Form 3 2018 MCH Survey Juris Module_CNMI_English_Formatted

Northern Mariana Islands

[ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

I am going to start by asking you a few questions about the health care you received for your most recent pregnancy.

1. Did you get prenatal care in the first trimester of your pregnancy? The first trimester is defined as weeks 1 through 12 of your pregnancy.

   1. ☐ Yes

   2. ☐ No

77. ☐ Don’t know

99. ☐ Prefer not to answer

2. [ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

Was there ever a time when you did not get the prenatal care you wanted?

1. ☐ Yes

2. ☐ No [Go to NM3]

77. ☐ Don’t know [Go to NM3]

3. ☐ Prefer not to answer [Go to NM3]

[If yes] Did any of these things keep you from getting prenatal care when you wanted it? For each item, check No if it did not keep you from getting prenatal care or Yes if it did.

	Yes	No	Don’t Know	Prefer not to answer
NM2a. I couldn’t get an appointment when I wanted one	1 ☐	2 ☐	77 ☐	99 ☐
NM2b. I didn’t have enough money or insurance to pay for my visits	1 ☐	2 ☐	77 ☐	99 ☐
NM2c. I didn’t have any transportation to get to the clinic or doctor’s office	1 ☐	2 ☐	77 ☐	99 ☐
NM2d. The doctor or my health plan would not start care as early as I wanted	1 ☐	2 ☐	77 ☐	99 ☐
NM2e. I had too many other things going on	1 ☐	2 ☐	77 ☐	99 ☐
NM2f. I couldn’t take time off from work or school	1 ☐	2 ☐	77 ☐	99 ☐
NM2g. I didn’t have my Medicaid <or state Medicaid name> card	1 ☐	2 ☐	77 ☐	99 ☐
NM2h. I didn’t have anyone to take care of my children	1 ☐	2 ☐	77 ☐	99 ☐
NM2i. Something else, please specify	1 ☐	2 ☐	77 ☐	99 ☐

3. [ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

Have you gone to any of the following places for your prenatal care visits?
Do not include visits for WIC.

	Yes	No	Don’t Know	Prefer not to answer
NM3a. Private doctor’s office	1 ☐	2 ☐	77 ☐	99 ☐
NM3b. Hospital clinic	1 ☐	2 ☐	77 ☐	99 ☐
NM3c. CHCC Women's Clinic	1 ☐	2 ☐	77 ☐	99 ☐
NM3d. Marianas Medical Center	1 ☐	2 ☐	77 ☐	99 ☐
NM3e. Saipan Health Clinic	1 ☐	2 ☐	77 ☐	99 ☐
NM3f. Medical Associates of the Pacific	1 ☐	2 ☐	77 ☐	99 ☐
NM3g. Kagman Community Health Clinic	1 ☐	2 ☐	77 ☐	99 ☐
NM3h. Tinian Health Center	1 ☐	2 ☐	77 ☐	99 ☐
NM3i. Rota Health Center	1 ☐	2 ☐	77 ☐	99 ☐
NM3i. Another place, please specify	1 ☐	2 ☐	77 ☐	99 ☐

4. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD AND BIOLOGICAL MOTHER]

During your most recent pregnancy, were you on WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)?

1. ☐ Yes

2. ☐ No [Go to NM6]

77. ☐ Don’t know [Go to NM6]

99. ☐ Prefer not to answer [Go to NM6]

5. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD AND BIOLOGICAL MOTHER]

   1. Since your youngest child was born, have you used WIC services for yourself or your child?

   2. ☐ Yes, only I am using WIC services

   3. ☐ Yes, both my child and I use WIC services

   4. ☐ Yes, only my child uses WIC services

   5. ☐ No

77. ☐ Don’t know

99. ☐ Prefer not to answer

6. [ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

At any time during your most recent pregnancy or after delivery, did a doctor, nurse, or other health care worker talk with you about any of the things listed below? For each one, answer No if they did not talk with you about it or Yes if they did.

	YES	NO	Don’t Know	Prefer Not to Answer
NM6a. Breastfeeding my baby	1 ☐	2 ☐	77 ☐	99 ☐
NM6b. How long to wait before getting pregnant again	1 ☐	2 ☐	77 ☐	99 ☐
NM6c. Family planning services or using contraception	1 ☐	2 ☐	77 ☐	99 ☐
NM6d. Postpartum depression	1 ☐	2 ☐	77 ☐	99 ☐
NM6e. Resources in my community to support new parents	1 ☐	2 ☐	77 ☐	99 ☐
NM6f. Getting to and staying at a healthy weight after delivery	1 ☐	2 ☐	77 ☐	99 ☐
NM6g. How to quit or keep from smoking	1 ☐	2 ☐	77 ☐	99 ☐
NM6h. How to get the health care that my baby or I need	1 ☐	2 ☐	77 ☐	99 ☐

7. [ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEARS OLD AND IF BIOLOGICAL MOTHER]

For the next set of questions, please select the answer that comes closest to how you have felt after your most recent pregnancy?

NM7a. I have been able to laugh and see the funny side of things.

