Family Baseline Survey

MIHOPE FAMILY BASELINE SURVEY

QUESTIONNAIRE

August 27, 2013

all

FILL RESPONDENT PHONE NUMBER AND EXTENSION FROM PRELOAD

MakeDialPhone.

phone number details:

phone number= [phone number]

extension= [extension]

auto dial 1 CallDialer

manual dial 2 DialResult

quick exit 3 Finished

respondent calling in 4 Hello

field interviewer calling in 5 FirstName

makedialphone=5

F

irstName. What is the first name of the field interviewer?

(STRING 50)

FIRST NAME

makedialphone=5

L

astName. What is the last name of the field interviewer?

(STRING 50)

LAST NAME

makedialphone=5

U

serID. What is the Field Interviewer ID number?

PROBE:

INTERVIEWER:

| | | | | | ID number Hello

(0-99999)

Makedialphone=1

CallDialer.

INTERVIEWER: please click on the button in the field with three dots to make the call.

CALL OUT

DialResult.

INTERVIEWER: code result of dialing

someone answers 1 Hello

no answer 2 LeaveCase

busy 3 LeaveCase

answering machine 4 Verified

answering service 5 AnsService

PRIVACY MANAGER 6 Finished

PHONE/LINE PROBLEMS 7 PhoneProb

CHANGED TO NEW NUMBER 8 PhoneNumber

dialresult=4

FILL NAME FROM PRELOAD

Verified.

INTERVIEWER: DID RECORDING VERIFY [name] at this number?

Yes 1 Finished

No 0 Finished

dialresult=5

FILL NAME FROM PRELOAD

AnsService.

INTERVIEWER: Is this the answering service for [NAME]?

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

AnsOther

dialresult=7

P

honeProb.

INTERVIEWER: code phone problem

not in service; disconnected; not working 1 Finished

temporarily not in service 2 Finished

circuit problems; circuits overloaded 3 Finished

fast busy; fast ring; no ring 4 Finished

computer/fax line 5 Finished

PAGER 6 Finished

CELL PHONE 7 Finished

OTHER PHONE DEVICE………………………………………………………8 Finished

dialresult=1

FILL NAME FROM PRELOAD

H

ello. Hello, my name is [INTERVIEWER NAME]. I am calling on behalf of Mathematica Policy Research in Princeton, New Jersey. May I please speak to [NAME]?

speaking to [name] 1 SampMemb

[name] comes to the phone 2 SampMemb

person asks what call is about 3 WhatAbout

need to call back 4 CallBack

never heard of [name]/wrong number 5 PhoneCheck

HELLO=3

WhatAbout. I’m calling about a study we are conducting about families who enroll in home visiting programs and how those programs provide different kinds of services to children and families. May I speak with [NAME]? IF RE-ENTRY: I’m calling to finish the interview we are conducting with [NAME]. When is a good time to reach [NAME]?

[NAME] COMES TO THE PHONE 1 SampMemb

NEED TO CALL BACK 2 CALLBACK

SUPERVISOR REVIEW 3 Finished

WHATABOUT=1 OR HELLO=1,2 AND RE-ENTRY

SampMemb. I’m calling to finish the interview we are conducting about families who enroll in home visiting programs. Is now a good time?

CONTINUE INTERVIEW 1 NextQuestion

NOT A GOOD TIME……………………………….. 2 CallBack

SUPERVISOR REVIEW 3 Finished

INSERT UNIVERSE

CallBack. When would be a good time to call back?

INTERVIEWER: make appointment using the parallel block

Hello=5

Fill PHONE NUMBER from preload

P

honeCheck. I’m sorry, I must have misdialed. I thought I dialed [PHONE NUMBER]. Can you tell me what number I’ve reached to see what kind of mistake I made?

right number, no such person 1 WRONGNUMBER

wrong connection/misdial 2 THANKS

supervisor review required 3 THANKS

refused to confirm number 4 THANKS

PHONECHECK=1 AND RE-ENTRY

FILL NAME FROM PRELOAD

WrongNumber. I’m [INTERVIEWER NAME] from Mathematica Policy Research in Princeton, New Jersey. I thought we’d recently spoken to someone there and according to the information I have, we were supposed to call back to interview [NAME]. There must have been some mistake.

Thanks you for your help. I’ll turn this over to my supervisor.

dialresult=8

P

honeNumber. Please give me the telephone number, area code first.

| | | | - | | | | - | | | | | HaveExten

DIALRESULT=8 OR

Fill PHONE NUMBER FROM PhoneNumber

HaveExten. Is there an extension number?

programmer: display phone number

YES 1 EXTENSION

NO 0 TIMEZONE

HAVEEXTEN=1

Fill PHONE NUMBER FROM PhoneNumber

E

xtension. What is the extension number?

programmer: display phone number

| | | | | extension TIMEZONE

(0-9999)

dialresult=8

FILL TIMEZONE FROM PRELOAD

TimeZone. What time zone is that in?

PROGRAMMER: DISPLAY CURRENT TIME ZONE

HAWAII/ALEUTIAN TIME ZONE 2

ALASKA TIME ZONE 3

PACIFIC TIME ZONE 4

MOUNTAIN TIME ZONE 5

CENTRAL TIME ZONE 6

EASTERN TIME ZONE 7

ATLANTIC TIME ZONE 8

NEWFOUNDLAND 9

OTHER INTERNATIONAL TIME ZONE 98

INSERT UNIVERSE

ObserveDST. Is Daylight Saving Time observed in the area?

YES 1

NO 0

DON’T KNOW d

REFUSED r

INSERT UNIVERSE

P

honeType. Is this a home phone, business phone or a cell phone?

home phone 1

office phone 2

home and office phone 3

cell phone 4

pager 5

COMPUTER/FAX LINE 6

OTHER 7

INSERT UNIVERSE

T

imeOfDay. Should this number be used only at certain times of day?

anytime 1

daytime only 2

evening only 3

INSERT UNIVERSE

FILL CONTACT INFORMATION FROM PREVIOUS ITEMS

C

onfirm.

programmer: fill contact information from previous items

interviewer: confirm the info above with respondent, then press enter.

ALL

SC2. As the MIHOPE study representative has already mentioned, the purpose of the study is to learn more about families who enroll in home visiting programs and how those programs provide different kinds of services to children and families.

I will ask you some questions and type in your answers. This interview should take about an hour to complete. There are no right or wrong answers to these questions. The things you tell me are very important, so please be as accurate as possible.

You may stop me at any time, and you may ask me to go back to earlier questions to change your answers. If I ask you something that you are uncomfortable answering, just tell me and I will move on to the next question.

Everything we talk about today is completely private. No one from the home visiting program will see or hear your answers. All of the study results will be reported for groups of parents; no results will be analyzed or reported for individuals.

Your participation is completely voluntary. If you choose not to complete this interview, it will not affect your or your child’s participation in home visiting services. When we finish, Mathematica will send you a $25 gift card to thank you for your help.

If you have any questions at any time during the interview, please feel free to ask them. Do you have any questions before we begin?

YES 1 FAQ

NO 0

DON’T KNOW d

REFUSED r

all

SC2a. Did you receive and sign the MIHOPE study (consent/assent) form?

YES 1

NO 0 SUPERVISOR REVIEW

DON’T KNOW d SUPERVISOR REVIEW

REFUSED r SUPERVISOR REVIEW

respondent’s age lt 18

INSERT FILL CONDITION OR DELETE ROW

SC2b. Has your legal guardian given consent for you to participate in the MIHOPE study?

YES 1

NO 0 SUPERVISOR REVIEW

DON’T KNOW d SUPERVISOR REVIEW

REFUSED r SUPERVISOR REVIEW

ALL

SC3. First, I’d like to confirm the spelling of your name. Could you spell your name for me?

display name as interviewer note

INTERVIEWER: SPELL NAME FOR RESPONDENT.

PROGRAMMER: ALLOW RESPONDENT INFO TO BE ENTERED/REVISED IN INFO SCREEN. FIRST, HAVE INTERVIEWER INDICATE WHETHER THE NAME IS SPELLED CORRECTLY, THEN IF INCORRECT, ALLOW NAME TO BE REVISED,

(STRING (15))

FIRST NAME

(STRING (15))

MIDDLE INITIAL/NAME

(STRING (30))

LAST NAME

DON’T KNOW d

REFUSED r

ALL

SC4. Do you go by any other name?

YES 1

NO 0 SC6

DON’T KNOW d SC6

REFUSED r SC6

SC4=1

SC5. What is that name? ENTER NAME

(STRING (99))

DON’T KNOW d

REFUSED r

PROGRAMMER: GO TO INFO SCREEN AND LOAD UNDER “OTHER NAME”

ALL

Fill PARENT’S DOB from PRELOAD

SC6DOB. What is your birth date?

PROGRAMMER: DISPLAY DOB AS INTERVIEWER NOTE

PROGRAMMER: ALLOW BIRTH DATE INFO TO BE ENTERED/REVISED IN INFO SCREEN

INTERVIEWER: COMPARE RESPONSE WITH BIRTH DATE DISPLAYED

IF DOB IS LESS THAN 15 YEARS OLD, GO TO SUPERVISOR REVIEW

DOB CORRECT…………………………………………………………………..1

DOB INCORRECT………………………………………………………………..2

DON’T KNOW d SC7

REFUSED r SC7

ALL

Fill PARENT’S DOB from PRELOAD

SC6. What is your birth date?

PROGRAMMER: DISPLAY DOB AS INTERVIEWER NOTE

PROGRAMMER: ALLOW BIRTH DATE INFO TO BE ENTERED/REVISED IN INFO SCREEN

INTERVIEWER: COMPARE RESPONSE WITH BIRTH DATE DISPLAYED

| | | / | | | / | | | | | (1963 – 1998)

MONTH DAY YEAR

IF DOB IS LESS THAN 15 YEARS OLD, GO TO SUPERVISOR REVIEW

DON’T KNOW d SC7

REFUSED r SC7

SC6=d, r

SC7. How old are you?

| | | YEARS (15 – 50)

if age is less than 15 YEARS, go to supervisor review

DON’T KNOW d

REFUSED r

pregnant moms

INSERT FILL CONDITION OR DELETE ROW

SC8. According to our records, you are currently pregnant. Is that correct?

