Form 0920-0222 2019 Questions for Cognitive Testing

Collaborating Center for Questionnaire Design and Evaluation Research

0920 0222 PRAMS Attach 1 Questions final

Cognitive Test for the Pregnancy Risk Assessment Monitoring System (PRAMS)

OMB: 0920-0222

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Attachment 1: PRAMS 2019 questions to be cognitively tested (Phone/English version) Form Approved

OMB No. 0920-0222

Exp. Date 08/31/2021



Notice - CDC estimates the average public reporting burden for this collection of information as 85minutes 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 (0920-0222).


Assurance of confidentiality - We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347).


The first questions are about you and your health.


  1. I’m going to read a list of health conditions. For each one, please tell me if you currently have it. Do you have____?


(PROBE: Do you currently have______?)


Condition

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Depression





  1. Anxiety





  1. Hepatitis B





  1. Hepatitis C





  1. Chronic Pain, which is pain lasting more than 12 weeks or 3 months






  1. Since your baby was born, how many health care visits have you had with a doctor, nurse, or other health care worker, including a dental or mental health worker? Do not include any home visits you may have had by a doctor, nurse or other health care worker.


(Don’t Read)

1

Number of Visits [ _______ ]


2

Have not had any health care visits since baby was born

Go to Question 5






8

Refused



9

Don’t know/Don’t Remember



  1. What type of health care visit have you had since your baby was born?



Types of Visits

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Postpartum checkup





  1. Visit for problems I was having related to the delivery of my baby





  1. Regular checkup at my family doctor’s or OB/GYN’s office





  1. Visit for an illness or chronic condition





  1. Visit for an injury





  1. Visit for family planning or birth control





  1. Visit for depression or anxiety





  1. Visit to have my teeth cleaned by a dentist or dental hygienist





  1. Prenatal care visit for a new pregnancy





  1. Have you had another type of health care visit?





  1. If YES, ask: What type of visit?




  1. During any of your health care visits since your baby was born, did a doctor, nurse, or other health care worker do any of the following things?

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Talked to you about managing pain after the birth of your baby





  1. Asked you, in person or on a form, if you drank alcoholic beverages





  1. Asked you, in person or on a form, if you smoked cigarettes or used other tobacco products





  1. Asked me if I was feeling down or depressed






  1. I’m going to read a list of prescription pain relievers. For each one, please tell me if you used it since your baby was born. Please include any medications that you may have taken to relieve pain associated with your baby’s birth. Did you use _____________since your baby was born?


Prescription pain reliever

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Hydrocodone like Vicodin®, Norco®, or Lortab®






  1. Codeine like Tylenol® 3 or 4, these are not regular Tylenol®






  1. Oxycodone like Percocet®, Percodan®, OxyContin®, or Roxicodone®






  1. Tramadol like Ultram® or Ultracet®






  1. Hydromorphone or meperidine like Demerol®, Exalgo®, or Dilaudid®






  1. Oxymorphone like Opana®






  1. Morphine like MS Contin®, Avinza®, or Kadian ®






  1. Fentanyl like Duragesic®, Fentora®, or Actiq®







↓






If ALL No, go to question O10


INTERVIEWER: If mom said “Yes” for any of the options in Question 5, continue with the next question. If not, go to Question 7.


  1. Since your baby was born, for how many week or months have you used prescription pain relievers? Please tell me the total number of weeks or months you have used prescription pain relievers since your baby was born.


(Don’t Read)

1

Number of weeks ___________

(Range: 1-45 weeks)



OR



2

Number of months ___________

(Range: 1-10 months)






3

Less than a week







8

Refused



9

Don’t know/Don’t Remember







  1. Since your baby was born, how often have you used the following tobacco products? I’m going to read a list of options. For each one, please tell me Every day if you have used that tobacco product since your baby was born, Some Days if you have used it occasionally since your baby was born, or Never if you have not used it. Did you take or use _______?


(PROBE: Would you say you have used ______ Everyday, Some Days, or Never?)


Tobacco Products

(Don’t Read)

Every day

(1)

Some Days

(2)

Never

(3)

Refused

(8)

Don’t know

(9)

  1. E-cigarettes or other electronic vaping products with nicotine






  1. Hookah






  1. Chewing tobacco, snuff, snus, or dip






  1. Cigars, cigarillos, or little filtered cigars







  1. Since your baby was born, have you needed treatment or counseling for your use of…


Substances

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Prescription pain relievers





  1. Drugs or medications other than pain relievers





  1. Alcohol





  1. Cigarettes or other tobacco products





  1. Did you need treatment or counseling for your use of any other substance?





  1. If YES, ask: For what?




INTERVIEWER: If mom marked “No” for all the options in Question 8, got to Question 15. Otherwise, continue with the next question.


