Maternal Interview Call
The Study to Explore Early Development (SEED) - Phase 3
Attachment 6 Maternal Interview
Maternal Interview Call
OMB: 0920-1171
Attachment 6
Study
to Explore Early Development (SEED) Page
A-
SECTION A: PRELIMINARY INFORMATION |
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TIME
STARTED |
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RECORD IN MILITARY TIME. |
INTERVIEWER NOTE: A1-A5 should be collected in the CIS during the follow-up/scheduling phone call. If the information is not available prior to this interview, and/or if the CIS is not available, ask A1*-A5* in the box below. Otherwise, confirm information using A1-A5 following the box. |
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A1*. |
I would like to begin by asking you some basic questions. What is your full name? |
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FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX: MAIDEN NAME: |
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A2*. |
What is your date of birth? |
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DOB MM DD YYYY |
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A3*. |
What is (CHILD)’s full name? |
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FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX: |
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A4*. |
What is (CHILD)’s date of birth? RECORD DATE HERE AND ON PREGNANCY REFERENCE FORM. |
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DOIB MM DD YYYY |
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A5*. |
Are you (CHILD)’s biological mother?
Yes…………………..01 No……………………02
If NO: STOP/SUSPEND THE INTERVIEW: I’m sorry but I need to speak with (CHILD)’s biological mother for this interview. Do you have information on how I might get in touch with her?
If R states she used an egg donor to become pregnant, but still carried the pregnancy, she still qualifies as the biological mother for the purpose of this interview.
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A1. |
I would like to begin by confirming some basic information about you and (CHILD). Is your full name (FULL NAME FROM CIS)? |
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YES 01 NO (UPDATE IN CIS) 02 |
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A2. |
Is your date of birth (MM/DD/YYYY DOB FROM CIS)? |
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YES 01 NO (UPDATE IN CIS) 02 |
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A3. |
Is (CHILD)’s full name (CHILD’S FULL NAME FROM CIS)? |
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YES 01 NO (UPDATE IN CIS) 02 |
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MI SEED III Sect A Prelim Info doc 8/25/2016
Study
to Explore Early Development (SEED) Page
A-
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A4. |
Is (CHILD)’s date of birth (MM/DD/YYYY DOIB FROM CIS)? |
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YES 01 NO (UPDATE IN CIS) 02 |
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A5. |
Are you (CHILD)’s biological mother?
If NO: STOP/SUSPEND THE INTERVIEW: I’m sorry but I need to speak with (CHILD)’s biological mother for this interview. Do you have information on how I might get in touch with her?
If R states she used an egg donor to become pregnant, but still carried the pregnancy, she still qualifies as the biological mother for the purpose of this interview.
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YES 01 NO (UPDATE IN CIS) 02 |
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During the interview, occasionally I’ll ask you to refer to the booklet you received in the mail labeled “Maternal Interview Prep Guide.” |
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A6. |
Do you have the guide in front of you now? |
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YES (SKIP TO B2) 01 NO 02 RF 98 DK 99 |
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The interview will go much faster if you have the Guide in front of you. I will wait while you find it. If you cannot find the guide or you lost it, I will ask some of the questions in more detail. This could add as much as an hour to the time it takes to complete the interview. Would you like me to mail you another copy of the Prep Guide? IF R WILL NOT PROCEED WITHOUT PREP GUIDE, RESCHEDULE THE INTERVIEW. |
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MI SEED III Sect A Prelim Info doc 8/25/2016
Study to Explore Early Development
(SEED) Page
B-
SECTION B: SOCIODEMOGRAPHICS |
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I am going to ask you some basic questions about your family background and education. |
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B1. |
DELETED |
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B2. |
Were you born in the US? |
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YES (SKIP TO B6) 01 NO 02 RF (SKIP TO B6) 98 DK (SKIP TO B6) 99 |
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B3. |
What country were you born in? |
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COUNTRY:
N/A (SKIP) 97 RF 98 DK 99 |
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B4. |
What year did you come to the US to live? |
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YEAR (SKIP
TO B6) N/A (SKIP) 9997 RF (SKIP TO B6) 9998 DK 9999 |
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B5. |
How old were you when you came to the US to live? |
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AGE: YEARS AND/OR
MONTHS N/A (SKIP) 97 97 RF 98 98 DK 99 99 |
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B6. |
What language do you usually speak at home? |
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ENGLISH 01 SPANISH 02 OTHER (SPECIFY) 90 RF 98 DK 99 |
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SPECIFY:
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B7. |
Do you consider yourself of Hispanic or Latina origin? |
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YES 01 NO (SKIP TO B8) 02 RF (SKIP TO B8) 98 DK (SKIP TO B8) 99 |
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A. Which Hispanic or Spanish group do you consider yourself a member of? (PROMPT: Mexican, Puerto Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South American, etc.?) |
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GROUP:
N/A (SKIP) 97 RF 98 DK 99 |
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MI SEED III Sect B Sociodemographics 8/25/2016
Study to Explore Early Development
(SEED) Page
B-
B8. |
What is your race? I’m going to read you a list and then please tell me all categories that apply to you. You can select more than one category. READ ANSWERS AND CODE ALL THAT APPLY. |
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American Indian or Alaska Native (ASK A) 01 Asian (ASK B) 02 Black or African American 03 Native Hawaiian or Other Pacific Islander (ASK B) 04 White 05 RF (SKIP TO B9) 98 DK (SKIP TO B9) 99 |
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IF B8 INCLUDES CODE 01, ASK B8A. OTHERWISE, SKIP TO B8B. |
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A. What tribe do you consider yourself a member of? |
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TRIBE:
N/A (SKIP) 97 RF 98 DK 99 |
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IF B8 INCLUDES CODE 02 OR 04, ASK B8B. OTHERWISE, SKIP TO B9. |
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B. What is your country of ethnic origin? (PROMPT: Referring to Asian, Native Hawaiian or other Pacific Island countries.) |
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COUNTRY:
N/A (SKIP) 97 RF 98 DK 99 |
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B9. |
What was the highest grade or year of school or college that you had completed at the time (CHILD) was born? READ LIST. SELECT ONE. |
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No formal schooling 01 Less than high school (ASK A) 02 12 years, completed high school or equivalent 03 1-3 Years of college 04 Completed technical college 05 Associate’s degree 06 4 years of college or bachelor’s degree 07 Master’s degree 08 Advanced degree 09 RF 98 DK 99 |
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IF B9 NOT EQUAL TO 02, SKIP TO B10. |
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A. How many years of school did you complete? |
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OF YEARS N/A (SKIP) 97 RF 98 DK 99 |
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B10. |
Is that the highest grade or year of school or college you have currently completed? |
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YES (SKIP TO B11B) 01 NO 02 RF (SKIP TO B11B) 98 DK (SKIP TO B11B) 99 |
MI SEED III Sect B Sociodemographics 8/25/2016
Study to Explore Early Development
(SEED) Page
B-
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B11. |
What is the highest grade or year of school or college that you have currently completed? READ LIST. SELECT ONE. |
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Less than high school (ASK A) 02 12 years, completed high school or equivalent 03 1-3 Years of college 04 Completed technical college 05 Associate’s degree 06 4 years of college or bachelor’s degree 07 Master’s degree 08 Advanced degree 09 N/A (SKIP) 97 RF 98 DK 99 |
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IF B11 NOT EQUAL TO 02, SKIP TO B11B. |
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A. How many years of school did you complete? |
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OF YEARS N/A (SKIP) 97 RF 98 DK 99
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B11B. |
At the time of (CHILD’S) birth, were you married, living with a partner, separated, divorced, widowed, or never married?