YES, STILL PREGNANT 1 SC9

NO, HAVE GIVEN BIRTH 0 SC10

HAD A MISCARRIAGE OR STILLBIRTH 77 SUPERVISOR REVIEW

DON’T KNOW d SC9

REFUSED r SC9

SC8=1

SC9. What is your due date?

DISPLAY DUE DATE AS INTERVIEWER NOTE

| | | / | | | / | | | | | (2011 – 2014; DO NOT ALLOW DATES THAT ARE MORE

Month Day Year THAN 4 WEEKS BEFORE OR 40 WEEKS AFTER INTERVIEW DATE)

IF DATE IS OUT OF RANGE, GO TO SUPERVISOR REVIEW

DON’T KNOW d

REFUSED r

SOFT CHECK: IF DUE DATE BETWEEN 1 DAY PRIOR TO AND 4 WEEKS PRIOR TO INTERVIEW DATE; I recorded that your due date was [SC9]. Is that correct?

SC8=0

INSERT FILL CONDITION OR DELETE ROW

SC10a. Did you have a single or multiple birth?

SINGLE 1 SC12

MULTIPLE 2 SC10B

HAD A MISCARRIAGE OR STILLBIRTH 77 SUPERVISOR REVIEW

SC10A=2

INSERT FILL CONDITION OR DELETE ROW

SC10B. How many babies did you give birth to?

1 1

2 2

3 3

4 4

NON-PREGNANT MOMS

Fill CHILD from PRELOAD

SC11. Now, I would like to make sure we have [CHILD]’s name recorded correctly. (IF MULTIPLE BIRTH =1: We realize that [CHILD] was part of a multiple birth. For the purposes of this study, all questions we ask will pertain to [CHILD].

PROGRAMMER: DISPLAY CHILD’S NAME as interviewer note

INTERVIEWER: VERIFY SPELLING

NAME CORRECT 1 SC13

NAME INCORRECT 2

DON’T KNOW d

REFUSED r

INTERVIEWER: IF RESPONDENT GIVES DIFFERENT NAME, MAKE SURE YOU ARE TALKING ABOUT THE RIGHT CHILD AND CORRECT FIRST NAME.

IF THE NAME IS CORRECT, PRESS ENTER.

PROGRAMMER BOX SC12-SC14

IF SC8=0, ASK SC12-SC14 FOR AS MANY TIMES AS NUMBER OF CHILDREN MENTIONED IN SC10A.

SC8=0 OR SC10=2

IF SC8=0, FILL ‘YOUR NEW BABY’, ELSE ‘CHILD’; fill “first, second, third, or fourth child” depending on number of babies reported at SC10b

SC12. Could you please spell ((your first/second/third/fourth) baby/[CHILD])’s name for me?

(STRING (15))

FIRST NAME

(STRING (15))

MIDDLE INITIAL/NAME

(STRING (30))

LAST NAME

DON’T KNOW d

REFUSED r

NON-PREGNANT MOMS OR SC8=0

Fill CHILD from SC11 OR SC12

SC13. Is [CHILD] a boy or a girl?

INTERVIEWER: CONFIRM IF ALREADY KNOWN

BOY 1

GIRL 2

DON’T KNOW d

REFUSED r

NON-PREGNANT MOMS OR SC8=0

Fill CHILD from SC11 OR SC12

SC14. What is [CHILD]’s birth date?

DISPLAY CHILD’S DOB AS INTERVIEWER NOTE

| | | / | | | / | | | | | (2011 – 2014; DATE MUST BE BEFORE DATE OF

MONTH DAY YEAR INTERVIEW; FUTURE DATES NOT ALLOWED; DATE MUST BE 6 MONTHS OR SOONER FROM DATE OF INTERVIEW)

IF DATE OUT OF RANGE, GO TO SUPERVISOR REVIEW

PROGRAMMER: ALLOW BIRTH DATE INFO TO BE ENTERED/REVISED IN INFO SCREEN

DON’T KNOW d

REFUSED r

PROGRAMMER BOX

if sc10b ne 1, randomly select one child from sc12

sc8=0 and sc10b ne 1

Fill CHILD from SC12

SC15. We have selected [CHILD] to be the focal child for this study. The questions we ask in this interview will be about [CHILD].

INTERVIEWER: ENTER 1 TO CONTINUE

SECTION A. PERINATAL AND CHILD HEALTH

all

A1. 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.

INTERVIEWER: TO RESPOND IN WEEKS, ENTER 1. TO RESPOND IN MONTHS, ENTER 2. TO RESPOND IN TRIMESTERS, ENTER 3.

| | | NUMBER OF WEEKS

(1-42)

| | | NUMBER OF MONTHS

(1-9)

DIDN’T RECEIVE ANY PRENATAL CARE 88

IF GIVES TRIMESTER RESPONSE:

1ST TRIMESTER, WEEKS UNSPECIFIED 55

2ND TRIMESTER, WEEKS UNSPECIFIED 66

3RD TRIMESTER, WEEKS UNSPECIFIED 77

DON’T KNOW d

REFUSED r

A1=88 OR A TRIMESTER RESPONSE OF 66 OR 77

if a1=88 display “at all” if a1=66 or 77, display “earlier”

A2. What kept you from getting prenatal care (at all/earlier)?

NOTHING, I GOT IT AS SOON AS I WANTED/DIDN’T WANT/NEED IT 0

I COULDN’T GET AN APPOINTMENT WHEN I WANTED ONE 1

I DIDN’T HAVE ENOUGH MONEY OR INSURANCE TO PAY FOR MY VISITS 2

I HAD NO TRANSPORTATION TO GET TO THE CLINIC OR DOCTOR’S OFFICE 3

THE DOCTOR OR MY HEALTH PLAN WOULD NOT START CARE AS EARLY AS I WANTED 4

I HAD TOO MANY OTHER THINGS GOING ON 5

I COULDN’T TAKE TIME OFF FROM WORK OR SCHOOL 6

I DIDN’T HAVE MY MEDICAID (OR STATE MEDICAID NAME) CARD 7

I HAD NO ONE TO TAKE CARE OF MY CHILDREN 8

I DIDN’T KNOW THAT I WAS PREGNANT 9

I DIDN’T WANT PRENATAL CARE, OR 10

SOME OTHER REASON? (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What other reason?

NON-PREGNANT MOMS

Fill CHILD, CHILD’S GENDER from PRELOAD

A3. How much did [CHILD] weigh when [he/she] was born?

| | | POUNDS (1 – 14) | | | OUNCES (0 – 28) A5

DON’T KNOW d A4

REFUSED r A4

A3=d, r

Fill CHILD from PRELOAD

A4. Was [CHILD]’s birth weight…

Normal (5 1/2 lbs. [2.5 kilograms] or more), 1

Low (between 3 1/2 [1.5 kilograms] and 5 1/2 lbs. [2.5 kilograms]), or 2

Very low (under 3 1/2 lbs. [1.5 kilograms])? 3

DON’T KNOW d

REFUSED r

NON-PREGNANT MOMS

A5. Was [CHILD] born earlier than the due date?

YES, BORN EARLIER THAN DUE DATE 1

NO, BORN ON TIME OR AFTER DUE DATE 2 A7

DON’T KNOW d A7

REFUSED r A7

A5=1

Fill CHILD from PRELOAD

A6. How many weeks before the due date was [CHILD] born?

PROBE: Your best estimate is fine.

INTERVIEWER: IF LESS THAN A WEEK, CODE 1.

| | | WEEK(S) ALLOW DECIMAL

(1 - 20)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF GT 14; I recorded that [CHILD] was born [A6] weeks early. Is that correct?

NON-PREGNANT MOMS

Fill CHILD’S GENDER, CHILD’S name from PRELOAD

A7. After [CHILD] was born, how long did [he/she] stay in the hospital?

LESS THAN 24 HOURS (LESS THAN 1 DAY), 1

24 TO 48 HOURS (1 TO 2 DAYS), 2

3 TO 5 DAYS, 3

6 TO 14 DAYS, 4

MORE THAN 14 DAYS, 5

BABY NOT BORN IN HOSPITAL 6

BABY IS STILL IN THE HOSPITAL 7

DON’T KNOW d

REFUSED r

A7 LT 6

Fill CHILD’S GENDER, NAME from preload

A8. Were any of these days in the Neonatal Intensive Care Unit (NICU), or were they all in the regular nursery?

PROBE: NICU-also known as a newborn intensive care unit, intensive care nursery (ICN), or special care baby unit (SCBU)—is an intensive care unit specializing in the care of ill or premature newborn infants

ALL IN NICU 1

SOME IN NICU 2

ALL IN REGULAR NURSERY 3

DON’T KNOW d

REFUSED r

A8=1 OR 2

Fill CHILD from preload

A8a. How long did [CHILD] stay in the neonatal intensive care unit (NICU) after birth?

| | | | | days

(1-180; CANNOT BE GT A7 RESPONSE)

DON’T KNOW d

REFUSED r

NON-PREGNANT MOMS

Fill CHILD from preload

A9. Is there a place you usually take [CHILD] for well child care, such as shots (vaccinations) and routine exams?

YES 1

NO 0

DON’T KNOW d

REFUSED r

NON-PREGNANT MOMS

Fill CHILD from preload

A10. Are you currently exclusively breastfeeding, breast and bottle feeding formula, or bottle feeding formula only?

INTERVIEWER: IF RESPONDENT SAYS “BOTTLE FEED BREAST MILK” CODE AS 1

EXCLUSIVELY BREASTFEEDING 1 A10A

BREAST AND BOTTLE FEEDING FORMULA 2 A12

BOTTLE FEEDING FORMULA ONLY 3 A11

DON’T KNOW d A15

REFUSED r A15

A10=1

A10a. How long do you intend to exclusively breastfeed?