  1. Since your baby was born, have you received treatment or counseling for your use of…


Substances

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Prescription pain relievers





  1. Drugs or medications other than pain relievers





  1. Alcohol





  1. Cigarettes or other tobacco products





  1. Drugs





  1. Did you receive treatment or counseling for your use of any other substance?





  1. If YES, ask: For what?




INTERVIEWER: If mom received the treatment or counseling she needed for her use of any substance, please go to Question 11. If she did not receive all the treatment or counseling she needed, please continue with the next question.




  1. I’m going to read a list of reasons why some people may not get the treatment or counseling they need for their use of any medications, drugs, alcohol or tobacco products. For each one, please tell me if it was a reason for you. Was it because _____________?


Reasons

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. You could not get an appointment or were put on a waiting list





  1. You was able to cut down or stop using without help





  1. You didn’t think I needed help





  1. You didn’t have enough money or insurance to pay for services





  1. You didn’t know where to go for help





  1. You didn’t have transportation





  1. You didn’t want people to think you had a problem





  1. Your partner did not want me to get help





  1. You were afraid to lose custody of your baby or children





  1. You had too many other things going on





  1. Was there another reason?





  1. If YES, ask: What was it?




INTERVIEWER: If mom has not receive any type of treatment or counseling, go to Question 15.



  1. Since your baby was born, which of the following types of treatment or counseling have you received? I’m going to read a list of types of treatment of counseling. For each one, please tell me if you received it. Was it ______________?


(PROBE: What type of treatment or counseling did you receive?)


Types of Treatment or Counseling

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Individual counseling with a behavioral health professional





  1. Group counseling with a behavioral health professional





  1. Counseling with a clergy member or other religious or community counselor





  1. Self-help or recovery group meetings (such as Alcoholics Anonymous, Self-Management and Recovery Training (SMART), Moderation Management (MM))





  1. Medication-assisted treatment (MAT) using medicines such as methadone, buprenorphine, Suboxone®, Subutex® or naltrexone (Vivitrol®).





  1. Tobacco cessation counseling or treatment





  1. Did you receive another type of treatment or counseling?

  1. If YES, ask: What did you receive?




  1. Since your baby was born, where have you received treatment for your use of any medications, drugs, or alcohol, not counting cigarettes? I’m going to read a list of places. For each one, please tell me if you received treatment there. Was it in_____________?


(PROBE: Did you receive treatment for your use of medications, drugs, or alcohol in _______________?)


Places

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Self-help group meetings





  1. A private doctor’s office





  1. An emergency room





  1. A hospital as an inpatient where I stayed at night





  1. A treatment facility as an outpatient where I did not stay at night





  1. A residential treatment facility where I stayed at night





  1. A prison or jail





  1. Did you receive treatment somewhere else?





  1. If YES, ask: Where?




  1. What was the outcome of the treatment or counseling you last received? Would you say that ___________?

1

You are still in treatment

Go to Question 15


2

You completed treatment, or

Go to Question 15


3

You did not finish treatment






(Don’t Read)

8

Refused

Go to Question 15


9

Don’t know/Don’t Remember

Go to Question 15


  1. What were the reasons that you did not finish treatment or counseling? I’m going to read a list of reasons. For each one, please tell me if it was a reason for you. Was it because ____________?


(PROBE: Why didn’t you finish treatment or counseling?)


Reasons

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. You had a problem with the program





  1. You could not afford to continue treatment





  1. Your family needed you





  1. You began using medications, drugs, or alcohol again





  1. Was there another reason?





If YES, ask: What was it?




The next questions are about your experiences when your baby was born.


  1. After your baby was born, did anyone suggest that you not breastfeed your new baby?


(Don’t Read)

1

No

Go to Question 18


2

Yes







8

Refused

Go to Question 18


9

Don’t know/Don’t Remember

Go to Question 18


  1. Who suggested that you not breastfeed your baby? I’m going to read a list of people. For each one, please tell me if they suggested you do not breastfeed your baby. Was it______?


Items

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Your baby’s doctor, nurse, or other health care worker





  1. Your doctor, nurse, or other health care worker





  1. Your husband or partner





  1. Your mother, father, or in-laws





  1. Other family member or relative





  1. Your friends





  1. Did someone else suggest you do not breastfeed your baby?





  1. IF YES, ask: Who?




INTERVIEWER: If a doctor, nurse or other health care worker recommended she didn’t breastfeed her baby go to the next question, otherwise go to Question 18.