1. ☐ As much as I always could

2. ☐ Not quite so much now

3. ☐ Definitely not so much now

4. ☐ Not at all

NM7b. I have looked forward with enjoyment to things.

1. ☐ As much as I ever did

2. ☐ Rather less than I used to

3. ☐ Definitely less than I used to

4. ☐ Hardly at all

NM7c. I have blamed myself unnecessarily when things went wrong.

1. ☐ Yes, most of the time

2. ☐ Yes, some of the time

3. ☐ Not very often

4. ☐ No, never

NM7d. I have been anxious or worried for no good reason.

1. ☐ No not at all

2. ☐ Hardly ever

3. ☐ Yes, sometimes

4. ☐ Yes, very often

NM7. I have felt scared or panicky for no very good reason.

1. ☐ Yes, quite a lot

2. ☐ Yes, sometimes

3. ☐ No, not much

4. ☐ No, not at all

NM7f. I have been so unhappy that I have had difficulty sleeping.

1. ☐ Yes, most of the time

2. ☐ Yes, sometimes

3. ☐ Not very often

4. ☐ No, not at all

NM7g. I have felt sad or miserable.

1. ☐ Yes, most of the time

2. ☐ Yes, sometimes

3. ☐ Not very often

4. ☐ No, not at all

NM7h. I have been so unhappy that I have been crying.

1. ☐ Yes, most of the time

2. ☐ Yes, quite often

3. ☐ Only occasionally

4. ☐ No, never

NM7i. The thought of harming myself has occurred to me.

1. ☐ Yes, quite often

2. ☐ Sometimes

3. ☐ Hardly ever

4. ☐ Never

1. [ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

Did you have a regular checkup about 4-6 weeks after giving birth?

1. ☐ Yes

2. ☐ No

77. ☐ Don’t Know

99. ☐ Prefer not to answer

[If yes] where did you go for your checkup?

1. ☐ My family doctor’s office

2. ☐ My OB/GYN’s office

3. ☐ Hospital clinic

4. ☐ Health department clinic

5. ☐ State-specific option

6. ☐ State-specific option

7. ☐ Another type, please specify

77. ☐ Don’t Know

99. ☐ Prefer not to answer

How did you feel about the care you got during your postpartum checkup?

	Satisfied	Not Satisfied	Don’t Know	Prefer Not to Answer
NM8a. The amount of time you had to wait	1 ☐	2 ☐	77 ☐	99 ☐
NM8b. The amount of time the doctor, nurse, or health care worker spent with you	1 ☐	2 ☐	77 ☐	99 ☐
NM8c. The advice you got on how to take care of yourself	1 ☐	2 ☐	77 ☐	99 ☐
NM8d. The understanding and respect shown toward you as a person	1 ☐	2 ☐	77 ☐	99 ☐

[If no] Did any of these things keep you from having a checkup after your most recent pregnancy?

	YES	NO	Don’t Know	Prefer Not to Answer
NM8e. I didn’t have health insurance to cover the cost of the visit	1 ☐	2 ☐	77 ☐	99 ☐
NM8f. I felt fine and did not think I needed to have a visit	1 ☐	2 ☐	77 ☐	99 ☐
NM8g. I couldn’t get an appointment when I wanted one	1 ☐	2 ☐	77 ☐	99 ☐
NM8h. I didn’t have any transportation to get to the clinic or doctor’s office	1 ☐	2 ☐	77 ☐	99 ☐
NM8i. I had too many things going on	1 ☐	2 ☐	77 ☐	99 ☐
NM8j. I couldn’t take time off from work	1 ☐	2 ☐	77 ☐	99 ☐
NM8k. Something else, please specify	1 ☐	2 ☐	77 ☐	99 ☐

9. In the past 12 months, have you had any trouble getting health care for yourself? By health care, we mean medical care as well as other kinds of care like dental care, vision care, and mental health services.

   1. ☐ Yes

   2. ☐ No [GO TO NM10]

77. ☐ Don’t Know [GO TO NM10]

99. ☐ Prefer not to answer [GO TO NM10]

[If yes] Did any of the following items affect your ability to get health care for you or your child? Check all that apply.

1. ☐ Transportation

2. ☐ Insurance status

3. ☐ Language differences

4. ☐ Difficulty of understanding the paperwork

5. ☐ The costs

6. ☐ Your immigration status

77. ☐ Don’t Know

99. ☐ Prefer not to answer

10. Thinking about the last time you took your child for sick-child care, well-child check-ups, physical exams, hospitalizations or any other kind of medical care, was your child's doctor a man or a woman?

    1. ☐ Man

    2. ☐ Woman

    3. ☐ Have not taken child for medical care

77. ☐ Don’t Know

99. ☐ Prefer not to answer

[ONLY ASK THIS QUESTION IF BIOLOGICAL MOTHER]

We would like to ask you some specific questions about your experiences with breast and cervical cancer screening.

11. Have you ever had a breast exam done by a doctor or other health professional to check for lumps or other signs of breast cancer? A breast exam is when the breasts are felt by a doctor or other health professional to check for lumps or other signs of breast cancer.