PROBE: INTERVIEWER: IF RESPONDENT SAYS “AS LONG AS I’M ABLE TO:” How long are you hoping that will be?

| | | | | MONTHS (1-36) A16a

DON’T KNOW d A15

REFUSED r A15

A10=3

Fill CHILD from preload

A11. Did you ever breastfeed or feed pumped milk to [CHILD]?

YES 1 A12

NO 0 A16a

DON’T KNOW d A15

REFUSED r A15

A11=1 or a10=2

Fill CHILD’S GENDER from preload

A12 For how many weeks or months (IF A10=2 have you been breastfeeding or feeding (him/her) pumped milk) (IF A11=1 did you feed (him/her) pumped milk)?

| | | WEEKS (1-26 WEEKS; CANNOT BE GT AGE OF BABY)

| | | MONTHS (1-7 MONTHS; CANNOT BE GT AGE OF BABY)

DON’T KNOW d

REFUSED r

PREGNANT MOMS

A13. Once your baby is born, do you plan to exclusively breastfeed, breast and bottle feed formula, or bottle feed formula only?

INTERVIEWER: IF RESPONDENT SAYS “BOTTLE FEED BREAST MILK” CODE AS 1

EXCLUSIVELY BREASTFEED 1 A14

BREAST AND BOTTLE FEED FORMULA 2 B1

BOTTLE FEED FORMULA ONLY 3 B1

DON’T KNOW d B1

REFUSED r B1

A13=1

A14. For how long do you intend to exclusively breastfeed?

Probe: IF RESPONDENT SAYS “AS LONG AS I’M ABLE TO:” How long are you hoping that will be?

INTERVIEWER: TO RESPOND IN WEEKS, ENTER 1. TO RESPOND IN MONTHS, ENTER 2. TO RESPOND IN YEARS, ENTER 3.

| | | WEEKS (1-312 WEEKS)

| | | MONTHS (1-72 MONTHS)

| | | YEARS (1 – 6 YEARS)

DON’T KNOW d

REFUSED r

NON-PREGNANT MOMS or d10a=d,r

Fill CHILD, CHILD’S GENDER from preload; IF A11=0 FILL “formula”; IF A11 NE 0 FILL “breast milk or formula”

A15. How old was [CHILD] in months when you began feeding (him/her) formula?

| | | WEEKS (1-26 WEEKS)

| | | MONTHS (1-6 MONTHS)

BABY WAS LESS THAN ONE WEEK OLD 0

DON’T KNOW d

REFUSED r

non-pregnant moms

FILL CHILD FROM

A16a. Have you introduced solid foods to [CHILD] yet? Solid foods include cereal and baby food in jars, but not finger foods.

YES 1 A16b

NO 0

DON’T KNOW d

REFUSED r

non-pregnant moms

Fill CHILD from preload

A16b. How old was [CHILD] in months when you introduced solid foods?

INTERVIEWER: IF LESS THAN ONE MONTH OLD, CODE AS 1 MONTH

| | MONTHS (1-6 MONTHS)

BABY WAS LESS THAN ONE WEEK OLD 0

DON’T KNOW d

REFUSED r

non-pregnant moms

Fill CHILD, CHILD’S GENDER from preload

A17. I am going to read a list of statements about children’s temperament. For each, please pick a number between 1 and 5 to describe how much it describes [CHILD], with 1 representing not at all like your child, and 5 representing very much like your child.

	1	2	3	4	5	DON’T KNOW	REFUSED
a. [He/She] cries easily.	1	2	3	4	5	d	r
b. [He/She] reacts frequently by getting upset or frightened.	1	2	3	4	5	d	r
c. [He/She] often fusses or cries.	1	2	3	4	5	d	r
d. [He/She] gets upset easily.	1	2	3	4	5	d	r
e. [He/She] reacts intensely when upset.	1	2	3	4	5	d	r

SECTION B:

ALL

B1. The next questions are about your health(IF PREGNANT, “before your current pregnancy”). In general, would you say your health is…

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

DON’T KNOW d

REFUSED r

ALL

B2. How tall are you without shoes?

PROBE: You may answer in feet and inches or meters and centimeters.

INTERVIEWER: TO RESPOND IN FEET AND INCHES, ENTER 1. TO RESPOND IN METERS AND CENTIMETERS, ENTER 2.

| | FEET (3 – 6)

| | | INCHES (0 – 11) ALLOW DECIMAL

| | | METERS (0-2)

| | | CENTIMETERS (0-211)

DON’T KNOW d

REFUSED r

ALL

IF PREGNANT, FILL THIS TIME, IF NOT PREGNANT FILL CHILD’S NAME

B3. Just before you got pregnant (IF PREGNANT, FILL “this time” IF NOT PREGNANT FILL “with [CHILD]”), how much did you weigh? Your best estimate is fine.

| | | | POUNDS (085 – 500)

| | | | KILOS (038 – 227)

DON’T KNOW d

REFUSED r

all

IF PREGNANT, FILL THIS TIME, IF NOT PREGNANT FILL CHILD’S NAME

B4. Before you got pregnant (IF PREGNANT, “this time” IF NOT PREGNANT, “with [CHILD]”), were you ever told by a doctor, nurse, or other health care worker that you had Type 1 or Type 2 diabetes? This is not the same as gestational diabetes or diabetes that starts during pregnancy.

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

if pregnant, display “this pregnancy” if not pregnant, display “your pregnancy with [child]” fill child from preload or sc10

B5. During (this pregnancy/your pregnancy with [CHILD]), were you told by a doctor, nurse, or other health care worker that you had gestational diabetes (diabetes that started during this pregnancy)?

HAVEN’T BEEN TESTED YET 55

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

B6. During (this/your pregnancy with [CHILD]) did you have high blood pressure, hypertension (including pregnancy-induced hypertension [PIH]), preeclampsia, or toxemia?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

B7. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities?

[READ STATEMENT]. Are you limited a lot, limited a little, or not limited at all?

	YES, LIMITED A LOT	LIMITED A LITTLE	NO, NOT LIMITED AT ALL	DON’T KNOW	REFUSED
a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?	1	2	3	d	r
b. Climbing several flights of stairs?	1	2	3	d	r

ALL

B8. Is there a place you go for general health care, if you are sick or need advice about your health - that is, any care except prenatal care or family planning?

YES 1

NO 0

DON’T KNOW d

REFUSED r

b8=1

INSERT FILL CONDITION OR DELETE ROW

B8a. What kind of place do you go to?

Clinic 1

Health Center 2

Hospital 3

Doctor’s office 4

Some other place 99

(STRING (99))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What kind of place do you go to for general health care?

ALL

B9. Is there a place you go, or have gone, for family planning or birth control?

YES 1

NO 0

DON’T KNOW d

REFUSED r

b9=1

B9a. What kind of place do you or did you go to?

The same place I receive general health care 1

Clinic 2

Health Center 3

Hospital 4

Doctor’s office 5

Some other place 99

(STRING (99))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What kind of place do you go to?

ALL

B10. How many more children would you like to have?

| | | NUMBER

(0-12)

DON’T KNOW d

REFUSED r

B10 ne 0,d,r

B11. How old would you like (If pregnant, ‘your unborn child’) [CHILD] to be when you have your next child?

PROBE: You may answer in months or years, or both.

| | | MONTHS

(9-24)

| | | YEARS

(1-16)

DON’T KNOW d

REFUSED r

ALL

B12. I’m going to read some statements about parents and children. For each, please tell me whether you strongly agree, agree, are undecided, disagree, or strongly disagree.

	STRONGLY AGREE	AGREE	UNDECIDED	DISAGREE	STRONGLY DISAGREE	DON’T KNOW		REFUSED
a. Children who express their opinions usually make things worse	1	2	3	4	5	d	r
b. Crying is a sign of weakness in boys	1	2	3	4	5	d	r
c. Parents’ needs are more important than children’s needs	1	2	3	4	5	d	r
d. Praising children is a good way to build their self-esteem	1	2	3	4	5	d	r
e. Children should be seen and not heard	1	2	3	4	5	d	r
f. Parents who encourage their children to talk to them only end up listening to complaints	1	2	3	4	5	d	r
g. The less children know, the better off they are	1	2	3	4	5	d	r
h. Two-year-old children make a terrible mess of everything	1	2	3	4	5	d	r
i. Parents should expect more from boys than girls	1	2	3	4	5	d	r
j. Children cry just to get attention	1	2	3	4	5	d	r

SECTION C:

all

C. Intro The next questions are about your background.

INTERVIEWER: enter 1 to continue

ALL

C1. Are you of Hispanic, Latino, or Spanish origin?

INTERVIEWER: IF YES, ASK: What is your origin?

NO, NOT OF HISPANIC, LATINO/A OR SPANISH ORIGIN 0

YES, MEXICAN, MEXICAN AMERICAN, CHICANO/A 1

YES, PUERTO RICAN 2

YES, CUBAN 3

YES, ANOTHER HISPANIC, LATINO/A OR SPANISH ORIGIN 4

DON’T KNOW d

REFUSED r

ALL

C2. What is your race?

INTERVIEWER: CODE ALL RESPONSES. ASK: Any other?

WHITE 11

BLACK OR AFRICAN AMERICAN 12

AMERICAN INDIAN OR ALASKA NATIVE 13

ASIAN INDIAN 14

CHINESE 15

FILIPINO 16

JAPANESE 17

KOREAN 18

VIETNAMESE 19

OTHER ASIAN 20

NATIVE HAWAIIAN 21

GUAMANIAN OR CHAMORRO 22

SAMOAN 23

OTHER PACIFIC ISLANDER 24

OTHER (SPECIFY) 99

(STRING (20))

DON’T KNOW d

REFUSED r

ALL

C3. Is any language other than English spoken in your home?

YES 1 C4

NO 0 C7

DON’T KNOW d C7

REFUSED r C7

C3=1

C4. What other languages are spoken in your home?