  1. Why did a doctor, nurse, or other health care worker suggest that you not breastfeed your baby? I’m going to read a list of reasons. For each one, please tell me if it was one a reasons for them. Was it because ____________?


Reasons

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. You had a medical condition that made breastfeeding a problem for you





  1. You had a medical condition that made breastfeeding unsafe for your baby





  1. There was concern that drugs or medications you were using would pass to the baby through your milk





  1. Your baby had a medical condition and breastfeeding was not recommended





  1. Was there another reason?





  1. If YES, ask: What was the reason?



The next questions are about your baby’s health when he or she was a newborn.

  1. After your baby was born, did a doctor, nurse, or other healthcare worker tell you that your baby had drug withdrawal sometimes known as neonatal abstinence syndrome or neonatal opioid withdrawal syndrome?


(Don’t Read)

1

No Go to Question 21



2

Yes







8

Refused Go to Question 21



9

Don’t know/Don’t Remember Go to Question 21




  1. Did your baby receive any of the following types of special care or treatment to help him or her with drug withdrawal symptoms? I’m going to read a list of special care or treatments. For each item, please tell me if your baby receive it. Did your baby receive______________?


Reasons

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Medications such as morphine, methadone, or buprenorphine





  1. Fluids through an IV





  1. Skin-to-skin care or Kangaroo Care





  1. Sleeping in quiet, dimly lit room





  1. High calorie formula





  1. Breastfeeding or pumped breast milk





  1. Donor breast milk





  1. Did your baby receive other treatment?





  1. If YES, ask: What did your baby receive?



  1. I’m going to read a list of things that the doctors, nurses, or health care workers might do after your baby was born. For each one, please tell me if they did it after your baby was born, or not.



(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Talk to me about why my baby had drug withdrawal





  1. Talk to me about treatment for babies with drug withdrawal





  1. Talk to me about how long my baby’s withdrawal signs may last





  1. Talk to me about the things my baby could experience





  1. Talk to me about my baby’s behavior





  1. Talk to me about when my baby would be able to go home





  1. Ask me about medications I was taking or took during pregnancy





  1. Suggest I receive counseling or treatment for my use of medications, drugs or alcohol





  1. Suggest I receive services for my baby such as early intervention or home visiting programs





  1. Did a blood test or scoring test to evaluate my baby for neonatal abstinence syndrome






  1. After your baby was born, how would you describe where he or she stayed most of the time during your time in the hospital? Did he or she stay ___________________ ?

1

In the hospital room with you, sometimes known as “rooming-in”



2

In the regular newborn nursery



3

In a specialized nursery for babies that need extra care such as a Special Care Nursery (SCN) or Neonatal Intensive Care Unit (NICU)






(Don’t Read)

4

Baby was not born in a hospital Go to Question 27







8

Refused



9

Don’t know/Don’t Remember



  1. Before you were discharged from the hospital after your baby was born, was a doctor, nurse or other health care worker able to answer any questions you had about your baby’s health?

1

No



2

Yes



3

You didn’t have any questions about your baby’s health






(Don’t Read)

8

Refused



9

Don’t know/Don’t Remember


  1. I’m going to read a list of things that the doctors, nurses, or health care workers might talk to you about. For each one, please tell me if they did it before you were discharged from the hospital.



(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. How to soothe your baby





  1. How to respond to your baby’s needs





  1. Feeling a bond with your baby





  1. Feeding your baby at home





  1. Having a safe place for your baby to sleep





  1. Having someone that can help you take care of your baby





  1. Taking your baby to doctors’ visits





  1. Keeping your baby safe in your home





  1. Recognizing signs or symptoms in my baby that require medical attention






  1. Were you and your baby discharged home from the hospital at the same time after the birth? Would you say ________________?



1

No



2

Yes, you were discharged at the same time, and your baby went home with you


3

Yes, you were discharged at the same time, but your baby did not go home with you





(Don’t Read)

8

Refused



9

Don’t know/Don’t Remember




  1. After being discharged from the hospital following birth, did your baby have to go back to the hospital and spend the night for any reason?


(Don’t Read)

1

No

Go to Question 27


2

Yes







8

Refused

Go to Question 27


9

Don’t know/Don’t Remember

Go to Question 27


  1. Why did your baby have to go back to the hospital after being discharged? I’m going to read a list a reasons, for each one please tell me if it was a reason for your baby. Was it because of ____________?


(PROBE: After being discharged, did your baby have to go back to the hospital because of __________?)