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Married……………………………..... 01 living with a partner 02 Separated……………. 03 Divorced………………. 04 Widowed………………. 05 Never Married………. 06 RF 98 DK…………………………………….………………………99 |
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B11C. |
Are you currently married, living with a partner, separated, divorced, widowed, or never married?
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Married 01 living with a partner 02 Separated…………….. 03 Divorced………………. 04 Widowed………………. 05 Never Married………. 06 RF 98 DK…………………………………………………………….99 |
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MI SEED III Sect B Sociodemographics 8/25/2016
Study to Explore Early Development
(SEED) Page
B-
B12. |
The next few questions are about (CHILD)’s biological father. If you do not know (CHILD)’s father, please let me know at this time. |
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DK FATHER (SKIP TO B34) 01 KNOWS FATHER 02 N/A (SKIP) 97 RF (SKIP TO B34) 98 |
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B13. |
What is (CHILD)’s biological father’s birthdate? |
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DOB MM DD YYYY N/A (SKIP) 97 97 9997 RF 98 98 9998 DK 99 99 9999 |
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B14. |
Was he born in the US? |
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YES (SKIP TO B18) 01 NO 02 N/A (SKIP) 97 RF (SKIP TO B18) 98 DK (SKIP TO B18) 99 |
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B15. |
What country was he born in? |
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COUNTRY:
N/A (SKIP) 97 RF 98 DK 99 |
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B16. |
What year did he come to the US to live? |
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YEAR (SKIP
TO B18) N/A (SKIP) 9997 RF (SKIP TO B18) 9998 DK 9999 |
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B17. |
How old was he when he came to the US to live? |
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AGE: YEARS AND/OR
MONTHS N/A (SKIP) 97 97 RF 98 98 DK 99 99 |
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B18. |
What language does he usually speak at home? |
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ENGLISH 01 SPANISH 02 OTHER (SPECIFY) 90 N/A (SKIP) 97 RF 98 DK 99
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SPECIFY:
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B19. |
Does he consider himself of Hispanic or Latino origin? |
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YES 01 NO (SKIP TO B20) 02 NA (SKIP) 97 RF (SKIP TO B20) 98 DK (SKIP TO B20) 99
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MI SEED III Sect B Sociodemographics 8/25/2016
Study to Explore Early Development
(SEED) Page
B-
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A. Which Hispanic or Spanish group does he consider himself a member of? (PROMPT: Mexican, Puerto Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South American, etc.?) |
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GROUP:
N/A (SKIP) 97 RF 98 DK 99 |
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B20. |
What is his race? I’m going to read you a list and then please tell me all categories that apply to him. You can select more than one category. READ ANSWERS AND CODE ALL THAT APPLY. |
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American Indian or Alaska Native (ASK A) 01 Asian (ASK B) 02 Black or African American 03 Native Hawaiian or Other Pacific Islander (ASK B) 04 White 05 N/A (SKIP) 97 RF (SKIP TO B21) 98 DK (SKIP TO B21) 99 |
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IF B20 INCLUDES CODE 01, ASK B20A. OTHERWISE, SKIP TO B20B. |
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A. What tribe does he consider himself a member of? |
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TRIBE:
N/A (SKIP) 97 RF 98 DK 99 |
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IF B20 INCLUDES CODE 02 OR 04, ASK B20B. OTHERWISE, SKIP TO B21. |
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B. What is his country of ethnic origin? (PROMPT: Referring to Asian, Native Hawaiian or other Pacific Island countries.) |
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COUNTRY:
N/A (SKIP) 97 RF 98 DK 99 |
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B21. |
What was the highest grade or year of school or college that (CHILD)’s father had completed at the time (CHILD) was born? READ LIST. SELECT ONE. |
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No formal schooling 01 Less than high school (ASK A) 02 12 years, completed high school or equivalent 03 1-3 Years of college 04 Completed technical college 05 Associate’s degree 06 4 years of college or bachelor’s degree 07 Master’s degree 08 Advanced degree 09 N/A (SKIP) 97 RF 98 DK 99 |
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IF B21 NOT EQUAL TO 02, SKIP TO B22. |
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A. How many years of school did he complete? |
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#
OF YEARS N/A (SKIP) 97 RF 98 DK 99
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MI SEED III Sect B Sociodemographics 8/25/2016
Study
to Explore Early Development (SEED) Page
B-
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B22. |
Is that the highest grade or year of school or college he has currently completed? |
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YES (SKIP TO B23B) 01 NO 02 N/A (SKIP) 97 RF (SKIP TO B23B) 98 DK (SKIP TO B23B) 99 |
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B23. |
What is the highest grade or year of school or college that he has currently completed? READ LIST. SELECT ONE. |
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Less than high school (ASK A) 02 12 years, completed high school or equivalent 03 1-3 Years of college 04 Completed technical college 05 Associate’s degree 06 4 years of college or bachelor’s degree 07 Master’s degree 08 Advanced degree 09 N/A (SKIP) 97 RF 98 DK 99 |
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IF B23 NOT EQUAL TO 02, SKIP TO B23B. |
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A. How many years of school did he complete? |
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#
OF YEARS N/A (SKIP) 97 RF 98 DK 99
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B23b. |
At the time of (CHILD’s) birth, did he live in the home with you and (CHILD)? |
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Yes, Lived with child and mother………. 01 Yes, Lived with child part-time, separate from mother….02 No, Did not live with child…………………………………..03 N/A (SKIP) 97 RF 98 DK 99
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b23c. |
Is he currently living in the home with you and (CHILD)? |
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Yes, Lives with child and mother …………………….01 Yes, Lives with child part-time, separate from mother....02 No, Does not live with child………………………………..03 N/A (SKIP) 97 RF 98 DK 99
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B24–B33. |
DELETED. |
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MI SEED III Sect B Sociodemographics 8/25/2016
Study to Explore Early Development
(SEED) Page
B-
The next few questions are about the family background and education of other adults living in the home who have major caregiving responsibilities for (CHILD).