FRENCH 11

SPANISH 12

CAMBODIAN (KHMER) 13

CHINESE 14

HAITIAN CREOLE 15

HMONG 16

JAPANESE 17

KOREAN 18

VIETNAMESE 19

ARABIC 20

OTHER (SPECIFY) 99

(STRING (20))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What other language? (STRING 100)

respondent reported more than one language in c4

C4a. Which language is spoken most often in your home?

PROGRAMMER: DISPLAY ONLY LANGUAGES PROVIDED IN C4

FRENCH 11

SPANISH 12

CAMBODIAN (KHMER) 13

CHINESE 14

HAITIAN CREOLE 15

HMONG 16

JAPANESE 17

KOREAN 18

VIETNAMESE 19

ARABIC 20

OTHER (SPECIFY) 99

(STRING (20))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What other language? (STRING 100)

C3=1

Fill LAN from C4

C5. How well do you speak [LAN]? Would you say . . .

Very well, 1

Well, 2

Not very well, or 3

Not at all? 4

DON’T KNOW d

REFUSED r

C3=1

Fill LAN from C4

C6. How well do you speak English? Would you say . . .

Very well, 1

Well, 2

Not very well, or 3

Not at all? 4

DON’T KNOW d

REFUSED r

all

C7. In what country were you born?

USA 059

MEXICO 303

GUATEMALA 313

CUBA 327

DOMINICAN REPUBLIC 329

INDIA 210

CHINA 207

PHILIPPINES 233

JAPAN 215

KOREA 217

VIETNAM 247

GUAM 066

SAMOA 527

OTHER (SPECIFY) 600

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (600): What other country?

all

C8. What is the highest grade or year of school that you have completed?

PROBE: IF GED: Before you received your GED, what was the highest grade or year of school you completed?

HIGHEST GRADE/YEAR IN SCHOOL SPECIFY GRADE 1

| | | GRADE (1 – 11)

HIGH SCHOOL DIPLOMA 2

ASSOCIATE DEGREE 3

BA/BS DEGREE 4

MA/MASTERS 5

PHD/DOCTORATE 6

SOME COLLEGE BUT NO DEGREE COMPLETION 7

NO REGULAR/FORMAL SCHOOL EDUCATION 0

OTHER (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): Please specify your highest level of education completed (string 99)

all

C9. Are you currently taking any education or training classes? This could include (IF C8 LT 5: high school, ABE, GED,) ESL or college courses, or any job skills training.

YES 1

NO 0 C10

DON’T KNOW d C10

REFUSED r C10

C9=0, d, r

child

C10. Do you plan to take any education or training classes before ([CHILD]’s/your unborn child’s) first birthday?

YES 1

NO 0

DON’T KNOW d

REFUSED r

SECTION D:

PROGRAMMER BOX (NUM)

ALL RESPONSES, GO TO D1

D1 Intro I’m now going to ask you some questions about the people who live in your household.

INTERVIEWER: ENTER 1 TO CONTINUE

all

FILL [CHILD] FROM PRELOAD

D1a. Besides you (IF PREGNANT: “and [CHILD]”) does anyone else live in your household?

YES 1 D1B

NO 0 D2

PROGRAMMER BEGIN LOOP

start by collecting all persons names first. then ask for dob, GENDER, AND RELATIONSHIP TO [CHILD] FOR EACH MEMBER OF THE HOUSEHOLD.

display the respondent’s name in row 1 of the roster and if R is not pregnant, display child in row 2.

IF R IS PREGNANT, MAX NUMBER OF PEOPLE IN HOUSEHOLD= 19. IF R IS NOT PREGNANT, MAX NUMBER OF PEOPLE IN HOUSEHOLD =18.

dob ranges: month= 1-12; day= 1-31

year= 1900-2012

Starting with the oldest person, please tell me the names of all the other people who D1Bnormally live here.

INTERVIEWER: IF R IS UNCOMFORTABLE, YOU CAN ASK THEM TO PROVIDE INITIALS ONLY AND NO NAMES. IF R IS UNCOMFORTABLE GIVING DATES OF BIRTH, SHE CAN JUST GIVE YEAR OF BIRTH

PROBE: Who else lives here?

WHAT IS [NAME]’S AGE?

IS [NAME] MALE OR FEMALE?

WHAT IS [NAME]’S RELATIONSHIP TO ([CHILD]/YOUR UNBORN CHILD)?

RELATIONSHIP CODES:

BIOLOGICAL MOTHER 11

BIOLOGICAL FATHER 12

ADOPTIVE MOTHER 13

ADOPTIVE FATHER 14

STEPMOTHER 15

STEPFATHER 16

GRANDMOTHER. 17

GRANDFATHER 18

GREAT GRANDMOTHER 19

GREAT GRANDFATHER 20

SISTER/STEPSISTER 21

BROTHER/STEPBROTHER 22

OTHER RELATIVE OR IN-LAW (FEMALE) 23

OTHER RELATIVE OR IN-LAW (MALE) 24

FOSTER PARENT (FEMALE) 25

FOSTER PARENT (MALE). 26

OTHER NON-RELATIVE (FEMALE) 27

OTHER NON-RELATIVE (MALE) 28

PARENT’S PARTNER (FEMALE) 29

PARENT’S PARTNER (MALE) 30

	Q#	Q#	Q#	Q#
	NAME	(DOB for minors, age for adults)	GENDER	RELATIONSHIP
a.	(STRING (20))	| | |/| | |/| | | | |	| | |	| | |
b.	(STRING (20))	| | |/| | |/| | | | |	| | |	| | |
c.	(STRING (20))	| | |/| | |/| | | | |	| | |	| | |
d.	(STRING (20))	| | |/| | |/| | | | |	| | |	| | |
e.	(STRING (20))	| | |/| | |/| | | | |	| | |	| | |
f.	(STRING (20))	| | |/| | |/| | | | |	| | |	| | |

END LOOP

END LOOP AT LAST HOUSEHOLD MEMBER.

aLL RESPONDENTS GO TO D2

all

D2. How many times have you moved in the past 12 months?

| | | NUMBER (0 – 12)

DON’T KNOW d

REFUSED r

ALL

D6. Intro The next questions are about ([CHILD]’s/ your unborn child’s) father.

INTERVIEWER: ENTER 1 TO CONTINUE

ENTER 1 TO CONTINUE 1

PARTICIPANTS IN WHICH THE BIOLOGICAL FATHER IS NOT LIVING IN HOUSEHOLD

Fill CHILD from preload; if respondent is pregnant, fill “your unborn child”

D7. What is the first name of ([CHILD]’s/your unborn child’s) biological father?

(STRING (20))

FIRST NAME

DON’T KNOW d

REFUSED r

all

fill CHILD’S BIOLOGICAL FATHER from household roster or d7; if d7=D,R, fill “[child]’s biological father

D8. Are you and ([BIO FATHER]/[CHILD]’S BIOLOGICAL FATHER] currently . . .

Married, 1

Divorced, 2

Separated, or 3

Have you never been married to each other? 4 D8a

BIO FATHER DECEASED n D16

DON’T KNOW d

REFUSED r

d8=4

FILL bio father FROM d7

D8a. Are you and [BIO FATHER] currently in a romantic relationship?

YES 1

NO 0

DON’T KNOW d

REFUSED r

FOR PARTICIPANTS IN WHICH THE BIOLOGICAL DAD IS NOT LIVING IN HOUSEHOLD

Fill NAME OF CHILD’S BIO FATHER from D7

D9. How old is [BIO FATHER]?

PROBE: Your best estimate is fine.

| | | YEARS (15 – 65)

BIO FATHER DECEASED 0 D16

DON’T KNOW d

REFUSED r

pregnant moms living with bio father

Fill NAME OF CHILD’S BIO FATHER from D7 or household roster;

D10a. Since this pregnancy began, how many months have you lived in the same household as [BIO FATHER]?

INTERVIEWER: IF RESPONDENT SAYS, “THE ENTIRE TIME” CODE 99

| | | MONTHS (0 - 9)

DON’T KNOW d

REFUSED r

pregnant moms not living with bio father

Fill NAME OF CHILD’S BIO FATHER from D7 or household roster

D10b. Since this pregnancy began, did you ever live in the same household as [BIO FATHER]?

YES 1

NO 0

DON’T KNOW d

REFUSED r

non-PREGNANT MOMS WHO LIVE WITH BIO FATHER

Fill NAME OF CHILD’S BIO FATHER from D7 or household roster, Fill CHILD’S DOB from SC11

D11. Since [CHILD’S DOB], how many months have you lived in the same household as [BIO FATHER]?

INTERVIEWER: IF RESPONDENT SAYS, “THE ENTIRE TIME” CODE 99

| | | MONTHS (0 – 6)

DON’T KNOW d

REFUSED r

pregnant moms

Fill NAME OF CHILD’S BIO FATHER from D7 or household roster; fill child’S NAME from preload or sc10; CALCULATE NUMBER OF MONTHS PREGNANT FROM SC12

D12. During the past (3 months/NUMBER OF MONTHS PREGNANT) of your pregnancy, how often did [BIO FATHER] buy things for your pregnancy or to prepare for the baby, such as formula, diapers, clothes or toys, or give you money to buy things for the baby? Would you say . . .

Every day or almost every day, 1

A few times a week, 2

A few times a month, 3

Less often than a few times a month, or 4

Never? 5

DON’T KNOW d

REFUSED r

pregnant moms

Fill NAME OF CHILD’S BIO FATHER from D7 or household roster; fill child’S NAME from preload or sc10; CALCULATE NUMBER OF MONTHS PREGNANT FROM DUE DATE IN SC12

D13. During the (3 months/NUMBER OF MONTHS PREGNANT)pregnancy, how often did [BIO FATHER] help you in other ways, such as getting ready for the baby, helping around the house or with chores, or providing transportation to prenatal visits or other places you needed to go? Would you say . . .

