Form 2 FINALNew Prenatal Jan 2020

Healthy Start Mandatory Prenatal Form | Jan 2020

OMB Control No. 0915-0338, Expiration Date XX/XX/202X

INFORMATION IN THIS BOX IS FOR GRANTEE records ONLY—DO NOT UPLOAD

Name of Primary Participant: ____________________________ Date of Birth:____________

Name of Accompanying Adult: ____________________________ Date of Birth: _________

Name of Interviewer: _______________________

Names and dates of birth are included above for grantee tracking purposes only and should not be submitted to hrsa. Each person’s unique ID# should remain the same across phases and years, and should include the grantee’s org code plus a unique number. Every mandatory form should include the primary participant’s Unique ID#. the primary participant for this form is a pregnant woman who is enrolled for prenatal services. the accompanying adult participant is the primary participant’s spouse or partner, and/or the enrolled child’s co-parent. The unique IDs of the enrolled woman and any accompanying adult should all be provided below as applicable, so that these can be linked in the electronic database.

Public Burden Statement: The purpose of this data collection is to obtain consistent information across all grantees about Healthy Start and its outcomes. 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. The OMB control number for this information collection is 0915-0338 and it is valid until XX/XX/202X. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 0.17 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

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• This Mandatory Prenatal Form is to be completed, along with a new or updated mandatory Background Information form, when a pregnant woman enrolls or as soon as it is known that an enrolled woman is pregnant.

• Only enrolled pregnant women complete this form.

• this form is updated by completing the post-pregnancy follow-up when the pregnant woman gives birth or the pregnancy otherwise ends.

• This prenatal form contains a post-pregnancy follow-up at the end. this must be completed/updated when the enrolled woman delivers or the pregnancy otherwise ends.

• unique id#s of both primary participant and accompanying adult must appear together on this form so that the two ID#s can be linked in the database.

________________________________________________________________________________________

GENERAL INFORMATION to be completed by staff before uploading data for this prenatal form:

1. Primary Participant Unique ID#: ______________________________________

• [Enter as One Number: Grantee Org Code + PP + Unique ID]

2. Accompanying Adult (if applicable) Unique ID#: ________________

• [Enter as One Number: Grantee Org Code + AA + Unique ID]

• Or indicate no AA

3. Dates of Enrollment in Healthy Start:

• Primary Participant Enrollment Date_________________

• Accompanying Adult Enrollment Date_____________

4. Initial completion of this form by Primary Participant:

   • Date of initial completion of this Prenatal form: _____________

5. this form has been Updated with the primary participant following its initial completion based on [select below as applicable]:

   • Pregnancy ends (Please complete the post-pregnancy follow-up at the end of this form)

     • Date post-pregnancy follow-up completed: _________

   • Other update (eg, woman chooses to exit HS before end of pregnancy)

     • Date updated: ___________

     • Specify reason for update: ________________

Additional INSTRUCTIONS

• This form must be administered by a trained case worker or other Healthy Start grantee staff member, to ensure consistency in responding across participants and grantees when questions or misunderstandings arise. It should not be self-administered or administered by untrained staff.

• If the accompanying adult changes during the pregnancy, a new background form will need to be completed with new unique ID for that new person in order to record changes that may have an impact on the woman and her pregnancy.

• Items in italics are questions for or statements to the participant. Instructions to staff may be [bracketed].

Please read the following statement to the participant:

Thank you for participating in the Healthy Start program. The purpose of these forms is to examine how well the Healthy Start program is meeting its goals of helping families improve their health and the health of their babies. This Form should take about 10 minutes to complete. Any information you provide will be kept confidential. You do not have to answer any questions you do not want to, and you can end the interview at any time without any penalty or loss of benefits.

Pregnancy and Health

Staff: Only enrolled women who are pregnant complete this form.

For this questionnaire, I’d like to start off by asking you a couple questions about your pregnancy.

1. First, what is your baby's due date? [Staff: if woman does not yet know her due date, then this question must be completed when she does.]

• Due Date: [month/day/year]______/____/_____

• Don’t know

• Declined to answer

2. How many weeks pregnant are you? [Staff, if woman is not sure how many weeks pregnant she is, help her determine this based on her due date and today’s date. If she does not yet know her due date, complete this question after she does.]

• ______ Weeks

• Unable to determine, Specify reason:_________________

3. [Staff, based on how many weeks pregnant the woman is, what trimester is she currently in?]

• First trimester (weeks 0-13)

• Second trimester (weeks 14-27)

• Third trimester (weeks 28-40)

4. [Staff, When did the participant enroll in Healthy Start?]

• Prior to this pregnancy

• During 1^st trimester of this pregnancy (weeks 0-13)

• During 2^nd trimester of this pregnancy (weeks 14-27)

• During 3^rd trimester of this pregnancy (weeks 28-40)

5. How many months pregnant were you when you had your first visit for prenatal care? [Staff, Please indicate number of months].

• _______Months

• I haven’t gone for prenatal care yet

• Don’t know

• Declined to answer

5a. [If participant has not yet had her first visit for prenatal care, ask:] Do you have an appointment scheduled?

• Yes, indicate date scheduled: _________

• No

• Declined to answer

6. [Staff, Please select corresponding trimester for when woman had her first prenatal care visit]:

• First trimester (0-13 weeks)

• Second trimester (14-27 weeks)

• Third trimester (28-40 weeks)

• No prenatal care visits yet

6a. Do you know if you are carrying multiple fetuses or not? Eg, twins, triplets, more?