B34. |
Do you live with any (other) adult who has major caregiving responsibilities for (CHILD)? |
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YES 01 NO (SKIP TO NEXT SECTION) 02 RF (SKIP TO NEXT SECTION) 98 DK (SKIP TO NEXT SECTION) 99 |
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A. What is that person’s relationship to (CHILD)?
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NONBIOLOGICAL FATHER …………………………...…00
STEPFATHER 02 MATERNAL GRANDMOTHER 03 MATERNAL GRANDFATHER 04 PATERNAL GRANDMOTHER 05 PATERNAL GRANDFATHER 06 BROTHER 07 SISTER 08 AUNT 09 UNCLE 10 MOM’S PARTNER 11
OTHER (SPECIFY) 90 N/A (SKIP) 97 RF 98 DK 99 |
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SPECIFY:
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B35. |
What is (CAREGIVER)’s birthdate? |
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DOB MM DD YYYY N/A (SKIP) 97 97 9997 RF 98 98 9998 DK 99 99 9999
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B36. |
Was (CAREGIVER) born in the US? |
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YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
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B37-B39 |
DELETED |
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B40. |
What language does (CAREGIVER) usually speak at home? |
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ENGLISH 01 SPANISH 02 OTHER (SPECIFY) 90 N/A (SKIP) 97 RF 98 DK 99 |
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SPECIFY:
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MI SEED III Sect B Sociodemographics 8/25/2016
Study to Explore Early Development
(SEED) Page
B-
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B41. |
Does (he consider himself/she consider herself) of Hispanic or (Latino/Latina) origin? |
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YES 01 NO (SKIP TO B42) 02 N/A (SKIP) 97 RF (SKIP TO B42) 98 DK (SKIP TO B42) 99
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A. Which Hispanic or Spanish group does (he/she) consider (himself/herself) a member of? (PROMPT: Mexican, Puerto Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South American, etc.?) |
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GROUP:
N/A (SKIP) 97 RF 98 DK 99 |
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B42. |
What is (CAREGIVER)’s race? I’m going to read you a list and then please tell me all categories that apply to (him/her). You can select more than one category. READ ANSWERS AND CODE ALL THAT APPLY. |
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American Indian or Alaska Native (ASK A) 01 Asian (ASK B) 02 Black or African American 03 Native Hawaiian or Other Pacific Islander (ASK B) 04 White 05 N/A (SKIP) 97 RF (SKIP TO B43) 98 DK (SKIP TO B43) 99 |
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IF B42 INCLUDES CODE 01, ASK B42A. OTHERWISE, SKIP TO B42B. |
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A. What tribe does (he/she) consider (himself/herself) a member of? |
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TRIBE:
N/A (SKIP) 97 RF 98 DK 99 |
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IF B42 INCLUDES CODE 02 OR 04, ASK B42B. OTHERWISE, SKIP TO B43. |
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B. What is (his/her) country of ethnic origin? (PROMPT: Referring to Asian, Native Hawaiian or other Pacific Island countries.) |
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COUNTRY:
N/A (SKIP) 97 RF 98 DK 99
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B43-44 |
DELETED |
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B45. |
What is the highest grade or year of school or college that (CAREGIVER) has currently completed? READ ANSWERS. SELECT ONE. |
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No formal schooling 01 Less than high school (ASK A) 02 12 years, completed high school or equivalent 03 1-3 Years of college 04 Completed technical college 05 Associate’s degree 06 4 years of college or bachelor’s degree 07 Master’s degree 08 Advanced degree 09 N/A (SKIP) 97 RF 98 DK 99 |
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MI SEED III Sect B Sociodemographics 8/25/2016
Study
to Explore Early Development (SEED) Page
B-
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IF B45 NOT EQUAL TO 02, SKIP TO B46. |
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A. How many years of school did (he/she) complete? |
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OF YEARS N/A (SKIP) 97 RF 98 DK 99 |
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B46. |
Are there any (other) adults living with you who have major caregiving responsibilities for (CHILD)? |
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YES 01 NO (SKIP TO NEXT SECTION) 02 RF (SKIP TO NEXT SECTION) 98 DK (SKIP TO NEXT SECTION) 99 |
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A. What is the relationship of that person or persons to (CHILD)? (Check all that apply)
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NONBIOLOGICAL FATHER …………………………...…00
STEPFATHER 02 MATERNAL GRANDMOTHER 03 MATERNAL GRANDFATHER 04 PATERNAL GRANDMOTHER 05 PATERNAL GRANDFATHER 06 BROTHER 07 SISTER 08 AUNT 09 UNCLE 10 MOM’S PARTNER 11
OTHER (SPECIFY) 90 N/A (SKIP) 97 RF 98 DK 99 |
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SPECIFY:
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SPECIFY:
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MI SEED III Sect B Sociodemographics 8/25/2016
Study to Explore Early Development
(SEED) Page
C-
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SECTION C: MATERNAL REPRODUCTIVE AND PREGNANCY HISTORY |
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C1. |
Now I’m going to ask you some questions about your reproductive and pregnancy experiences. How old were you when you had your first menstrual period? |
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AGE
IN YEARS AND MONTHS (SKIP TO C2) YRS MOS RF (SKIP TO C2) 98 98 DK 99 99 |
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A. What grade were you in when you had your first menstrual period? |
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GRADE N/A (SKIP) 97 RF 98 DK 99 |