Every day or almost every day, 1

A few times a week, 2

A few times a month, 3

Less often than a few times a month, or 4

Never? 5

DON’T KNOW d

REFUSED r

non-pregnant moms

Fill CHILD from preload; Fill NAME OF CHILD’S BIO FATHER from D7 or household roster

D14. During the past 3 months, how often did [BIO FATHER] buy things for [CHILD], such as formula, diapers, clothes, or toys, or give you money to buy things for [CHILD]? Would you say . . .

Every day or almost every day, 1

A few times a week, 2

A few times a month, 3

Less often than a few times a month, or 4

Never? 5

DON’T KNOW d

REFUSED r

NON-pregnant moms

Fill CHILD from preload; Fill NAME OF CHILD’S BIO FATHER from D7 or household roster

D15. During the past 3 months, how often did [BIO FATHER] help you in other ways, such as caring for [CHILD], helping around the house or with chores, or providing transportation to places you needed to go? Would you say . . .

Every day or almost every day, 1

A few times a week, 2

A few times a month, 3

Less often than a few times a month, or 4

Never? 5

DON’T KNOW d

REFUSED r

BIO father not living in household or mother not married to BIO father (D8 NE 1) or d8a ne 1

D16. Do you have a spouse or partner?

YES 1

NO 0

DON’T KNOW d

REFUSED r

d16=1

D17. What is the name of your spouse or partner?

(STRING (20))

FIRST NAME

DON’T KNOW d

REFUSED r

IF R HAS PARTNER/SPOUSE

D18. All things considered, on a scale from 1 to 7, where 1 is “completely unhappy” and 7 is “completely happy,” how happy are you with your spouse or partner?

INTERVIEWER: IF NECESSARY, YOU MAY READ CATEGORIES TO RESPONDENT

Completely unhappy 1

Moderately unhappy 2

Slightly unhappy 3

Not happy or unhappy 4

Slightly happy 5

Moderately happy or 6

Completely happy 7

DON’T KNOW d

REFUSED r

all

E. Intro The next questions are about income and services you or other members of your household may have received.

INTERVIEWER: enter 1 to continue

ENTER 1 TO CONTINUE 1

all

E1. Are you currently working for pay?

YES 1 E4

NO 0 E2

DON’T KNOW d E2

REFUSED r E2

E1 ne1

E2. Are you currently on maternity leave?

YES 1 E3

NO 0 E3

DON’T KNOW d E3

REFUSED r E3

ALL

IF PREGNANT, DISPLAY “YOUR UNBORN CHILD” IF NOT PREGNANT DISPLAY [CHILD]. FILL CHILD’S NAME FROM PRELOAD OF SC10

E3. Do you plan to work for pay before ([CHILD]/ your unborn child) turns one year old?

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

E4. How many months were you employed (did you work for pay) during the past 3 years (including your current job)?

RESPONDENT DIDN’T WORK 0 E6

Less than 6 months 1

7 to 12 months 2

13 to 24 months 3

More than 24 months 4

DON’T KNOW d

REFUSED r

E4 NE 0

programmer: we need to revise the year date each calendar year. fill prior month. WILL CODE NUMBER FIRST, THEN CODE FREQUENCY (PER HOUR, PER WEEK, PER MONTH)

E5. Last month, that is (MONTH/YEAR), what were your approximate total earnings from your work, including tips and overtime pay? When answering, please include income from all jobs you held last month.

PROBE: Please do not include earnings from anyone else in your household.

$ | | , | | | |

DON’T KNOW d

REFUSED r

E5=d,r

E5Probe. Could you give me a range? Would you say it was . . .[READ CATEGORIES]

Less than $500, 1

$500 to $999, 2

$1,000 to $1,499, 3

$1,500 to $1,999, 4

$2,000 to $2,500 5

$2,500 to $2,999, 6

$3,000 to $3,499, or 7

$3,5000 or over? 8

DON’T KNOW d

REFUSED r

all

Fill Local TANF from preload; Fill SPOUSE/PARTNER from household roster or D17

E6. Please tell me whether you or any other members of your household received income or benefits from the following sources in the past month. This includes anyone who you support and/or supports you and lives in your household. [READ STATEMENT]

PROBE: Did you or any other members of your household receive income from this source in the past month?

	yes	no	don’t know	refused
a. Cash welfare which is also known as TANF, or [Local name of TANF]	1	0	d	r
b. Food stamp or Supplemental Nutrition Assistance Program (SNAP) benefits	1	0	d	r
c. Disability insurance such as Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)	1	0	d	r
d. Earnings from other household members (including [SPOUSE/PARTNER])? Please report any earnings before taxes or other deductions, and include tips, commissions, and overtime pay	1	0	d	r
e. Benefits from WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)	1	0	d	r

all

E7. During the past year, have you ever received help in applying for public benefits, including TANF, SNAP, or WIC?

YES 1

NO 0

DON’T KNOW d

REFUSED r

E7=0,d,r

E7a. During the past year, did you ever want or need help in applying for public benefits, including TANF, SNAP, or WIC?

YES 1

NO 0

DON’T KNOW d

REFUSED r

E7=1

E7b. Are you currently receiving help in applying for public benefits, including TANF, SNAP, or WIC?

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

E8. Some earnings and income come from other sources, like unemployment insurance or help from family and friends. Thinking about these other sources of income, what is the total amount of additional income that you received (in addition to earnings) and the total amount of any income or earnings any other adult members of your household received last month?

PROBE: Your best estimate is fine.

$ | | | |, | | | | NUMBER

(0-250,000)

DON’T KNOW d

REFUSED r

E8=d, r

E9. Was it . . .

Less than $1,000, 1

$1,000 or more, but less than $2,000, 2

$2,000 or more but less than $3,000, 3

$3,000 or more but less than $4,000, 4

$4,000 or more but less than 5,000, or 5

More than $5,000? 6

DON’T KNOW d

REFUSED r

ALL; E10a_2, e10b_2, E10c_2, e10 d_2 only if other adults live in household

E10. Do you currently have any of the following… [READ ITEM].

	yes	no	DON’T KNOW	REFUSED
a. A checking account?	1	0	d	r
(a=NO) A_1 Could you get one if you wanted to?	1	0	d	r
(a=NO) A_2 Does anyone else in your household have one?	1	0	d	r
b. A savings account?	1	0	d	r
(b=NO) B_1 Could you get one if you wanted to?	1	0	d	r
(b=NO) B_2 Does anyone else in your household have one?	1	0	d	r
c. A credit card?	1	0	d	r
(c=NO) C_1 Could you get one if you wanted to?	1	0	d	r
(c=NO) C_2 Does anyone else in your household have one?	1	0	d	r
d. A driver’s license?	1	0	d	r
(d=NO) D_1 Could you get one if you wanted to?	1	0	d	r
(d=NO) D_2 Does anyone else in your household have one?	1	0	d	r

if respondent’s age gte 18

E11. Are you currently serving in the military?

YES 1

NO 0 E13

DON’T KNOW d E13

REFUSED r E13

E11=1

E12. Which of the following best describes your military status?

On active duty (not a member of the National Guard/Reserve), 1

As a member of the National Guard or Reserve in a full-time active duty program (AGR/FTS/AR), or 2

As a traditional National Guard/Reserve member (e.g., drilling unit, IMA, IRR)? 3

DON’T KNOW d

REFUSED r

r has spouse/PARTNER

FILL SPOUSE FROM D17 OR D7 IF D8=1

E13. Is [SPOUSE] currently serving in the military?

YES 1 E14

NO 0

DON’T KNOW d

REFUSED r

E13=1

E14. Which of the following best describes your spouse or partner’s military status?

On active duty (not a member of the National Guard/Reserve), 1

As a member of the National Guard or Reserve in a full-time active duty program (AGR/FTS/AR), or 2

As a traditional National Guard/Reserve member (e.g., drilling unit, IMA, IRR)? 3

DON’T KNOW d

REFUSED r

all

if pregnant and living alone, “i”

E15. Please tell me whether the next two statements are often true, sometimes true, or never true for your family within the past 12 months, that is, since (MONTH/YEAR).

Within the past 12 months (I/we) worried whether our food would run out before we got money to buy more. Was this . . .

Often true, 1

Sometimes true, or 2

Never true? 3

DON’T KNOW d

REFUSED r

all

if pregnant and living alone, “i”

E16. Within the past 12 months the food (I/we) bought just didn’t last and we didn’t have money to get more. Was this . . .

Often true, 1

Sometimes true, or 2

Never true? 3

DON’T KNOW d

REFUSED r

all

E17. The next questions are about health insurance, Including health insurance obtained through employment or purchased directly as well as government programs like Medicare and Medicaid that provide medical care or help pay medical bills. Are you covered by health insurance or some other kind of health care plan?

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

E18. What kind of health insurance or health care coverage do you have? Include those that pay for only one type of service (nursing home care, accidents, or dental care). Exclude private plans that only provide extra cash while hospitalized. If you have more than one kind of health insurance, tell me about all the plans that you have.

PROBE: IF R GIVES A NAME OF A HEALTH INSURANCE PLAN, LIKE “BLUE CROSS/BLUE SHIELD,” ASK: Is that private insurance paid for by you or an employer, or is it paid for by the state or federal government, like Medicaid or [STATE SPECIFIC MEDICAID NAME]?

IF R TELLS YOU ABOUT CHILD’S INSURANCE, DO NOT RECORD HERE. THAT GETS CODED IN A SUBSEQUENT QUESTION.

PRIVATE HEALTH INSURANCE 1

MEDICARE 2

MEDIGAP 3

MEDICAID 4

SCHIP (CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM) 5

MILITARY HEALTH CARE (TRICARE/VA/CHAMP-VA) 6

INDIAN HEALTH SERVICE 7

STATE-SPONSORED HEALTH PLAN 8

SINGLE SERVICE PLAN (E.G., DENTAL, VISION, PRESCRIPTIONS) 9

NO COVERAGE OF ANY TYPE 10

OTHER (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What other insurance?

all

E19. During the past year, have you ever received help in applying for health insurance for yourself?

YES 1 E19b

NO 0 E19a

DON’T KNOW d E19a

REFUSED r E19a

E19=0,d,r

E19a. During the past year, did you ever want or need help in applying for health insurance for yourself?

