Was it…
CODE ONE ONLY
Response 1-n .......................................................................................................... 1-n
IF ENROLLMENTRATE2 = 1: Text4baby .............................................................. n+1
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
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ALL
FILL STATE PROGRAM NAME
H3.
Have you ever gotten information about the following topics while you were pregnant?
PROGRAMMER: RANDOMLY ROTATE ORDER OF QUESTIONS
CODE ONE PER ROW
YES
NO
DK
REF
a. Taking prenatal vitamins? ............................................................
1
0
d
r
b. Seeing a dentist? ..........................................................................
1
0
d
r
c.
Getting help if you are feeling depressed? ...................................
1
0
d
r
d. Safe sleep positions for infants? ..................................................
1
0
d
r
e. Family planning or birth control? ..................................................
1
0
d
r
f.
Breastfeeding your baby? ............................................................
1
0
d
r
g. Quitting smoking during pregnancy? ............................................
1
0
d
r
h. Avoiding alcohol or other drugs? ..................................................
1
0
d
r
i.
What to do if you or someone you know has a partner that
hurts them physically? ..................................................................
1
0
d
r
j.
Signs of premature labor? ............................................................
1
0
d
r
k.
Taking your baby to get check-ups or well-child visits? ...............
1
0
d
r
l.
Getting vaccinations for your baby? .............................................
1
0
d
r
m. Getting a flu shot? ........................................................................
1
0
d
r
n. Finding out if you are eligible for Medicaid? You may also call
this [STATE PROGRAM NAME]? ................................................
1
0
d
r
o. Finding out if you are eligible for WIC? (WIC is the Special
Supplemental Nutrition Program for women, infants and
children.) .......................................................................................
1
0
d
r
Prepared by Mathematica Policy Research
57
IF A2 = YES (EVER SIGNED UP FOR TEXT4BABY) AND ANY items in H3 = YES
H3a.
Now, for each of the topics you just mentioned, I would like to ask you whether you got
this information from Text4baby, and if so, whether this information was very useful,
somewhat useful, or not very useful. Did you get information about [TOPIC] from
Text4baby?
[FOR ANY YES IN QE.7, ASK]: Did you get information about from Text4baby about
[TOPIC]?
[FOR ANY YES IN COLUMN A, ASK]: Was the Text4baby message about [TOPIC] very
useful, somewhat useful, or not useful?
GOT INFO FROM
TEXT4BABY
USEFULNESS OF INFO FROM TEXT4BABY
YES
NO
VERY
USEFUL
SOMEWHAT
USEFUL
NOT
USEFUL
DK
REF
a. Topic #1 ................
1
0
1
2
3
d
r
b. Topic #2 ................
1
0
1
2
3
d
r
c. Topic #3 ................
1
0
1
2
3
d
r
d. Topic #4 ................
1
0
1
2
3
d
r
ALL
FILL CHILD’S NAME
H4.
Is there any other health-related information you feel you needed since you became
pregnant with [CHILD] but did not get?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
GO TO H5
DON’T KNOW .......................................................................................................... d
GO TO H5
REFUSED ................................................................................................................ r
GO TO H5
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58
IF H4 = YES (HAS UNMET HEALTH INFORMATION NEEDS)
FILL CHILD’S NAME
H4a.
What information do you feel you needed but did not get since you became pregnant with
[CHILD]?
RECORD VERBATIM
CODE ONE ONLY
BREASTFEEDING ................................................................................................... 1
C-SECTION ............................................................................................................. 2
DELIVERY ............................................................................................................... 3
NEWBORN CARE ................................................................................................... 4
NUTRITION.............................................................................................................. 5
WIC .......................................................................................................................... 6
FLU SHOTS ............................................................................................................. 7
SMOKING/ DRINKING............................................................................................. 8
OTHER (SPECIFY) .................................................................................................. 99
______________________________________________________(STRING 400)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
IF OTHER SPECIFY (99): What information do you feel you needed but did not get since you
became pregnant with [CHILD]?
Prepared by Mathematica Policy Research
59
ALL
FILL CHILD’S NAME
H5.
Did you do any of the following while you were pregnant with [CHILD] or after [CHILD] was
born . . .
PROGRAMMER: FOR EACH NO RESPONSE: Did you need or want to [DISPLAY ITEM]
during the past year, but did not or were unable to?
CODE ONE PER ROW
YES
NO
DK
REF
DISPLAY ONLY IF R HAS SMOKED WITHIN PAST TWO
YEARS:
a. Call a smoking quit line or get help with quitting
smoking? .............................................................................
1
0
d
r
b. Get information about where you could get free or lowcost health services? ...........................................................
1
0
d
r
Talk to someone to get help signing up for Medicaid or
CHIP? ..................................................................................
1
0
d
r
d. Go to a place where you could get a flu shot? ....................
1
0
d
r
e. Talk to a counselor or social worker for mental health
help or treatment? ...............................................................
1
0
d
r
Talk to a counselor or social worker for alcohol or
substance abuse problems, or for help with domestic
violence? .............................................................................
1
0
d
r
g. Get information about family planning or birth control?.......