Reasons

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Breathing problems





  1. Feeding difficulties





  1. Dehydration





  1. Surgery





  1. Injury





  1. Drug withdrawal





  1. Jaundice





  1. Fever





  1. Infection





  1. Audiology screening / rescreening





  1. Did they have to go back to the hospital for another reason?





  1. If YES, ask: What was it?



  1. Is your baby living with you now? Would you say __________?

1

No, he or she is living with his or her biological father

Go to Question 31


2

No, he or she is living with another family member

Go to Question 31


3

No, he or she is in foster care

Go to Question 31


4

No, he or she has been adopted by someone else

Go to Question 31


5

No, he or she passed away

We are very sorry for your loss. Go to Question 31


6

Yes






(Don’t Read)

8

Refused

Go to Question 31


9

Don’t know/Don’t Remember

Go to Question 31



  1. How old was your baby at his or her most recent health care visit or checkup?



1

Age in months [ _______ ]

[Range: 0 – 10]





(Don’t Read)

2

My baby has never had a health care visit



8

Refused



9

Don’t know/Don’t Remember



  1. These next questions are about your baby's behavior. For each one, please tell me if it applies to your baby. For each question, please say Not at all if your baby doesn’t do it, Somewhat if your baby does it sometimes, or Very Much if your baby does it all the time.


(PROBE: Would you say that your baby __________________ not yet, somewhat or very much?)


Actions

(Don’t Read)

Not at all

(1)

Some-what

(2)

Very Much (3)

Refused

(8)

Don’t know

(9)

  1. Does your baby have a hard time being with new people?






  1. Does your baby have a hard time in new places?






  1. Does your baby have a hard time with change?






  1. Does your baby mind being held by other people?






  1. Does your baby cry a lot?






  1. Does your baby have a hard time calming down?






  1. Is your baby fussy or irritable?






  1. Is it hard to comfort your baby?






  1. Is it hard to keep your baby on a schedule or routine?






  1. Is it hard to put your baby to sleep?






  1. Is it hard for you to get enough sleep because of your baby?






  1. Does your baby have trouble staying asleep?







  1. I’m going to read a list of things about your baby's development. For each one, please tell me how much your baby is doing it right now. For each question, please say Not Yet if your baby is still not doing it, Somewhat if your baby does it sometimes, or Very Much if your baby does it all the time. If your baby doesn’t do something anymore, please tell us the option that describes how much he or she used to do it.


(PROBE: Would you say that your baby __________________ not yet, somewhat or very much?)


Actions

(Don’t Read)

Not at all

(1)

Some-what

(2)

Very Much (3)

Refused

(8)

Don’t know

(9)

  1. Holds up arms to be picked up






  1. Gets into a sitting position by him or herself






  1. Picks up food and eats it






  1. Pulls up to standing






  1. Plays games like "peek-a-boo" or "pat-a-cake"






  1. Calls parents "mama" or "dada" or similar name






  1. Looks around when people say things like "Where's your bottle?" or "Where's your blanket?"






  1. Copies sounds that other people make






  1. Walks across a room without help






  1. Follows directions like "Come here" or "Give me the ball"







  1. Since your baby was born, have you used any of the following services? I’m going to read a list of services. For each one, please tell me if you have used any of the services since your baby was born.


Services

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. WIC





  1. SNAP





  1. Parenting groups





  1. Housing assistance





  1. Financial assistance





  1. Transportation assistance





  1. Emergency child care






The following questions are about things you may have experienced in the past 30 days.


In the past 30 days, please tell us how often the following statements were true:


  1. “We worried whether our food would run out before we got money to buy more”.

Would you say that statement has been often true, sometimes true, or never true in the past 30 days?

1

Often true



2

Sometimes true



3

Never true






(Don’t Read)

8

Refused



9

Don’t know/Don’t Remember



  1. “The food that we bought just didn’t last, and we didn’t have money to get more.”

Would you say that statement has been often true, sometimes true, or never true in the past 30 days?

1

Often true



2

Sometimes true



3

Never true






(Don’t Read)

8

Refused



9

Don’t know/Don’t Remember



These last questions are about things that could have happened or that you may have experienced before you were 18 years of age. We understand that some of these questions may be difficult, but your answers will help us understand some of the things people may experience when they are growing up.


  1. When you were growing up, during the first 18 years of your life…


Questions

(Don’t Read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Were your parents ever separated or divorced?





  1. Was your mom less than 18 years old when she had you?





  1. Was your dad less than 18 years old when you were born?





  1. Did you live with anyone who was a problem drinker or alcoholic?





  1. Did you live with anyone who was depressed, mentally ill, or suicidal?





  1. Did you live with anyone who used illegal drugs or who abused prescription medications?





  1. Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?





  1. Did you frequently have to move houses or leave the places where you were living?





  1. Did you like going to school?





  1. Did you drop out of school before you were able to graduate?





  1. Were you ever bullied?







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