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C2. |
Before you were pregnant with (CHILD), what was the average or typical number of days between your menstrual periods? That is, how many days were there from the first day of one menstrual period to the first day of the next menstrual period? Please think back to a time when you were not using birth control pills or other hormonal contraceptives. |
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OF DAYS IRREGULAR PERIOD 90 RF 98 DK 99 |
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C3. |
How many times have you been pregnant? Please count all pregnancies, including those that ended in live birth, stillbirth, miscarriage, abortion, or a tubal, ectopic, or molar pregnancy. Include pregnancies from other relationships and your pregnancy with (CHILD). |
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#
OF PREGNANCIES RF 98 DK 99 |
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C4. |
How many babies were you carrying during your (1st/2nd/3rd) pregnancy? (PROBE: Did you have a single baby, twins, or more babies?) |
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ANSWER C4 FOR EACH PREGNANCY, THEN TOTAL NUMBER OF BABIES. IF R REPORTS ZERO OR DK, ADD 1 TO BABY COUNT. IF R REFUSES NUMBER OF BABIES, DO NOT INCLUDE IN COUNT. |
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# OF BABIES |
N/A (SKIP) |
RF |
DK |
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PREGNANCY 1 |
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98 |
99 |
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PREGNANCY 2 |
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97 |
98 |
99 |
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PREGNANCY 3 |
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97 |
98 |
99 |
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PREGNANCY 4 |
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97 |
98 |
99 |
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PREGNANCY 5 |
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97 |
98 |
99 |
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PREGNANCY 6 |
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97 |
98 |
99 |
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PREGNANCY 7 |
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97 |
98 |
99 |
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PREGNANCY 8 |
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97 |
98 |
99 |
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BABY COUNT |
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98 |
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(IF ALL PREGS=RF, SKIP TO C18) |
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NUMBER
OF BABIES/PREGNANCY SUPPLEMENTS |
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MI SEED III Sect C Maternal History 8/25/2016
Study
to Explore Early Development (SEED) Page
C-
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C5. |
C6. |
C7. |
C8. |
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BABY COUNT:
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IF C4 = 0, 1 OR 99, READ: Was your (1st/2nd/3rd) pregnancy a (READ ANSWERS)? OTHERWISE, READ: Was the (1st/2nd/3rd) baby in your (1st/2nd/3rd) pregnancy a (READ ANSWERS)?
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Is this baby (CHILD)?
If C3=1 and C4=1 Read: This baby must be (CHILD)
If at last pregnancy and no index has been identified Read: This baby must be (CHILD) |
What is the first name of this baby? |
IF C4=2 AND C5=02-04 READ: Was this baby a boy or a girl? OTHERWISE, READ: Is (BABY) a boy or girl?
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What is (BABY)’s birthdate? |
BABY: |
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1 |
Live birth 01 Stillbirth 02 Abortion 03 Miscarriage 04 Ectopic or tubal preg 05 Molar pregnancy 06 RF 98 DK 99 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99
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N/A (SKIP) 97 RF 98 DK 99 |
BOY 01 GIRL 02 N/A (SKIP) 97 RF 98 DK 99 |
MM DD
YYYY N/A (SKIP) 97 97 9997 RF 98 98 9998 DK 99 99 9999 |
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IF C5=02-06, SKIP TO C9B.IF C5 = 98 OR 99, SKIP TO NEXT BABY/C15. |
IF C6 = 01, CODE REMAINING C6 AS 02 AND SKIP TO C10. |
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SKIP TO C10. |
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2 |
Live birth 01 Stillbirth 02 Abortion 03 Miscarriage 04 Ectopic or tubal preg 05 Molar pregnancy 06 CURRENTLY PREGNANT 90 N/A (SKIP) 97 RF 98 DK 99 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99
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N/A (SKIP) 97 RF 98 DK 99 |
BOY 01 GIRL 02 N/A (SKIP) 97 RF 98 DK 99 |
MM DD
YYYY N/A (SKIP) 97 97 9997 RF 98 98 9998 DK 99 99 9999 |
|
IF C5=02-06, SKIP TO C9B.IF C5 = 98 OR 99, SKIP TO NEXT BABY/C15. |
IF C6 = 01, CODE REMAINING C6 AS 02 AND SKIP TO C10. |
|
|
SKIP TO C10. |
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|
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|
|
|
3 |
Live birth 01 Stillbirth 02 Abortion 03 Miscarriage 04 Ectopic or tubal preg 05 Molar pregnancy 06 CURRENTLY PREGNANT 90 N/A (SKIP) 97 RF 98 DK 99 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99 |
BOY 01 GIRL 02 N/A (SKIP) 97 RF 98 DK 99 |
MM DD
YYYY N/A (SKIP) 97 97 9997 RF 98 98 9998 DK 99 99 9999 |
|
IF C5=02-06, SKIP TO C9B.IF C5 = 98 OR 99, SKIP TO NEXT BABY/C15. |
IF C6 = 01, CODE REMAINING C6 AS 02 AND SKIP TO C10. |
|
|
SKIP TO C10. |
|
|
|
|
|
|
4 |
Live birth 01 Stillbirth 02 Abortion 03 Miscarriage 04 Ectopic/tubal preg 05 Molar pregnancy 06 CURRENTLY PREGNANT 90 N/A (SKIP) 97 RF 98 DK 99 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99 |
BOY 01 GIRL 02 N/A (SKIP) 97 RF 98 DK 99 |
MM DD
YYYY N/A (SKIP) 97 97 9997 RF 98 98 9998 DK 99 99 9999 |
|
IF C5=02-06, SKIP TO C9B.IF C5 = 98 OR 99, SKIP TO NEXT BABY/C15. |
IF C6 = 01, CODE REMAINING C6 AS 02 AND SKIP TO C10. |
|
|
SKIP TO C10. |
-
MI SEED III Sect C Maternal History 8/25/2016
Study to Explore Early Development
(SEED) Page
C-
C9B. |
C10. |
C11. |
C12. |
|
On what date did the pregnancy (for this baby) end?