    1. ☐ Yes

    2. ☐ No [Go to NM12]

77. ☐ Don’t know [Go to NM12]

3. ☐ Prefer not to answer [Go to NM12]

[If yes] when did you have your MOST RECENT breast exam?

1. ☐ A year ago or less

2. ☐ More than 1 year, but not more than 2 years

3. ☐ More than 2 years, but not more than 3 years

4. ☐ More than 3 years, but not more than 5 years

5. ☐ Over 5 years ago

77. ☐ Don’t know

99. ☐ Prefer not to answer

12. [ONLY ASK THIS QUESTION IF BIOLOGICAL MOTHER]

Have you ever had a pap smear done by a doctor or other health professional?

1. ☐ Yes

2. ☐ No [Go to NM13]

77. ☐ Don’t know [Go to NM13]

99. ☐ Prefer not to answer [Go to NM13]

[If yes] When did you have your MOST RECENT pap smear?

1. ☐ A year ago or less

2. ☐ More than 1 year, but not more than 2 years

3. ☐ More than 2 years, but not more than 3 years

4. ☐ More than 3 years, but not more than 5 years

5. ☐ Over 5 years ago

77. ☐ Don’t know

99. ☐ Prefer not to answer

[ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Now I would like to ask you some questions about your child. I understand that some of these questions are sensitive and may be difficult for you to answer. Please remember that you do not have to answer any question you do not want to answer. Please just answer to the best of your ability.

13. The next 2 questions ask about bullying. Bullying is when 1 or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again. It is not bullying when 2 students of about the same strength or power argue or fight or tease each other in a friendly way.

Has your child ever been bullied on school property?

1. ☐ Yes

2. ☐ No

77. ☐ Don’t know

99. ☐ Prefer not to answer

14. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Has your child ever been electronically bullied? Count being bullied through texting, Instagram, Facebook, or other social media.

1. ☐ Yes

2. ☐ No

77. ☐ Don’t know

99. ☐ Prefer not to answer

[ONLY ASK THIS QUESTION IF CHILD IS 6-11 or 12-17 YEARS OLD]

The next few questions are about swim safety.

15. For each of the following, please indicate if it is something your child can or cannot do or if you are not sure.

	YES	NO	Don’t Know/ Unsure	Prefer Not to Answer
NM15a. Step or jump into water over his or her head and return to the surface	1 ☐	2 ☐	77 ☐	99 ☐
NM15b. Float or tread water for 1 minute without using a flotation device	1 ☐	2 ☐	77 ☐	99 ☐
NM15c. Turn around in a full circle in the water and then find a way out of the water	1 ☐	2 ☐	77 ☐	99 ☐
NM15d. Swim 25 yards (equal to the length of a standard swimming pool) without stopping	1 ☐	2 ☐	77 ☐	99 ☐
NM15e. Exit a pool, not using a ladder	1 ☐	2 ☐	77 ☐	99 ☐

The next few questions ask about car safety.

[ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

16. When your child rides in an infant car seat, is he or she usually in the front or back seat of the car, truck, or van?

    1. ☐ Front seat

    2. ☐ Back seat

    3. ☐ Never rides in a car [Go to end]

77. ☐ Don’t know

99. ☐ Prefer not to answer

[ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

17. When your child rides in an infant car seat, is he or she usually facing forward or facing the rear of the car, truck, or van?

    1. ☐ Facing forward

    2. ☐ Facing the rear

    3. ☐ Never rides in a car [Go to end]

77. ☐ Don’t know

99. ☐ Prefer not to answer

[ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

18. Does the car, truck, or van that your child usually rides in have an airbag on the passenger side?

    1. ☐ Yes

    2. ☐ No

    3. ☐ Never drive or ride in a car [Go to end]

77. ☐ Don’t know

99. ☐ Prefer not to answer

19. How often do you use seat belts when you drive or ride in a car? Would you say:

    1. ☐ Always

    2. ☐ Nearly always

    3. ☐ Sometimes

    4. ☐ Rarely

    5. ☐ Never

    6. ☐ Never drive or ride in a car [Go to end]

77. ☐ Don’t know

99. ☐ Prefer not to answer

20. During the last 3 months of your most recent pregnancy, how often did you wear a seat belt when you drove or rode in a car?

    1. ☐ Always

    2. ☐ Often

    3. ☐ Sometimes

    4. ☐ Rarely

    5. ☐ Never

77. ☐ Don’t Know

99. ☐ Prefer not to answer

21. During the past 30 days, how many times did you ride in a car or other vehicle driven by someone who had been drinking alcohol?

    1. ☐ 0 times

    2. ☐ 1 time

    3. ☐ 2 or 3 times

    4. ☐ 4 or 5 times

    5. ☐ 6 or more times

77. ☐ Don’t know

99. ☐ Prefer not to answer

22. During the past 30 days, how many times did YOU drive a car or other vehicle when you had been drinking alcohol?

    1. ☐ 0 times

    2. ☐ 1 time

    3. ☐ 2 or 3 times

    4. ☐ 4 or 5 times

    5. ☐ 6 or more times

77. ☐ Don’t know

99. ☐ Prefer not to answer