ZEN Columbia - Pregnant Woman Enrollment Questionnaire -

STUDY ID: __________ -___-______________________ Form Approved

OMB No. 0920-XXXX

Date: __ __/__ __ __ /__ __ __ __ Exp. Date xx/xx/20xx

D D M M M Y Y Y Y

Staff Administered: ___________________________

PREGNANT WOMAN Enrollment Questionnaire

City: _______________________________________________________

Clinic: ______________________________________________________

First, I will start with some questions about you.

1. What is your birthdate?

__ __/__ __ __ /__ __ __ __ ₇₇ Don’t know ₈₈ Refused

D D M M M Y Y Y Y

2. What is the highest level of education that you have completed?

₁ Less than primary ₂ Primary ₃ Secondary ₄ Technical ₅ University or more ₆ None

₇₇ Don’t know ₈₈ Refused

3. What is your household’s socioeconomic stratum?

₁ 1 ₂ 2 ₃ 3 ₄ 4 ₅ 5 ₆ 6 ₇₇ Don’t know ₈₈ Refused

4. What type of health insurance do you have?

₁ Contributory ₂ Subsidized ₃ Not insured ₄ Specialized ₅ Exception

₆ Indeterminate / independent ₇₇ Don’t know ₈₈ Refused

5. What is the name of your health insurance provider?

Name: ___________________________________________ ₇₇ Don’t know ₈₈ Refused

6. How many adults and children live in your household, including yourself?

______ adults (18+ years) ______ children (<18 years) ₇₇ Don’t know ₈₈ Refused

7. What is your marital status?

₁ Married ₂ Free Union ₃ Single, divorced, or widowed ₄ Other, specify: ______________

₇₇ Don’t know ₈₈ Refused

8. Do you live in the same household as your husband or male partner?

₁ Yes ₀ No ₆₆ I don’t have a husband or a male partner ₇₇ Don’t know ₈₈ Refused

The next questions are about mosquito bites.

9. In the past 7 days, how many mosquito bites did you get?

₀ None ₁ Less than 20 ₂ 20 or more, or too many to count ₇₇ Don’t know ₈₈ Refused

10. In the past 7 days, how often have you done the following things? Response options include never, some of the time, or always.

	Never0	Some of the time1	Always2	Don’t know77	Refused88
Worn long pants that covered your legs
Worn shirts or jackets with long sleeves that covered your arms
Kept your feet and ankles completely covered
Used mosquito repellant

11. In the past 7 days, when you were inside your home, how often was the air conditioner running?

₃ Never ₂ Some of the time ₁ Always ₀ I don’t have air conditioning

₇₇ Don’t know ₈₈ Refused

12. Does your home have intact screens on all windows and doors that prevent mosquitos from entering?

₂ Yes, on all windows and doors ₁ Some ₀ None ₇₇ Don’t know ₈₈ Refused

The next questions are about what you might have heard about Zika virus.

13. Do you think it’s possible for a person to get Zika virus in your community?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

14. Do you think that everybody with Zika virus has symptoms?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

15. Do you know anyone who has had Zika virus?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

Have you had Zika virus?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

16. How worried have you been about getting Zika virus during this pregnancy?

₃Very worried ₂ Somewhat worried ₁ Not at all worried

₇₇ Don’t know ₈₈ Refused

17. Momentarily, I will give you a number of statements about Zika virus; we ask that you respond if you consider it to be “very likely”, “somewhat likely”, or “impossible” that Zika can be transmitted by any of these means.

	Very likely2	Somewhat likely1	Impossible0	Don’t know77	Refused88
Being bitten by an infected mosquito
Having vaginal sex with a man who has Zika without using a condom
Kissing someone on the mouth who has Zika
Shaking hands with someone who has Zika
Being coughed or sneezed on by someone who has Zika
Receiving a blood transfusion with Zika in it
Being in utero if a mother has Zika during pregnancy

18. Momentarily, I will give you a number of statements about the possible side effects on a baby if their mother was infected with Zika during her pregnancy; we ask that you respond if you consider it to be “very likely”, “somewhat likely”, or “impossible” that a baby could be born with the following conditions:

	Very likely2	Somewhat likely1	Impossible0	Don’t know77	Refused88
Microcephaly (a small sized head)
Other birth defects
Intrauterine growth restriction (small baby)
Miscarriages/stillbirths

The next few questions are about Zika symptoms that you or your family might have had.