|
How many pounds and ounces did (BABY) weigh? |
Is (BABY) still living? |
What did (BABY) die of? RECORD VERBATIM. |
How old was (BABY) when (he/she) died? |
BABY: |
|
|
|
|
MM DD
YYYY N/A (SKIP) 97 97 9997 RF 98 98 9998 DK 99 99 9999
|
LBS OUNCES OR
GRAMS OR
KILOGRAMS N/A (SKIP) 9797 RF 9898 DK 9999 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
N/A (SKIP) 97 RF 98 DK 99 |
DAYS
AND/OR
MONTHS
AND/OR
YEARS N/A (SKIP) 97 97 97 RF 98 98 98 DK 99 99 99 |
IF C5 = 02–04, SKIP TO C14. OTHERWISE, SKIP TO NEXT BABY/C15. |
IF C6 = 01, SKIP TO C14. |
IF C11 = 01, 98, OR 99, SKIP TO C14. |
|
IF
C13A NOT DK, |
|
|
|
|
|
MM DD
YYYY N/A (SKIP) 97 97 9997 RF 98 98 9998 DK 99 99 9999 |
LBS OUNCES OR
GRAMS OR
KILOGRAMS N/A (SKIP) 9797 RF 9898 DK 9999 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
N/A (SKIP) 97 RF 98 DK 99 |
DAYS
AND/OR
MONTHS
AND/OR
YEARS N/A (SKIP) 97 97 97 RF 98 98 98 DK 99 99 99 |
IF C5 = 02–04, SKIP TO C14. OTHERWISE, SKIP TO NEXT BABY/C15. |
IF C6 = 01, SKIP TO C14. |
IF C11 = 01, 98, OR 99, SKIP TO C14. |
|
IF
C13A NOT DK, |
|
|
|
|
|
MM DD
YYYY N/A (SKIP) 97 97 9997 RF 98 98 9998 DK 99 99 9999 |
LBS OUNCES OR
GRAMS OR
KILOGRAMS N/A (SKIP) 9797 RF 9898 DK 9999 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
N/A (SKIP) 97 RF 98 DK 99 |
DAYS
AND/OR
MONTHS
AND/OR
YEARS N/A (SKIP) 97 97 97 RF 98 98 98 DK 99 99 99 |
IF C5 = 02–04, SKIP TO C14. OTHERWISE, SKIP TO NEXT BABY/C15. |
IF C6 = 01, SKIP TO C14. |
IF C11 = 01, 98, OR 99, SKIP TO C14. |
|
IF
C13A NOT DK, |
|
|
|
|
|
MM DD
YYYY N/A (SKIP) 97 97 9997 RF 98 98 9998 DK 99 99 9999 |
LBS OUNCES OR
GRAMS OR
KILOGRAMS N/A (SKIP) 9797 RF 9898 DK 9999 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
N/A (SKIP) 97 RF 98 DK 99 |
DAYS
AND/OR
MONTHS
AND/OR
YEARS N/A (SKIP) 97 97 97 RF 98 98 98 DK 99 99 99 |
IF C5 = 02–04, SKIP TO C14. OTHERWISE, SKIP TO NEXT BABY/C15. |
IF C6 = 01, SKIP TO C14. |
IF C11 = 01, 98, OR 99, SKIP TO C14. |
|
IF
C13A NOT DK, |
C13A.
.
MI SEED III Sect C Maternal History 8/25/2016
Study to Explore Early Development
(SEED) Page
C-
C13B. |
C14. (IF C5 = 02–04, READ C14A FROM OTHER SIDE.) |
||
What was the date of (BABY)’s death? |
Now I will ask you about some developmental information a doctor or health care provider may have told you about your child. Please note that a health care provider at the child's school such as a child psychologist, physical therapist, occupational therapist, or school nurse should also be considered a qualified health care professional in answering these questions; however, the child's teachers should not be considered health care providers.
ASK R TO REFER TO LIST 1 IN PREP GUIDE. Has a doctor or health care provider ever told you that (BABY) had or has any of the conditions in list 1 in the prep guide? READ CHOICES BELOW IN CODE LIST. CODE ALL THAT APPLY. |
||
|
IF C5 = 02–04, ONLY READ SHADED CODES. |
CODE LIST Asperger’s Syndrome 01 Attention Deficit Hyperactivity Disorder (ADHD) or ADD 02 Autism 03 Behavioral problem (SPECIFY) 04 Bipolar disorder 05 Birth Defects (SPECIFY) 06 Cerebral palsy 07 Childhood Disintegrative Disorder 08 Childhood onset schizophrenia 09 Developmental delay 10 Down Syndrome 11 Fragile X Syndrome 12 Hearing problems 13 Learning disabilities 14
Intellectual
disability or mental Movement or coordination problems 16 Neurofibromatosis 17 Obsessive compulsive disorder 18
Pervasive
Developmental Disorder Reactive attachment disorder of infancy or early childhood 20 Reading difficulty 21 Rett’s Syndrome 22 Seizure disorder or Epilepsy 23 Self-injuring behavior 24 Sensory integration disorder 25 Sleep disorder 26 Speech delays 27 Tourette’s Disorder or tic disorder 28 Tuberous sclerosis 29 Vision problems that cannot be corrected with glasses or contact lenses 30
Other
developmental problem N/A(SKIP) 97 RF 98 DK 99 NONE 00 
RETURN TO C5 FOR NEXT BABY. FINAL INTERVIEWER CHECKS: ONE ANSWER TO C6 MUST BE YES. ASK: Did you have any other pregnancies that we did not discuss? IF YES, CHANGE C3. IF NO, CONTINUE WITH C15. |
|
MM DD
YYYY N/A (SKIP) 97 97 9997 RF 98 98 9998 DK 99 99 9999 |
PROBLEM
CODE(S):
SPECIFY:
|
||
|
|||
|
|
|
|
MM DD
YYYY N/A (SKIP) 97 97 9997 RF 98 98 9998 DK 99 99 9999
|
PROBLEM
CODE(S):
SPECIFY:
|
||
|
|||
|
|
|
|
MM DD
YYYY N/A (SKIP) 97 97 9997 RF 98 98 9998 DK 99 99 9999
|
PROBLEM
CODE(S):
SPECIFY:
|
||
|
|||
|
|
|
|
MM DD
YYYY N/A (SKIP) 97 97 9997 RF 98 98 9998 DK 99 99 9999 |
PROBLEM
CODE(S):
SPECIFY:
|
||
|
|||
|
|||
MI SEED III Sect C Maternal History 8/25/2016
Study to Explore Early Development
(SEED) Page
C-
NUMBER
OF BABY TABLE SUPPLEMENTS 
UNFOLD PAGE FOR 3-PAGE TABLE
C14A. |
During or just after this pregnancy, did a doctor or health care provider ever tell you that the baby or fetus had any of the conditions in list 1b of the prep guide? READ SHADED CHOICES IN CODE LIST ON OTHER SIDE AND CODE ALL THAT APPLY. |
MI SEED III Sect C Maternal History 8/25/2016
Study to Explore Early Development
(SEED) Page
C-
|
IF C3 = 1 AND C4 = 1, SKIP TO C18. |
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||||||
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|||||
|
COMPLETE ONE ROW (C15–C17) FOR EACH PREGNANCY IN C3. |
|
||||||
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|||||
|
I have just a few more questions about each of your pregnancies. |
|
||||||
|
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||||
|
IF C4 = 0, 1, OR 99, SKIP TO C17. IF C4 = 2 AND C8 ANSWERS ARE DIFFERENT, SKIP TO C17. |
|
IF C6=1 OR B12=1, SKIP TO NEXT PREGNANCY/C18. |
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||||
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||||
|
C15. |
C16. |
C17. |
|
||||
|
Were the babies in your (1st/2nd/3rd) pregnancy identical?