YES 1

NO 0

DON’T KNOW d

REFUSED r

E19=1

E19b. Are you currently receiving help in applying for health insurance for yourself?

YES 1

NO 0

DON’T KNOW d

REFUSED r

non-pregnant moms

Fill child from preload

E20. Does [CHILD] have any kind of health care coverage, including health insurance, prepaid plans such as HMOS, or government plans such as Medicaid?

PROBE: Medicaid refers to a medical assistance program that provides health care coverage to low-income and disabled persons. The Medicaid program is a joint federal-state program that is administered by the states. HMO is Health Maintenance Organization.

YES 1

NO 0

DON’T KNOW d

REFUSED r

non-pregnant moms

child’s gender, state medicaid name, state schip name; if state ne nj, wa, IL, ks, ma, ok, sc, or wi, fill conditional text

E21. Is [he/she] insured by Medicaid or the State Children’s Health Insurance Program or S-CHIP? if state = nj, wa, IL, ks, ma, ok, sc, or wi: In this state, the program is sometimes called [FILL MEDICAID NAME].

YES 1

NO 0

DON’T KNOW d

REFUSED r

non-pregnant moms

E22. Have you ever received help in applying for health insurance for [CHILD]?

YES 1 e22b

NO 0 E22a

DON’T KNOW d E22a

REFUSED r E22a

E22=0,d,r

child

E22a. Have you ever wanted or needed help in applying for health insurance for [CHILD]?

YES 1

NO 0 E23

DON’T KNOW d E23

REFUSED r E23

E22=1

E22b. Are you currently receiving help in applying for health insurance for [CHILD]?

YES 1

NO 0

DON’T KNOW d

REFUSED r

NON-PREGNANT MOMS

child

E23. Since [CHILD] was born, has s/he been in child care or taken care of by anyone other than yourself on a regular basis?

YES 1

NO 0

DON’T KNOW d

REFUSED r

E23=0,d,r

E23a. Since [CHILD] was born, did you ever want or need child care services for [CHILD]?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

F1 Now, I am going to read you a list of ways you may have felt in the past two weeks.

Please tell me how often you have felt this way during the past two weeks. [READ STATEMENT]. Did you feel this way several days, over half the days, nearly every day, or not at all?

	SEVERAL DAYS	OVER HALF THE DAYS	NEARLY EVERY DAY	NOT AT ALL	DON’T KNOW	REFUSED
a. Feeling nervous, anxious, or on edge	1	2	3	4	d	r
b. Not being able to stop or control worrying	1	2	3	4	d	r
c. Worrying too much about different things	1	2	3	4	d	r
d. Trouble relaxing	1	2	3	4	d	r
e. Being so restless that it's hard to sit still	1	2	3	4	d	r
f. Becoming easily annoyed or irritable	1	2	3	4	d	r
g. Feeling afraid as if something awful might happen	1	2	3	4	d	r

ALL

F2 I am going to read you a list of ways you may have felt or behaved in the past week.

Please tell me how often you have felt this way during the past week. [READ STATEMENT]. Did you feel this way rarely or none of the time, some or a little of the time, occasionally or a moderate amount of time, or most or all of the time?

INTERVIEWER: INSTRUCT RESPONDENT TO CONSULT SHOW CARD

	Rarely or none of the time (less than 1 day)	Some or a little of the time (1-2 days)	Occasionally or moderate amount of time (3-4 days)	Most or all of the time (5-7 days)	don’t know	refused
a. I felt depressed	1	2	3	4	d	r
b. I felt that everything I did was an effort	1	2	3	4	d	r
c. My sleep was restless	1	2	3	4	d	r
d. I was happy	1	2	3	4	d	r
e. I felt lonely	1	2	3	4	d	r
f. People were unfriendly	1	2	3	4	d	r
g. I enjoyed life	1	2	3	4	d	r
h. I felt sad	1	2	3	4	d	r
i. I felt that people disliked me	1	2	3	4	d	r
j. I could not get going	1	2	3	4	d	r

ALL

F

Var

3. Please listen to each of the following statements and tell me if you strongly agree, agree, disagree, or strongly disagree with each one.

	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE	DON’T KNOW	REFUSED
a. I have little control over the things that happen to me.	1	2	3	4	d	r
b. There is really no way I can solve some of the problems I have.	1	2	3	4	d	r
c. There is little I can do to change many of the important things in my life.	1	2	3	4	d	r
d. I often feel helpless in dealing with the problems of life.	1	2	3	4	d	r
e. Sometimes I feel that I'm being pushed around in life.	1	2	3	4	d	r
f. What happens to me in the future mostly depends on me.	1	2	3	4	d	r
g. I can do just about anything I really set my mind to do.	1	2	3	4	d	r

ALL

F

Var

3a. Placeholder for cognitive functioning.

ALL

F4. The next questions are about how you relate to other people. For each statement I read, please tell me if you totally disagree, strongly disagree, disagree, agree, strongly agree, or totally agree.

INTERVIEWER: INSTRUCT RESPONDENT TO CONSULT SHOW CARD

	TOTALLY DISAGREE	STRONGLY DISAGREE	disagree	AGREE	STRONGLY AGREE	TOTALLY AGREE	REFUSED
a. I feel confident that other people will be there for me when I need them	1	2	3	4	5	6	r
b. I prefer to depend on myself rather than other people	1	2	3	4	5	6	r
c. I prefer to keep to myself	1	2	3	4	5	6	r
d. Achieving things is more important than building relationships	1	2	3	4	5	6	r
e. Doing your best is more important than getting on with others	1	2	3	4	5	6	r
f. If you've got a job to do, you should do it no matter who gets hurt	1	2	3	4	5	6	r
g. It's important to me that others like me	1	2	3	4	5	6	r
h. I find it hard to make a decision unless I know what other people think	1	2	3	4	5	6	r
i. My relationships with people are generally shallow	1	2	3	4	5	6	r
j. Sometimes I think I am no good at all	1	2	3	4	5	6	r
k. I find it hard to trust people	1	2	3	4	5	6	r
l. I find it difficult to depend on others	1	2	3	4	5	6	r
m. I find that others don’t want to get as close as I would like	1	2	3	4	5	6	r
n. I find it relatively easy to get close to other people	1	2	3	4	5	6	r
o. I find it easy to trust others	1	2	3	4	5	6	r
p. I feel comfortable depending on other people	1	2	3	4	5	6	r
q. I worry that others won't care about me as much as I care about them	1	2	3	4	5	6	r
r. I worry about people getting too close	1	2	3	4	5	6	r
s. I worry that I won't measure up to other people	1	2	3	4	5	6	r
t. I have mixed feelings about being close to others	1	2	3	4	5	6	r
u. I wonder why people would want to be involved with me	1	2	3	4	5	6	r
v. I worry a lot about my relationships	1	2	3	4	5	6	r
w. I wonder how I would cope without someone to love me	1	2	3	4	5	6	r
x. I feel confident about relating to others	1	2	3	4	5	6	r
y. I often feel left out or alone	1	2	3	4	5	6	r
z. I often worry that I do not really fit with other people	1	2	3	4	5	6	r
aa. Other people have their own problems, so I don't bother them with mine	1	2	3	4	5	6	r
bb. If something is bothering me, others are generally aware and concerned	1	2	3	4	5	6	r
cc. I am confident that other people will like and respect me	1	2	3	4	5	6	r

all

F5. The next questions are about smoking cigarettes during the past 2 years. Have you smoked at least 100 cigarettes in the past 2 years?

YES 1

NO 0

DON’T KNOW d

REFUSED r

F5 = 0, d, r

F6. Have you smoked any cigarettes in the past 2 years?

YES 1 F7

NO 0 F10

DON’T KNOW d F10

REFUSED r F10

F5=1 or F6=1

F7. In the 3 months before you got pregnant, 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 (1-60) AND CODE

CIGARETTES 1

PACKS 2

DON’T KNOW d

REFUSED r

F5=1 or F6=1

F8. In the last 3 months of your pregnancy, 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 (1-60) AND CODE

CIGARETTES 1

PACKS 2

DON’T KNOW d

REFUSED r

F5=1 or F6=1

F9. How many cigarettes or packs do you currently 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 (1-60) AND CODE

CIGARETTES 1

PACKS 2

DON’T KNOW d

REFUSED r

ALL

F10. Which of the following statements best describes the rules about smoking inside your home now?

No one is allowed to smoke anywhere inside my home, 1

Smoking is allowed in some rooms or at some times, or 2

Smoking is permitted anywhere inside my home? 3

DON’T KNOW d

REFUSED r

ALL

F11. The next questions are about drinking alcoholic beverages. By a “drink” we mean a can or bottle of beer, a wine cooler or glass of wine, a shot of liquor, or a mixed drink.

During the 3 months before you got pregnant, how many alcoholic drinks did you have in an average week?

NOTE: A HELP SCREEN IS AVAILABLE WITH EQUIVALENCES

DIDN’T DRINK THEN 0

LESS THAN 1 DRINK 1

1 TO 3 DRINKS 2

4 TO 6 DRINKS 3

7 TO 13 DRINKS 4

14 TO 19 DRINKS 5

20 OR MORE DRINKS 6

DON’T KNOW d

REFUSED r

f12 ne 0

F12. During the 3 months before you got pregnant, how many times did you drink 4 alcoholic drinks or more in one sitting? Would you say…

PROBE: A sitting is a two hour time span.

6 or more times, 4

4 to 5 times, 3

2 to 3 times, 2

1 time, or 1

Never? 0

DON’T KNOW d

REFUSED r

ALL

IF PREGNANT AND LESS THAN 3 MONTHS PREGNANT (CALCULATE FROM SC12) DISPLAY NUMBER OF MONTHS PREGNANT

F13. In the (last three months of your pregnancy(if less than 3 months pregnant, ‘In the last [1 or 2] months of your pregnancy’; if SC12 = DK or RF, ‘last three months of your pregnancy’) how many alcoholic drinks did you have in an average week?