1
0
d
r
h. Get information about how to pay for child care for
[CHILD]? ..............................................................................
1
0
d
r
i.
Get a home visit?.................................................................
1
0
d
r
j.
Use WIC services? ..............................................................
1
0
d
r
c.
f.
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60
I. PARTICIPANT CHARACTERISTICS
We are almost done. Thank you so much for answering my questions. The last questions are
about your background.
ALL
I1.
Are you of Hispanic or Latino origin?
YES, HISPANIC OR LATINO .................................................................................. 1
NO, NOT HISPANIC OR LATINO............................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
I2.
What is your race? You may choose more than one. Are you . . .
INTERVIEWER:
DO NOT READ “OTHER.” CODE ONLY IF NECESSARY.
CODE ALL THAT APPLY
American Indian or Alaska Native, ....................................................................... 1
Asian,....................................................................................................................... 2
Black or African American, ................................................................................... 3
Native Hawaiian or other Pacific Islander, or ...................................................... 4
White? ..................................................................................................................... 5
OTHER (SPECIFY) .................................................................................................. 99
_______________________________________________________(STRING 100)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
I3.
Do you speak a language other than English at home?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
GO TO I4
DON’T KNOW .......................................................................................................... d
GO TO I4
REFUSED ................................................................................................................ r
GO TO I4
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61
IF I3 = YES (SPEAKS A LANGUAGE OTHER THAN ENGLISH AT HOME)
I3a.
What language do you speak at home?
PROBE:
Any others?
_____________________________________________________ (STRING 100)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
I4.
In what country were you born?
CODE ONE ONLY
UNITED STATES (ONE OF THE 50 STATES OR THE DISTRICT OF
COLUMBIA) ............................................................................................................. 1
GO TO I5
PUERTO RICO, GUAM, AMERICAN SAMOA, U.S. VIRGIN ISLANDS,
MARIANA ISLANDS, OR SOLOMON ISLANDS (ONE OF THE U.S.
TERRITORIES) ........................................................................................................ 2
GO TO I5
MEXICO ................................................................................................................... 303
GUATEMALA ........................................................................................................... 313
CUBA ....................................................................................................................... 327
DOMINICAN REPUBLIC.......................................................................................... 329
INDIA ........................................................................................................................ 210
CHINA ...................................................................................................................... 207
PHILIPPINES ........................................................................................................... 233
JAPAN ...................................................................................................................... 215
KOREA ..................................................................................................................... 217
VIETNAM ................................................................................................................. 247
ANOTHER COUNTRY (SPECIFY) ......................................................................... 99
_______________________________________________________ (STRING 100)
DON’T KNOW .......................................................................................................... d
GO TO I5
REFUSED ................................................................................................................ r
GO TO I5
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IF I4 ≠1 OR 2 (NOT BORN IN UNITED STATES OR ONE OF THE U.S. TERRITORIES)
I4a.
How old were you when you first moved to the United States?
PROBE:
Your best estimate is fine.
INTERVIEWER:
[IF R MOVED TO/FROM THE U.S. MULTIPLE TIMES, ASK]: “How old
were you the last time you moved to the United States?”
INTERVIEWER:
CODE LESS THAN ONE YEAR OLD = 0, ROUND UP OR DOWN TO THE
NEAREST YEAR
|
|
| AGE
(0–55)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
I5.
What is the highest grade or level of school that you have completed?
PROBE:
IF RESPONDENT SAYS SHE WAS HOME SCHOOLED, PROBE FOR
HIGHEST YEAR, GRADE, DEGREE, OR CERTIFICATE COMPLETED.
CODE ONE ONLY
8TH GRADE OR LESS ............................................................................................ 1
SOME HIGH SCHOOL BUT DID NOT GRADUATE ............................................... 2
HIGH SCHOOL GRADUATE OR GED.................................................................... 3
SOME COLLEGE OR 2-YEAR DEGREE ................................................................ 4
4-YEAR COLLEGE GRADUATE ............................................................................. 5
MORE THAN 4-YEAR COLLEGE DEGREE ........................................................... 6
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
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ALL
I6.
Are you currently . . .
CODE ONE ONLY
Married, ................................................................................................................... 1
Separated, ............................................................................................................... 2
Divorced, ................................................................................................................. 3
Widowed, ................................................................................................................ 4
Never married, or ................................................................................................... 5
Living with a partner? ............................................................................................ 6
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
ALL
I7.
Are you currently working 35 hours or more per week, less than 35 hours per week, or are
you not currently working?
PROBE:
[IF R SAYS ON MATERNITY LEAVE OR ON VACATION, PROBE]: Are you
usually employed 35 hours or more per week, less than 35 per week, or
are you not working?
CODE ONE ONLY
35 OR MORE HOURS PER WEEK ......................................................................... 1
LESS THAN 35 HOURS PER WEEK ...................................................................... 2
NOT WORKING (INCLUDES RETIRED, HOMEMAKER, STUDENT,
DISABLED) .............................................................................................................. 3
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
I7 = 2,3,D,R (NOT WORKING 35 OR MORE HOURS PER WEEK)
IF I7 = LESS THAN 35 HOURS PER WEEK, FILL [MORE]
I8.