|
How do you know they (are/are not) identical? CODE ALL THAT APPLY. |
Was the father of your (1st/2nd/3rd) pregnancy the same as (CHILD)’s father? |
|
||||
PREGNANCY: |
|
|
|
|
||||
1 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
DOCTOR TOLD YOU 01 GENETIC TESTS 02 THEY ARE AS ALIKE AS TWO PEAS IN A POD 03 THEY LOOK NOTHING ALIKE 04 N/A (SKIP) 97 RF 98 DK 99 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
|
||||
|
IF C15 = 98 OR 99, SKIP TO C17. |
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2 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
DOCTOR TOLD YOU 01 GENETIC TESTS 02 THEY ARE AS ALIKE AS TWO PEAS IN A POD 03 THEY LOOK NOTHING ALIKE 04 N/A (SKIP) 97 RF 98 DK 99 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
|
||||
|
IF C15 = 98 OR 99, SKIP TO C17. |
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||||
|
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||||
3 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
DOCTOR TOLD YOU 01 GENETIC TESTS 02 THEY ARE AS ALIKE AS TWO PEAS IN A POD 03 THEY LOOK NOTHING ALIKE 04 N/A (SKIP) 97 RF 98 DK 99 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
|
||||
|
IF C15 = 98 OR 99, SKIP TO C17. |
|
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|
||||
|
|
|
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|
||||
4 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
DOCTOR TOLD YOU 01 GENETIC TESTS 02 THEY ARE AS ALIKE AS TWO PEAS IN A POD 03 THEY LOOK NOTHING ALIKE 04 N/A (SKIP) 97 RF 98 DK 99 |
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
|
||||
|
IF C15 = 98 OR 99, SKIP TO C17. |
|
|
|
||||
NUMBER
OF PREGNANCY TABLE SUPPLEMENTS 
MI SEED III Sect C Maternal History 8/25/2016
Study to Explore Early Development
(SEED) Page
C-
|
We are interested in any hormonal medications you might have taken during your lifetime for any reason other than to prevent pregnancy or to prevent a miscarriage during pregnancy. |
||
|
|
|
|
C18. |
Did a doctor or other medical provider ever prescribe hormonal medication for any reason other than to prevent pregnancy or to prevent a miscarriage during pregnancy? |
|
YES 01 NO (SKIP TO D1) 02 RF (SKIP TO D1) 98 DK (SKIP TO D1) 99 |
|
|
|
|
C19. |
What was the reason that the hormonal medication was prescribed? READ ANSWERS AND CODE ALL THAT APPLY.
|
|
To regulate your cycle 01 To jump-start puberty 02 Growth regulation 03 Acne 04 Thyroid functioning 05 To help become pregnant 06 Other (SPECIFY) 90 N/A (SKIP) 97 RF 98 DK 99 |
|
SPECIFY:
|
||
MI SEED III Sect C Maternal History 8/25/2016
Study to Explore Early Development
(SEED) Page
C-
BLANK PAGE FOR END OF SECTION
MI SEED III Sect C Maternal History 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
SECTION D: INDEX PREGNANCY |
|
|
|
INTERVIEWER NOTE: ASK R TO TAKE OUT PREGNANCY REFERENCE FORM SENT WITH THE PREP GUIDE.
|
|||
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|
|
READ DATES FROM EACH LINE OF THE FORM BEGINNING WITH: We will refer to the 3 months before you became pregnant as the pre-pregnancy months, labeled as -3, -2, and -1. From what we’ve computed, the dates for your pre-pregnancy period are [READ BEGIN DATE OF -3 and END DATE OF -1]. Your first trimester would then be months 1, 2, and 3 with dates of… |
|||
|
|
||
Do these time periods look correct to you? IF NO, ADJUST AS NEEDED. Thank you. We will begin using the Pregnancy Reference Form in a few minutes. |
|||
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
|
|
|
|
D1. |
How much did you weigh before your pregnancy with (CHILD)? |
|
LBS OR KG RF 998 DK 999 |
|
|
|
|
D2. |
Overall, how much weight did you gain or lose during your pregnancy with (CHILD)? |
|
LBS OR KG GAINED 1 LOST 2 RF 998 8 DK 999 9 NO CHANGE 000 3 |
|
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|
D3. |
What is your height without your shoes? |
|
FEET INCHES OR M CM RF 998 DK 999 |
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|
D4. |
How far along were you when you found out you were pregnant with (CHILD)? |
|
MONTHS AND/OR WEEKS RF 98 98 DK 99 99 |
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
PAGE INTENTIONALLY LEFT BLANK.