NOTE: A HELP SCREEN IS AVAILABLE WITH EQUIVALENCES.

DIDN’T DRINK THEN 0

LESS THAN 1 DRINK 1

1 TO 3 DRINKS 2

4 TO 6 DRINKS 3

7 TO 13 DRINKS 4

14 TO 19 DRINKS 5

20 OR MORE DRINKS 6

DON’T KNOW d

REFUSED r

F14 NE 0

IF PREGNANT AND LESS THAN 3 MONTHS PREGNANT (CALCULATE FROM SC12) DISPLAY NUMBER OF MONTHS PREGNANT

F14. In the last 3 (NUMBER OF MONTHS PREGNANT) months of your pregnancy, how many times did you drink 4 alcoholic drinks or more in one sitting? Would you say…

PROBE: A sitting is a two hour time span.

6 or more times, 4

4 to 5 times, 3

2 to 3 times, 2

1 time, or 1

Never? 0

DON’T KNOW d

REFUSED r

ALL

F14a. The next questions are about drug use on your own before and during pregnancy. By “on your own” we mean either without a doctor’s prescription, in larger amounts than prescribed, or for a longer period than prescribed. Did you use any of the following drugs on your own in the month before you got pregnant? [READ LIST, CODE ONE FOR EACH]

	YES	NO	DON’T KNOW	REFUSED
a. Prescription drugs?	1	0	d	r
(IF YES) What kinds? ENTER MEDICINE NAMES: (STRING 50)
b. Marijuana (pot, bud) or Hashish (Hash)?	1	0	d	r
c. Amphetamines(uppers, ice, speed, crystal meth, crank)?	1	0	d	r
d. Cocaine (rock, coke, crack) or heroin (smack, horse)?	1	0	d	r
e. Tranquilizers (downers, ludes) or hallucinogens (LSD/acid, PCP/angel dust, ecstasy)?	1	0	d	r
f. Sniffing gasoline, glue, hairspray, or other aerosols?	1	0	d	r

F14a_ANY=1

F14b. Did you use any of the following drugs on your own while you were pregnant? [READ LIST, CODE ONE FOR EACH]

	YES	NO	DON’T KNOW	REFUSED
a. Prescription drugs?	1	0	d	r
(IF YES) What kinds? ENTER MEDICINE NAMES: (STRING 50)
b. Marijuana (pot, bud) or Hashish (Hash)?	1	0	d	r
c. Amphetamines(uppers, ice, speed, crystal meth, crank)?	1	0	d	r
d. Cocaine (rock, coke, crack) or heroin (smack, horse)?	1	0	d	r
e. Tranquilizers (downers, ludes) or hallucinogens (LSD/acid, PCP/angel dust, ecstasy)?	1	0	d	r
f. Sniffing gasoline, glue, hairspray, or other aerosols?	1	0	d	r

all

F15. During the past year, have you received help or treatment for alcohol or substance abuse problems?

YES 1 F16

NO 0 F16

DON’T KNOW d F16

REFUSED r F16

all

programmer; for each YES RESPONSE, GO TO NEXT ITEM IN LIST. FOR EACH no response, display question on screen: DID YOU NEED OR WANT The SERVICE DURING THE PAST YEAR?

F16. I’m going to read a list of places where people may go to receive help or treatment for alcohol or substance abuse problems. For each one, please tell me whether you used the service, or if you needed or wanted the service during the past year.

	YES	NO	WANTED OR NEEDED	DON’T KNOW	REFUSED
a. Doctor or other health care professional	1	0	3	d	r
b. A hospital or other inpatient program	1	0	3	d	r
c. A support group	1	0	3	d	r
d. A priest, minister, or rabbi	1	0	3	d	r
e. A spiritualist or healer	1	0	3	d	r
f. A social worker, counselor, or other mental health professional	1	0	3	d	r

all

F17. During the past year, have you received mental health help or treatment?

YES 1 F18

NO 0 F18

DON’T KNOW d F18

REFUSED r F18

all

programmer; for each YES RESPONSE, GO TO NEXT ITEM IN LIST. FOR EACH no response, display question on screen: DID YOU NEED OR WANT The SERVICE DURING THE PAST YEAR?

F18. I’m going to read a list of places where people may go to receive mental health services. For each one, please tell me whether you used the service, or if you needed or wanted the service during the past year.

	YES	NO	WANTED OR NEEDED	DON’T KNOW	REFUSED
a. Doctor or other health care professional	1	0	3	d	r
b. A hospital or other inpatient program	1	0	3	d	r
c. A support group	1	0	3	d	r
d. A priest, minister, or rabbi	1	0	3	d	r
e. A spiritualist or healer	1	0	3	d	r
f. A social worker, counselor, or other mental health professional	1	0	3	d	r

D8=1 OR D8A=1 OR D16=1; IF D8=1 OR D8A=1, FILL NAME OF BIO DAD FROM D7; IF D16=1, FILL NAME OF SPOUSE FROM D17

F20. The next questions are about your relationship with [SPOUSE]. For each statement I read, please tell me if you disagree strongly, disagree somewhat, disagree a little, agree a little, agree somewhat, or agree strongly.

[READ STATEMENT]. Do you disagree strongly, disagree somewhat, disagree a little, agree a little, agree somewhat, or agree strongly?

	DISAGREE STRONGLY	DISAGREE SOMEWHAT	DISAGREE A LITTLE	AGREE A LITTLE	AGREE SOMEWHAT	AGREE STRONGLY
a. He makes me feel unsafe even in my own home	1	2	3	4	5	6
b. I feel ashamed of the things he does to me	1	2	3	4	5	6
c. I try not to rock the boat because I am afraid of what he might do	1	2	3	4	5	6
d. I feel like I am programmed to react a certain way to him	1	2	3	4	5	6
e. I feel like he keeps me prisoner	1	2	3	4	5	6
f. He makes me feel like I have no control over my life, no power, no protection	1	2	3	4	5	6

D8=1 OR D8A=1 OR D16=1; IF D8=1 OR D8A=1, FILL NAME OF BIO DAD FROM D7; IF D16=1, FILL NAME OF SPOUSE FROM D17

F21. In the past year, how many times did . . .[READ LIST; CODE ONE FOR EACH]. Would you say never, 1 time, 2 times, 3 to 5 times, or 6 times or more?

	NEVER	1 TIME	2 TIMES	3-5 TIMES	6 OR MORE TIMES	don’t know	refused
a. [SPOUSE/PARTNER] throw something at you?	1	2	3	4	5	d	r
b. you throw something at [SPOUSE/PARTNER]?	1	2	3	4	5	d	r
c. [SPOUSE/PARTNER] push, shove, hit, slap, or grab you?	1	2	3	4	5	d	r
d. you push, shove, hit, slap, or grab [SPOUSE/PARTNER]?	1	2	3	4	5	d	r
e. [SPOUSE/PARTNER] use a knife, gun, or weapon on you?	1	2	3	4	5	d	r
f. you use a knife, gun, or weapon on [SPOUSE/PARTNER]?	1	2	3	4	5	d	r
g. How many times did [SPOUSE/PARTNER] choke, slam, kick, burn, or beat you?	1	2	3	4	5	d	r
h. How many times did you choke, slam, kick, burn, or beat [SPOUSE /PARTNER]?	1	2	3	4	5	d	r
i. How many times did [SPOUSE/PARTNER] use threats or force (like hitting, holding down, or using a weapon) to make you have sex?	1	2	3	4	5	d	r

all

F22. Have you ever received any services for domestic violence?

YES 1 F22b

NO 0 F22a

DON’T KNOW d F22a

REFUSED r F22a

F22=0,d,r

F22a. Did you ever want or need services for domestic violence?

YES 1

NO 0

DON’T KNOW d

REFUSED r

F22=1

F22b. Are you currently receiving services for domestic violence?

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

F23. During the past year, have you received counseling for domestic violence or anger management?

YES 1 F23b

NO 0 F23a

DON’T KNOW d F23a

REFUSED r F23a

F23=0,d,r

F23a. During the past year, did you ever want or need counseling for domestic violence or anger management?

YES 1

NO 0

DON’T KNOW d

REFUSED r

F23=1

F23b. Are you currently receiving counseling for domestic violence or anger management?

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

F24. Have you been arrested within the past year?

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

G. Intro The next questions are about home visiting services.

INTERVIEWER: enter 1 to continue

ENTER 1 TO CONTINUE 1

ALL

G1a-c. Families enroll in home visiting for many different reasons. What are the main reasons you want to enroll in home visiting?

PROBE: Any other reason? PLEASE CODE UP TO 3 REASONS.

CODE THREE REASONS

TO LEARN HOW TO HAVE A HEALTHY PREGNANCY 1

TO LEARN HOW TO HELP MY BABY BE HEALTHY 2

TO LEARN HOW TO HELP MY BABY LEARN AND DEVELOP 3

TO GET HELP COMPLETING MY EDUCATION OR JOB TRAINING 4

TO HAVE SOMEONE TO TALK TO WHEN I HAVE PROBLEMS 5

TO HELP GET SERVICES FOR MENTAL HEALTH, SUBSTANCE USE, OR DOMESTIC VIOLENCE IN MY FAMILY 6

TO GET TRANSPORTATION TO SER VICES MY FAMILY NEEDS 7

TO GET HEALTH INSURANCE FOR MYSELF OR MY BABY 8

TO GET HELP GETTING FINANCIAL ASSISTANCE 9

TO GET HELP GETTING GOOD CHILD CARE AND CHILD EDUCATION SERVICES 10

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What other reason?

all

G2. How often do you think you will have home visits? Would you say . . .

A few times a week, 1

Once a week, 2

Once every two weeks, 3

Once a month, or 4

Once every few months? 5

DON’T KNOW d

REFUSED r

all

G3. Mothers have different preferences for what they would like to do in home visits. I will read a list of things that might be a part of home visiting. For each one, please tell me whether this is something you would like to do in home visiting.