19. In the past 3 months, have you had symptoms of Zika virus? Symptoms of Zika virus means being sick with 2 or more of fever, rash, red eyes, and joint pain that are not explained by other causes.

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

When did these symptoms first start?

__ __/__ __ __ /__ __ __ __ ₇₇ Don’t know ₈₈ Refused

D D M M M Y Y Y Y

20. At any time, has a doctor or healthcare provider ever told you that you might have Zika virus?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

When?

__ __/__ __ __ /__ __ __ __ ₇₇ Don’t know ₈₈ Refused

D D M M M Y Y Y Y

• If according to question #6, this participant lives alone in her house, go to question #23.

21. In the past 3 months, did anyone in your household other than you have symptoms of Zika? Symptoms of Zika means being sick with 2 or more of fever, rash red eyes, or joint pain that are not explained by any other cause.

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

Was it…

Your husband or partner?	1 Yes 0 No 66 Not applicable 77 Don’t know 88 Refused
Your child?	1 Yes 0 No 66 Not applicable 77 Don’t know 88 Refused
Another person in the household?	1 Yes 0 No 66 Not applicable 77 Don’t know 88 Refused If yes:,Who was it? _____________________________________

22. Has a doctor or healthcare provider ever told anyone in your household, aside from yourself, that they might have Zika virus?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

Was it…

Your husband or partner?	1 Yes 0 No 66 Not applicable 77 Don’t know 88 Refused
Your child?	1 Yes 0 No 66 Not applicable 77 Don’t know 88 Refused
Another person in the household?	1 Yes 0 No 66 Not applicable 77 Don’t know 88 Refused If yes:,Who was it? _____________________________________

Next I’ll ask you some questions about your home, community, and environment.

23. Where do you usually get your drinking water? (Select all that apply.)

Public or private water utility	1 Yes 0 No 77 Don’t know 88 Refused
Well	1 Yes 0 No 77 Don’t know 88 Refused
Cistern or tank	1 Yes 0 No 77 Don’t know 88 Refused
Bottled water	1 Yes 0 No 77 Don’t know 88 Refused
Lake, river, or other natural source	1 Yes 0 No 77 Don’t know 88 Refused
Another water source, specify:

24. In the past 3 months, have you worked at a job? Include jobs in which you don’t have a formal employer, such as selling goods or providing services.

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

Have any of your jobs in the past 3 months involved:

X-rays	1 Yes 0 No 77 Don’t know 88 Refused
Contact with body fluids such as urine, saliva, or blood	1 Yes 0 No 77 Don’t know 88 Refused
Applying pesticides, insecticides, or rat poison	1 Yes 0 No 77 Don’t know 88 Refused
Battery manufacturing or battery recycling	1 Yes 0 No 77 Don’t know 88 Refused
Electronic waste recycling	1 Yes 0 No 77 Don’t know 88 Refused
Gold mining or gold processing	1 Yes 0 No 77 Don’t know 88 Refused
Other metal mining (for example: uranium, nickel, cobalt)	1 Yes 0 No 77 Don’t know 88 Refused
A job in which you or your coworkers use lead	1 Yes 0 No 77 Don’t know 88 Refused
A job in which you your coworkers use mercury	1 Yes 0 No 77 Don’t know 88 Refused

• If according to question #6, this participant lives alone in her house, go to question #26.

25. In the past 3 months, has anyone in your household other than yourself worked in the following jobs?

Battery manufacturing or battery recycling	1 Yes 0 No 77 Don’t know 88 Refused
Electronic waste recycling	1 Yes 0 No 77 Don’t know 88 Refused
Gold mining or gold processing	1 Yes 0 No 77 Don’t know 88 Refused
Other metal mining (for example: uranium, nickel, cobalt)	1 Yes 0 No 77 Don’t know 88 Refused
A job in which they or their coworkers use lead	1 Yes 0 No 77 Don’t know 88 Refused
A job in which they or their coworkers use mercury	1 Yes 0 No 77 Don’t know 88 Refused

26. In the past 3 months, have you or your household members used any pesticides, insecticides, or rat poison in or around your home?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

Now I’ll ask you about medical conditions you might have had.