MI SEED III Sect D Index Pregnancy 8/25/2016
Study
to Explore Early Development (SEED) Page
D-
D5. |
Please refer to the pregnancy reference form. Between (-3) and (DOIB/END BF) did you use any birth control pills or morning after pills? |
|
YES 01 NO (SKIP TO D8) 02 RF (SKIP TO D8) 98 DK (SKIP TO D8) 99 |
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|||||
D6. |
ASK R TO REFER TO LIST 2 IN PREP GUIDE. What was the name of the pill? Any others? IF R CAN’T RECALL, READ CONTRACEPTIVES LISTED BELOW. Was it (READ LIST)? CODE ALL THAT APPLY. |
|||||||
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|
|||||
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Alesse 01 Brevicon 02 Demulen 03 Desogen 04 Estrostep 05 Levlen 06 Levlite 07 Levora 08 |
Loestrin 09 Lo/Ovral 10 Micronor 11 Mircette 12 Modicon 13 Necon 14 Nordette 15 Norethindrone 16 |
Norinyl 17 Nor-Q.D 18 Ortho-Cept 19 OrthoCyclen 20 Ortho-Novum 21 Ortho Tri-Cyclen 22 Ovcon 23 Ovral 24 |
Tri-Levlen 25 Tri-Norinyl 26 Triphasil 27 Trivora 28 Zovia 29 Other (SPECIFY IN GRID) 90 N/A (SKIP) 97 RF 98 DK 99 |
||||
D7A was deleted. |
D7B. |
D7C. |
||||||||
COMPLETE ONE ROW FOR EACH PILL TAKEN. |
Would you say you were using the pill in the three months before you became pregnant, from (-3) to (-1)? |
|
||||||||
PILL NAME: |
||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
#1:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
#2:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
#3:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
||||||||
|
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|
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|
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|
||
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
|
|
|
|
|||
|
|
|
IF
R DID NOT BREASTFEED, |
|
||
D7D. |
D7E. |
D7F. |
||||||||||||
Would you say you were using the pill in your second trimester, from (4) to (6)? |
Would you say you were using the pill in your third trimester, from (7) to (10)? |
Would you say you were using the pill during the months you breastfed, from (DOIB/10) to (END BF)?
|
||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
IF DK, ASK B-F. |
|
||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
IF DK, ASK B-F. |
|
||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
#
OF BIRTH CONTROL PILL SUPPLEMENTS 
MI SEED III Sect D Index Pregnancy 8/25/2016
Study
to Explore Early Development (SEED) Page
D-
D8. |
Between (-3) and (DOIB/END BF) did you use any other method of contraception to avoid getting pregnant? |
|
YES 01 NO (SKIP TO D11) 02 RF (SKIP TO D11) 98 DK (SKIP TO D11) 99 |
||||
|
|
|
|
||||
D9. |
ASK R TO REFER TO LIST 3 IN PREP GUIDE. What method of contraception were you using? If you used more than one type of contraception, please tell me all the ones that you used. READ METHODS LISTED BELOW. CODE ALL THAT APPLY. |
||||||
|
|
|
|
||||
|
Birth control patch or Ortho-Evra 01 Condoms, male or female 02 Depo-Provera 03 Diaphragm or cervical cap 04 Intrauterine device or IUD 05 Jelly, foam or suppositories, or other spermicide 06 Norplant 07 Rhythm or calendar method 08 Sponge 09 |
Tubal Ligation 10 Vaginal ring or Nuva Ring 11 Vasectomy 12 Withdrawal method 13 Other (SPECIFY IN GRID) 90 N/A (SKIP) 97 RF 98 DK 99 |
|
||||
D10A was deleted. |
D10B. |
D10C. |
||||||||
COMPLETE ONE ROW FOR EACH METHOD USED. |
Would you say you were using (METHOD) in the three months before you became pregnant, from (-3) to (-1)? |
|
||||||||
METHOD NAME: |
||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
#1:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
#2:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
#3:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
||||||||
|
|
|
|
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
|
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|||||||
|
|
IF
R DID NOT BREASTFEED, |
|
|||||
|
|
|
|
|
||||
D10D. |
D10E. |
D10F. |
||||||||||||
Would you say you were using (METHOD) in your second trimester, from (4) to (6)? |
Would you say you were using (METHOD) in your third trimester, from (7) to (10)? |
Would you say you were using (METHOD) during the months you breastfed, from (DOIB/10) to (END BF)?
|
||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99
|
|
|
|
||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
IF DK, ASK B-F. |
|
||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
#
OF CONTRACEPTION METHOD SUPPLEMENTS
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
For DCC Programming For Interviewers
|
IF R DID NOT USE CONTRACEPTION 3 MONTHS BEFORE PREGNANCY OR DURING PREGNANCY ASK D11A –NOTE THIS INCLUDES WOMEN WHO REPORTED USING NO CONTRACEPTION IN D5 AND D8(OR REPORTED DK OR RF). IT ALSO INCLUDES WOMEN WHO REPORTED USING CONTRACEPTION ONLY DURING THE BREASTFEEDING PERIOD (D7F=01 OR D10F=01 BUT NONE OF THE FOLLOWING IS CODED AS 01 YES: D7B, D7C, D7D, D7E, D10B, D10C, D10D, D10E). IF R USED CONTRACEPTION 3 MONTHS BEFORE PREGNANCY OR DURING PREGNANCY (EITHER D5 OR D8 = 01 AND ONE OR MORE OF THE FOLLOWING IS CODED AS 01 YES: D7B, D7C, D7D, D7E, D10B, D10C, D10D, D10E), SKIP TO EITHER D11B OR D11C.