Are you currently actively looking for [more] work?
YES .......................................................................................................................... 1
NO ............................................................................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Prepared by Mathematica Policy Research
64
GO TO I9
ALL
FILL STATE MEDICAID NAME, STATE CHIP NAME, LOCAL INDIGENT CARE PROGRAM NAME
I9.
Please tell me all the types of health insurance that you currently have. Do you have…
CODE ONE PER ROW
YES
NO
DK
REF
a. Medicaid or [STATE MEDICAID NAME]? ........
1
0
d
r
b. CHIP or [STATE CHIP NAME]? .......................
1
0
d
r
Health insurance from your job or the job of
your husband, partner, or parents? ..................
1
0
d
r
d. Health insurance that you or someone else
paid for (not from a job)? ..................................
1
0
d
r
e. TRICARE or other military health care? ...........
1
0
d
r
f.
Indian Health Service? .....................................
1
0
d
r
g. Indigent Care Program or [LOCAL
PROGRAM NAME]?.........................................
1
0
d
r
h. Other (SPECIFY) ..............................................
1
0
d
r
c.
_______________________ (STRING 100)
IF OTHER SPECIFY (99): Please tell me the type of health insurance that you currently have.
IF ALL RESPONSES IN I9_A THROUGH I9_H = NO, DON’T KNOW, OR REFUSED
I10.
It appears that you do not currently have health insurance coverage to help pay for
services from hospitals, doctors, and other health care providers. Is that correct?
INTERVIEWER:
IF RESPONDENT SAYS THEY DO HAVE COVERAGE, GO BACK
TO THE PREVIOUS QUESTION AND CODE “YES” TO THE TYPE
OF INSURANCE THAT THE RESPONDENT CURRENTLY HAS.
CODE ONE ONLY
CORRECT, HAS NO COVERAGE .......................................................................... 1
WRONG, HAS SOME COVERAGE ........................................................................ 0
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
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IF I9_A= YES (CURRENTLY ENROLLED IN MEDICAID)
I11.
About how long ago did you enroll in Medicaid? Your best estimate is fine.
|
|
| NUMBER OF WEEKS (1–52)
|
|
| NUMBER OF MONTHS (1–12)
|
| NUMBER OF YEARS (1–9)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
SOFT CHECK: IF NUMBER OF YEARS GT 5; I just wanted to confirm that I recorded correctly that
you enrolled in Medicaid [X] years ago. Is that correct?
IF I9_A = NO, DON’T KNOW, REFUSED (NOT CURRENTLY ENROLLED IN MEDICAID)
FILL CHILD’S NAME
I12.
Earlier you said that you had health insurance through Medicaid at some point during your
pregnancy with [CHILD]. Did you sign up for Medicaid while you were pregnant with
[CHILD] or before you became pregnant with [CHILD]?
WHILE PREGNANT ................................................................................................. 1
BEFORE BECOMING PREGNANT ......................................................................... 2
GO TO I14
DON’T KNOW .......................................................................................................... d
GO TO I14
REFUSED ................................................................................................................ r
GO TO I14
IF I12 = 1 (NOT CURRENTLY ENROLLED IN MEDICAID BUT SIGNED UP WHILE PREGNANT)
I13.
How many months pregnant were you when you signed up for Medicaid or [FILL STATE
MEDICAID NAME]? Were you . . .
CODE ONE ONLY
1 to 3 months pregnant, ........................................................................................ 1
4 to 6 months pregnant, or .................................................................................... 2
7 to 9 months pregnant? ....................................................................................... 3
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
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I9_A = NO, DON’T KNOW, REFUSED (NOT CURRENTLY ENROLLED IN MEDICAID)
I14.
About how long ago did you stop receiving Medicaid benefits? Your best estimate is fine.
|
|
| NUMBER OF WEEKS (1–52)
|
|
| NUMBER OF MONTHS (1–12)
|
| NUMBER OF YEARS (1–9)
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
SOFT CHECK: IF NUMBER OF YEARS GT 1: I just wanted to confirm that I recorded correctly that
you stopped receiving Medicaid benefits [X] years ago. Is that correct?
ALL
FILL ADDRESS FROM PRELOAD
I15.
We are done with the survey. Thank you very much for taking the time to speak with me. I
would like to confirm the address where we should mail your $25 gift card. Is it . . .
INTERVIEWER:
READ ADDRESS TO RESPONDENT. EDIT ADDRESS AS
NECESSARY.
___________________________________________________
STREET 1
___________________________________________________
STREET 2
___________________________________________________
STREET 3
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
DON’T KNOW .......................................................................................................... d
REFUSED ................................................................................................................ r
Goodbye.
Thank you for your participation in this important survey. We will mail the
gift card to you within 3 weeks. Thank you again and have a great day.
Goodbye.
Prepared by Mathematica Policy Research
67
| File Type | application/pdf |
| File Title | Medicaid Postpartum Survey |
| Subject | Medicaid Postpartum Survey |
| Author | Mathematica Policy Research |
| File Modified | 2017-01-20 |
| File Created | 2016-03-18 |