27. Have you ever had…?

27a. Yellow fever

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

When?

Less than 3 months ago	1 Yes 0 No 77 Don’t know 88 Refused
Between 3-6 months ago	1 Yes 0 No 77 Don’t know 88 Refused
7-12 months ago	1 Yes 0 No 77 Don’t know 88 Refused
13 months-5 years ago	1 Yes 0 No 77 Don’t know 88 Refused
More than 5 years ago	1 Yes 0 No 77 Don’t know 88 Refused

27b. Dengue

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

When?

Less than 3 months ago	1 Yes 0 No 77 Don’t know 88 Refused	Was it hemorrhagic? 1 Yes 0 No 77 Don’t know 88 Refused
Between 3-6 months ago	1 Yes 0 No 77 Don’t know 88 Refused	Was it hemorrhagic? 1 Yes 0 No 77 Don’t know 88 Refused
7-12 months ago	1 Yes 0 No 77 Don’t know 88 Refused	Was it hemorrhagic? 1 Yes 0 No 77 Don’t know 88 Refused
13 months-5 years ago	1 Yes 0 No 77 Don’t know 88 Refused	Was it hemorrhagic? 1 Yes 0 No 77 Don’t know 88 Refused
More than 5 years ago	1 Yes 0 No 77 Don’t know 88 Refused	Was it hemorrhagic? 1 Yes 0 No 77 Don’t know 88 Refused

27c. Chikungunya

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

When?

Less than 3 months ago	1 Yes 0 No 77 Don’t know 88 Refused
Between 3-6 months ago	1 Yes 0 No 77 Don’t know 88 Refused
7-12 months ago	1 Yes 0 No 77 Don’t know 88 Refused
13 months-5 years ago	1 Yes 0 No 77 Don’t know 88 Refused
More than 5 years ago	1 Yes 0 No 77 Don’t know 88 Refused

28. Have you ever been vaccinated for yellow fever?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

The next questions are about smoking, drug use, alcohol, and vitamin use.

29. In the past 3 months, have you …?

Smoked cigarettes	1 Yes 0 No 77 Don’t know 88 Refused
Smoked marijuana	1 Yes 0 No 77 Don’t know 88 Refused
Used drugs such as crack, cocaine, or heroin	1 Yes 0 No 77 Don’t know 88 Refused

30. In the past 3 months, how many alcoholic drinks (such as beer, wine, or others) have you had in an average week?

₆ I drank, but I don’t know how much

₅ 14 drinks or more a week

₄ 7–13 drinks a week

₃ 4-6 drinks a week

₂ 1–3 drinks a week

₁ Less than 1 drink a week

₀ None

₇₇ Don’t know

₈₈ Refused

31. In the past 3 months, have you taken folic acid?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

31a. When did you start taking it?

₁ Before I found out I was pregnant

₀ After I found out I was pregnant

₇₇ Don’t know

₈₈ Refused

31b. Are you currently taking folic acid?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

The next questions are about your pregnancies.

32. What was your weight when you got pregnant?

_______ kg ₇₇ Don’t know ₈₈ Refused

33. What is your height?

________cm ₇₇ Don’t know ₈₈ Refused

34. How many total pregnancies have you had (not including this pregnancy)? (All previous pregnancies, including miscarriages):

_________ number of pregnancies ₇₇ Don’t know ₈₈ Refused

• If participant responds “zero”, go to question #39.

35. Did any of these pregnancies have more than one fetus, such as twins or triplets?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

How many pregnancies had more than one fetus?