	Yes, would like to do this in home visiting	No, would not like to do this in home visiting	No opinion; don’t care either way	DON’T KNOW	REFUSED
a. Watch videos or read about being a parent	1	0	2	d	r
b. Have your home visitor give you feedback on how to interact with your baby	1	0	2	d	r
c. Talk with your home visitor about your own childhood	1	0	2	d	r
d. Make and follow plans to solve a parenting problem	1	0	2	d	r
e. Talk with your home visitor about personal feelings	1	0	2	d	r
f. Get reassurance from your home visitor about being a parent	1	0	2	d	r
g. Make and follow plans to continue your education	1	0	2	d	r
h. Make and follow plans to get services your family needs	1	0	2	d	r

all

G4. Did anyone encourage you to enroll in the home visiting program? For example, a relative, a friend, a neighbor, a health care provider or a social services provider?

YES 1

NO 0

DON’T KNOW d

REFUSED r

G4=1

G5. Who encouraged you to enroll in the home visiting program? Was it a family member or relative, a friend, or a provider or other type of professional staff?

PROBE: Anyone else?

FAMILY MEMBER/RELATIVE 1

FRIEND 2

PROVIDER/PROFESSIONAL STAFF 3

OTHER (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What other person encouraged you to enroll in the home visiting program? (string 99)

all

G6. Was there anyone who did not want you to enroll in the home visiting program?

YES 1

NO 0

DON’T KNOW d

REFUSED r

G6=1

G7. Who did not want you to enroll in the home visiting program? Was it a family member or relative, a friend, or a provider or other type of professional staff?

PROBE: Anyone else?

FAMILY MEMBER/RELATIVE 1

FRIEND 2

PROVIDER/PROFESSIONAL STAFF 3

OTHER (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What other person did not want you to enroll in the home visiting program? (string 99)

all

H1a. We are almost done with the survey. Thank you very much for answering my questions. I just have a few more. First, what is your e-mail address? This will be kept private and only used as a way of contacting you when we need to talk to you again for the follow-up survey.

(STRING (50))

E-MAIL ADDRESS

DON’T KNOW d

REFUSED r

SAMPLE LOAD DID NOT INCLUDE RESPONDENT’S PHONE NUMBER OR IF THERE IS A BREAKOFF

H1b. What is your telephone number?

INTERVIEWER: WE SHOULD COLLECT TWO NUMBERS IF POSSIBLE.

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

CELL PHONE:

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

all

H1c. Next, what is your Social Security Number? Like your e-mail address and all other information collected, this will be kept private to the extent allowed by law.It will be used to help us find you, or to confirm your identity when we need to talk to you again for the follow-up survey or for obtaining your Medicaid health records.

INTERVIEWER: ENTER SOCIAL SECURITY NUMBER WITHOUT DASHES

| | | |-| | |-| | | | | SOCIAL SECURITY NUMBER

DON’T KNOW d

REFUSED r

e18=4

H1d. Next, what is your Medicaid ID number? Like your e-mail address and all other information collected, this will be kept private to the extent allowed by law. It will be used to help us find you, or to confirm your identity when we need to talk to you again for the follow-up survey or for obtaining your Medicaid health records.

| | | || | || | | | || | | | | MEDICAID ID NUMBER

DON’T KNOW d

REFUSED r

all

H2a. Please tell me the names, addresses, telephone numbers, and e-mail addresses of three people who do not live with you but who will know how to contact you roughly a year from now. This will help us contact you if you move so we can still complete a follow up interview with you.

What is the name of the first person who will know how we can reach you?

interviewer: enter name of person

(STRING (50))

NAME

DON’T KNOW d CONCLUDE

REFUSED r CONCLUDE

H2 ne d, r

H2b. How is this person related to you?

BIOLOGICAL MOTHER 11

BIOLOGICAL FATHER 12

ADOPTIVE MOTHER 13

ADOPTIVE FATHER 14

STEPMOTHER 15

STEPFATHER 16

GRANDMOTHER 17

GRANDFATHER 18

GREAT GRANDMOTHER 19

GREAT GRANDFATHER 20

SISTER/STEPSISTER 21

BROTHER/STEPBROTHER 22

OTHER RELATIVE OR IN-LAW (FEMALE) 23

OTHER RELATIVE OR IN-LAW (MALE) 24

FOSTER PARENT (FEMALE) 25

FOSTER PARENT (MALE). 26

OTHER NON-RELATIVE (FEMALE) 27

OTHER NON-RELATIVE (MALE) 28

PARENT’S PARTNER (FEMALE) 29

PARENT’S PARTNER (FEMALE) 30

DON’T KNOW d

REFUSED r

IF OTHER RELATIVE OR IN-LAW (FEMALE) (23): What is her relationship? (string (99))

IF OTHER RELATIVE OR IN-LAW (MALE) (24): What is his relationship? (string (99))

IF OTHER NON-RELATIVE (FEMALE) (27): What is her relationship? (string (99))

IF OTHER NON-RELATIVE (MALE) (28): What is his relationship? (string (99))

H2a NE d, r

H2c. What is that person’s telephone number?

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

CELL PHONE:

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

H2a ne d, r

H2d. Please give me their permanent address.

STREET 1

STREET 2

STREET 3

CITY

STATE

ZIP

DON’T KNOW d

REFUSED r

H2a ne d, r

H

2e. Please give me their e-mail address.

(STRING (50))

E-MAIL ADDRESS

INTERVIEWER: CODE E-MAIL ADDRESS TYPE

DON’T KNOW d

REFUSED r

H3a NE d, r

H3a. What is the name of a second person?

interviewer: enter name of person

(STRING (50))

NAME

DON’T KNOW d CONCLUDE

REFUSED r CONCLUDE

H3a ne d, r

H3b. How is this person related to you?

BIOLOGICAL MOTHER 11

BIOLOGICAL FATHER 12

ADOPTIVE MOTHER 13

ADOPTIVE FATHER 14

STEPMOTHER 15

STEPFATHER 16

GRANDMOTHER 17

GRANDFATHER 18

GREAT GRANDMOTHER 19

GREAT GRANDFATHER 20

SISTER/STEPSISTER 21

BROTHER/STEPBROTHER 22

OTHER RELATIVE OR IN-LAW (FEMALE) 23

OTHER RELATIVE OR IN-LAW (MALE) 24

FOSTER PARENT (FEMALE) 25

FOSTER PARENT (MALE). 26

OTHER NON-RELATIVE (FEMALE) 27

OTHER NON-RELATIVE (MALE) 28

PARENT’S PARTNER (FEMALE) 29

PARENT’S PARTNER (FEMALE) 30

DON’T KNOW d

REFUSED r

IF OTHER RELATIVE OR IN-LAW (FEMALE) (23): What is her relationship? (string (99))

IF OTHER RELATIVE OR IN-LAW (MALE) (24): What is his relationship? (string (99))

IF OTHER NON-RELATIVE (FEMALE) (27): What is her relationship? (string (99))

IF OTHER NON-RELATIVE (MALE) (28): What is his relationship? (string (99))

H3a NE d, r

H3c. What is that person’s telephone number?

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

CELL PHONE:

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

H3a ne d, r

H3d. Please give me their permanent address.

STREET 1

STREET 2

STREET 3

CITY

STATE

ZIP

DON’T KNOW d

REFUSED r

H3a ne d, r

H

3e. Please give me their e-mail address.

(STRING (50))

E-MAIL ADDRESS

INTERVIEWER: CODE E-MAIL ADDRESS TYPE

DON’T KNOW d

REFUSED r

H4a NE d, r

H4a. What is the name of a third person?

interviewer: enter name of person

(STRING (50))

NAME

DON’T KNOW d CONCLUDE

REFUSED r CONCLUDE

H4a ne d, r

H4b. How is this person related to you?

BIOLOGICAL MOTHER 11

BIOLOGICAL FATHER 12

ADOPTIVE MOTHER 13

ADOPTIVE FATHER 14

STEPMOTHER 15

STEPFATHER 16

GRANDMOTHER 17

GRANDFATHER 18

GREAT GRANDMOTHER 19

GREAT GRANDFATHER 20

SISTER/STEPSISTER 21

BROTHER/STEPBROTHER 22

OTHER RELATIVE OR IN-LAW (FEMALE) 23

OTHER RELATIVE OR IN-LAW (MALE) 24

FOSTER PARENT (FEMALE) 25

FOSTER PARENT (MALE). 26

OTHER NON-RELATIVE (FEMALE) 27

OTHER NON-RELATIVE (MALE) 28

PARENT’S PARTNER (FEMALE) 29

PARENT’S PARTNER (FEMALE) 30

DON’T KNOW d

REFUSED r

IF OTHER RELATIVE OR IN-LAW (FEMALE) (23): What is her relationship? (string (99))

IF OTHER RELATIVE OR IN-LAW (MALE) (24): What is his relationship? (string (99))

IF OTHER NON-RELATIVE (FEMALE) (27): What is her relationship? (string (99))

IF OTHER NON-RELATIVE (MALE) (28): What is his relationship? (string (99))

H4a NE d, r

H4c. What is that person’s telephone number?

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

CELL PHONE:

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

H4a ne d, r

H4d. Please give me their permanent address.

STREET 1

STREET 2

STREET 3

CITY

STATE

ZIP

DON’T KNOW d

REFUSED r

H4a ne d, r

H

4e. Please give me their e-mail address.

(STRING (50))

E-MAIL ADDRESS

INTERVIEWER: CODE E-MAIL ADDRESS TYPE

DON’T KNOW d

REFUSED r

INSERT UNIVERSE

FILL ADDRESS FROM PRELOAD

P

mt. I would like to confirm the name and address where we should send your thank-you gift card. Is it…

INTERVIEWER: READ ADDRESS TO RESPONDENT

STREET 1

STREET 2

STREET 3

CITY

STATE

ZIP

DON’T KNOW d

REFUSED r

INSERT UNIVERSE

INSERT FILL CONDITION OR DELETE ROW

Thank you. Thank you for your cooperation. This completes the survey! Thank you again.