• Not pregnant with multiples

• Pregnant with multiples

  • Number of fetuses: _____________

Staff: If mother has not yet had a prenatal visit and/or does not yet know whether she is pregnant with multiples, then information regarding when she began prenatal care and whether she is carrying multiples needs to be completed for questions 5, 5a, 6, and 6A when she has.

7. During the 3 months before you got pregnant with this child, did you have any of the following health conditions? For each one, check No if participant did not have the condition or Yes if she did.

	No	Yes	Not Sure	Declined to Answer
Type 1 or Type 2 diabetes (not gestational diabetes or diabetes that starts during pregnancy)
High blood pressure or hypertension
Depression
Other chronic condition or illness, Specify: ____________________

8. [Staff, if mother currently has another child besides the one she is pregnant with, ask:] Thinking about your child who was born just before the one you’re now pregnant with, how old was he/she when you learned about this pregnancy?

• 0 to 12 months

• 13 to 18 months

• 19 to 24 months

• More than 2 years

• This is my first pregnancy

• Don’t know

• Declined to answer

Home Life

Next, we have a couple questions about your home life and plans for the baby.

9. What method do you plan to use to feed your new baby in the first few weeks?

Select one only.

• Breastfeed only (baby will not be given formula)

• Formula feed only

• Both breast and formula feed

• Don't know yet

• Declined to answer

9. Would you describe your partner or the father of this baby as:

Select only one.

• Involved in my pregnancy and supportive of me and the child I’m carrying

• Involved with the child I’m carrying but not supportive of me

• Involved and supportive of me but not the child I’m carrying

• Not involved/supportive of either me or the child I’m carrying

• Not aware I am pregnant

• Declined to answer

Tobacco and Alcohol

Finally, I'd like to ask you some additional questions about your current use of tobacco and alcohol.

9. How many cigarettes are you smoking now on an average day? A pack has 20 cigarettes.

• 41 cigarettes or more

• 21 to 40 cigarettes

• 11 to 20 cigarettes

• 6 to 10 cigarettes

• 1 to 5 cigarettes

• Less than 1 cigarette

• I didn’t smoke then

• Don’t know

• Declined to answer

9. How often, on average, are you using other tobacco or nicotine products now?

E-cigarettes (electronic cigarettes) and other electronic nicotine vaping products (such as vape pens, e-hookahs, hookah pens, e-cigars, e-pipes) are battery-powered devices that use nicotine liquid rather than tobacco leaves, and produce vapor instead of smoke.

A hookah is a water pipe used to smoke tobacco. It is not the same as an e-hookah or hookah pen.

	More than once a day	Once a day	2-6 days a week	1 day a week or less	Not at all	Don’t Know	Declined to Answer
E-cigarettes or other electronic nicotine products
Hookah
Chewing tobacco, snuff, snus, or dip
Cigars, cigarillos, or little filtered cigars

9. Since you found out you were pregnant, how often have you been drinking alcoholic beverages?

• Nearly every day

• Several times a week

• Several times a month

• Less than once a month

• Never

The Mandatory Prenatal Form is Complete

POST-PREGNANCY FOLLOW-UP

Date:__________________

Enrolled Woman Unique ID#______________________

Staff: Please complete the questions below regarding the outcome of this pregnancy once you have been able to confirm the details.

• IT IS IMPORTANT TO RECORD THE PREGNANCY OUTCOME FOR EVERY WOMAN WHO WAS IN HEALTHY START DURING HER PRENATAL PHASE, even if she leaves the program.

• Do not read these questions to the woman. Instead, determine the outcome in a way that is sensitive to the woman’s feelings, and record below:

1. Record initial outcomes of this pregnancy:

• Live birth

  • Indicate how many live births from this pregnancy:__________

• Ectopic or tubal pregnancy

• Miscarriage (pregnancy ended spontaneously before 20 weeks)

• Stillbirth or fetal death (pregnancy ended at 20 weeks or more)

  • Indicate how many fetal deaths occurred with this pregnancy:__________

• Termination of pregnancy

• Outcome unknown

  • Describe methods used to track pregnancy outcome: ______________________________________________________________________________________________

2. If this pregnancy resulted in a live baby who is now enrolled in HS, indicate the enrolled child’s Unique ID#_________________________

3. Among the babies who were born alive from this pregnancy, did any end with a neonatal death (that is, baby is born alive but dies within 0-27 days of life)?

• No

• Yes

• Indicate how many neonatal deaths from this pregnancy:

  • Number __________

  • Unable to determine_________

  • Describe methods used to track neonatal death: ______________________________________________________________________________________________

4. Please indicate if this delivery resulted in a maternal death.

• No

• Yes

• Outcome unknown

  • Describe methods used to track maternal mortality: ______________________________________________________________________________________________

5. Source(s) of information [Select all that apply]:

• Hospital records

• Vital records

• Primary Participant

• Other family member

• Other source, Specify: ___________

Follow-up Instructions

• If the outcome of the pregnancy was a healthy mother and baby, then please go on to complete the mandatory Parent/Child Form and update a Background information form with the participant.

• If the outcome was mixed and included both a live baby and a fetal or neonatal death, or a very ill baby or mother, then please be cognizant of the sensitivity of the participant, and potentially delay completing the Parent/Child Form for the live baby, or updating the mother’s Background Information Form until later, eg, the next visit.

• If the outcome of the pregnancy did not include a live birth (e.g., miscarriage, ectopic or tubal pregnancy, fetal death or stillbirth, other pregnancy termination, neonatal death), staff need to be cognizant of the sensitivity of the participant, and potentially delay updating the Background Information Form until later, eg, the next visit.