______ number of pregnancies ₇₇ Don’t know ₈₈ Refused

36. In how many of your previous pregnancies (not including this pregnancy) did you have…?

Live birth	________ number of live births 77 Don’t know 88 Refused
Miscarriage (loss before 20th week)	________ number of miscarriages (loss before 20th week) 77 Don’t know 88 Refused
Stillbirth (loss at or after the 20th week)	________ number of stillbirths (loss at or after the 20th week) 77 Don’t know 88 Refused
Abortion	________ number of abortions 77 Don’t know 88 Refused
Ectopic or molar pregnancy	________ number of ectopic or molar pregnancies 77 Don’t know 88 Refused

37. During your previous [pregnancy/pregnancies], in how many pregnancies (not including this pregnancy)…?

Did your doctor tell you that you had pre-eclampsia (high blood pressure in pregnancy)	__________ number of pregnancies with with pre-eclampsia 77 Don’t know 88 Refused
Did your doctor tell you that you had gestational diabetes (diabetes diagnosed in pregnancy)	__________ number of pregnancies with gestational diabetes 77 Don’t know 88 Refused
Did you have a premature birth (delivery before 37 weeks)	__________ number of premature births 77 Don’t know 88 Refused
Did you have a baby who was born weighing less than 2500g, or 2.5 kg	__________ number of babies with low birth weight 77 Don’t know 88 Refused
Did you have a Cesarean section	__________ number of Cesarean sections 77 Don’t know 88 Refused
Did you breastfeed your baby	__________ number of babies breastfed 77 Don’t know 88 Refused

38. When did your last pregnancy end?

__ __/__ __ __ /__ __ __ __ ₇₇ Don’t know ₈₈ Refused

D D M M M Y Y Y Y

39. For your current pregnancy, when was your last menstrual period?

__ __/__ __ __ /__ __ __ __ ₇₇ Don’t know ₈₈ Refused

D D M M M Y Y Y Y

How sure are you about the date of your last menstrual period?

₀ Not sure ₁ Sure ₇₇ Don’t know ₈₈ Refused

40. Did you use any fertility treatments to help you get pregnant?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

Did you use…?

Medicine for ovarian stimulation, such as clomiphene citrate or Femara	1 Yes 0 No 77 Don’t know 88 Refused
Intrauterine insemination	1 Yes 0 No 77 Don’t know 88 Refused
In vitro fertilization (IVF)	1 Yes 0 No 77 Don’t know 88 Refused
Intracytoplasmic sperm injection	1 Yes 0 No 77 Don’t know 88 Refused

41. Thinking back to right before you became pregnant, which of these statements best describes how you felt about being pregnant?

₄ I wanted to be pregnant sooner

₃ I wanted to be pregnant later

₂ I wanted to be pregnant then

₁ I didn’t want to be pregnant then or at any time in the future

₇₇ I don’t know

₈₈ Refused

These next few questions are about your recent sexual experiences. You do not have to answer any questions if they make you uncomfortable.

42. In the past 3 months, how many men have you had sex with?

₀ None  This is the end of the questionnaire.

₁ 1

₂ 2
₃ 3 or more

₇₇ Don’t know  This is the end of the questionnaire.

₈₈ Refused  This is the end of the questionnaire.

43. In the past 3 months, how often have you had vaginal sex with a man? Choose the best answer.

₁ Once a day or more (About 7 times or more per week)

₂ 2-6 times a week

₃ Once a week (About 4 times per month)

₄ 2-3 a month

₅ Once a month

₆ Less than once a month

₀ Never  Go to question #46

₇₇ Don’t know  Go to question #46

₈₈ Refused  Go to the question #46

44. When you had vaginal sex in the past 3 months, how often has your male partner used a condom?

₂ Always ₁ Sometimes ₀ Never ₇₇ Don’t know ₈₈ Refused

45. In the past 3 months, have you…?

Received oral sex from someone	1 Yes 0 No 77 Don’t know 88 Refused
Performed oral sex on someone	1 Yes 0 No 77 Don’t know 88 Refused
Had anal sex	1 Yes 0 No 77 Don’t know 88 Refused

46. Since you found out that you were pregnant, have you and your male partner changed how often you use condoms during sex?

₁ Yes, we use them more often

₂ Yes, we use them less often

₃ No, we haven’t changed how often we use condoms

₄ No, we don’t use condoms

₀ I haven’t had regular sex with a male partner

₇₇ Don’t know

₈₈ Refused

Thank you for answering the questionnaire. Do you have any questions?

Page 1 of 21

Appendix F1, version 19/MAY/2017

CDC estimates the average public reporting burden for this collection of information as 35 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).