SKIP
TO D11B
IF R ONLY USED
CONTRACEPTION
DURING SECOND
TRIMESTER SKIP TO D11C IF R USED CONTRACEPTION DURING 3 MONTHS BEFORE PREGNANCY OR FIRST TRIMESTER (AT LEAST ONE OF THE FOLLOWING IS CODED AS 01 YES: D7B, D7C, D10B, D10C) |
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ASK D11A IF R: 1- DID NOT USE CONTRACEPTION 3 MONTHS BEFORE PREGNANCY OR DURING PREGNANCY OR 2-ONLY USED CONTRACEPTION DURING BREASTFEEDING IF R USED CONTRACEPTION 3 MONTHS BEFORE PREGNANCY OR DURING PREGNANCY SKIP TO D11B OR D11C ASK D11B IF R:
1-
ONLY USED CONTRACEPTION SECOND OR THIRD TRIMESTER ASK D11C IF R: 1-ONLY USED CONTRACEPTION 3 MONTHS BEFORE PREGNANCY OR FIRST TRIMESTER |
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D11A. |
Did you (READ ANSWERS)? |
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Stop using contraception to get pregnant with (CHILD) 01 Get pregnant with (CHILD) during an interruption in using contraception 02 Not use any contraception before this pregnancy 03 N/A (SKIP) 97 RF 98 DK 99 |
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SKIP TO D12. |
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D11B. |
Did you (READ ANSWERS)? |
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Stop using contraception to get pregnant with (CHILD) 01 Get pregnant with (CHILD) during an interruption in using contraception 02 N/A (SKIP) 97 RF 98 DK 99 |
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D11C. |
Did you (READ ANSWERS)? |
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Stop using contraception to get pregnant with (CHILD) 01 Get pregnant with (CHILD) during an interruption in using contraception 02 Get pregnant with (CHILD) while consistently using contraception 03 N/A (SKIP) 97 RF 98 DK 99 |
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MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
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D12. |
Before getting pregnant with (CHILD), was there ever a time you had regular intercourse for a period of 12 months or more without using contraception and did not become pregnant? In answering this question, consider a time with either (CHILD’s) father or another partner, if that applies. |
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YES 01 NO (SKIP TO D14) 02 RF (SKIP TO D14) 98 DK …………………….(SKIP TO D14) 99 |
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IF FATHER UNKNOWN (B12 = 01), SKIP TO D14. |
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D13. |
Was there ever a time you had regular intercourse for a period of 12 months or more with (CHILD)’s father without using contraception and did not become pregnant? |
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YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
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D14. |
Before getting pregnant with (CHILD), were you trying to get pregnant? |
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YES 01 NO (SKIP TO D16) 02 RF (SKIP TO D16) 98 DK (SKIP TO D16) 99 |
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D15. |
How long had you been trying to get pregnant? |
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MONTHS AND/OR
YEARS N/A (SKIP) 97 97 RF 98 98 DK 99 99 |
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D16. |
Prior to becoming pregnant with (CHILD), had you ever been told by a doctor or other health care provider that it would be impossible for you to get pregnant without medical help?
You should only answer yes, if pregnancy was truly IMPOSSIBLE because of ovary removal, hysterectomy, tubal sterilization, or some similar condition that made it impossible for you to conceive a pregnancy. I will ask you about other conditions that might have made it difficult for you to get pregnant in just a moment. |
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YES 01 NO (SKIP TO D18) 02 RF (SKIP TO D18) 98 DK (SKIP TO D18) 99 |
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D17. |
Why were you told that it would be impossible for you to get pregnant without medical help? Was it because (READ ANSWERS AND CODE ALL THAT APPLY)? |
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Both of your ovaries were missing or removed 01 Both of your fallopian tubes were missing or removed 02 You had a tubal sterilization. For example, you had your tubes tied or clamped 03 Some other reason (SPECIFY) 90 N/A (SKIP) 97 RF 98 DK 99 |
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SPECIFY:
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MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
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D18. |
Prior to becoming pregnant with (CHILD), had you ever been told by a doctor or other health care provider that it might be difficult for you to get pregnant without medical help?
Even if you already stated that you had a condition making it impossible to get pregnant, we are still interested in other conditions related to infertility that you might have also had at some time. |
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YES 01 NO (SKIP TO D21) 02 RF (SKIP TO D21) 98 DK (SKIP TO D21) 99 |
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D19. |
Were you ever told by a doctor or health care provider that you had (READ ANSWERS AND CODE ALL THAT APPLY)? |
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Blocked or damaged fallopian tubes or pelvic inflammatory disease 01 Polycystic ovary syndrome or multiple ovary cysts 02 Premature ovarian failure 03 Reduced ovarian production because of your age or medical cause 04 Endometriosis 05 A problem with your uterus, for example uterine fibroids, scar tissue, or abnormal uterine structure 06 Fertility problems because your mother took DES when she was pregnant with you 07 Antisperm antibodies (ASK D20) 08 Another condition that caused fertility problems (SPECIFY) 90 Unexplained infertility 96 N/A (SKIP) 97 RF 98 DK 99 |
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SPECIFY:
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IF FATHER UNKNOWN (B12 = 01), SKIP TO D23. |
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IF D19 NOT EQUAL TO 08, SKIP TO D21. |
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D20. |
Were the anti-sperm antibodies associated with (CHILD)’s father or a different partner? |
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(CHILD’S) FATHER 01 DIFFERENT PARTNER 02 N/A (SKIP) 97 RF 98 DK 99 |
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D21. |
Prior to you becoming pregnant with (CHILD), had (CHILD)’s father ever been told by a doctor or other health care provider that it might be difficult for him to father a child because of a low sperm count or other difficulties with his sperm? |
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YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
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D22. |
Prior to becoming pregnant with (CHILD), had (CHILD)’s father ever been told by a doctor or other health care provider that he had anti-sperm antibodies? |
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YES 01 NO 02 N/A (SKIP) 97 RF 98 |
MI SEED III Sect D Index Pregnancy 8/25/2016
Study
to Explore Early Development (SEED) Page
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DK 99 |
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
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ASSISTED REPRODUCTION
Now, I’m going to ask you some detailed questions about what type of help you (or [CHILD]’s father) may have received to help you get pregnant. Some of these questions pertain to any time before your pregnancy with (CHILD), others pertain to the time period just prior to your pregnancy with (CHILD) or during your early pregnancy with (CHILD). |
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IF FATHER UNKNOWN (B12 = 01), SKIP TO D27. |
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D23. |
Prior to becoming pregnant with (CHILD), did (CHILD)’s father take any medications to help you become pregnant with (him/her)? |
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YES 01 NO (SKIP TO D25) 02 N/A (SKIP) 97 RF (SKIP TO D25) 98 DK (SKIP TO D25) 99 |
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
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D24. |
ASK R TO REFER TO LIST 4a IN PREP GUIDE. What medications did he take? READ BOLDED WORDS AND INDIVIDUAL MEDICATIONS IF NEEDED. CODE ALL THAT APPLY. |
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Antibiotics 01 Anti-estrogen medications Clomid 02 Clomiphene citrate 03 Milophene 04 Serophene 05 Tamoxifen 06 Hormonal injections Bravelle 07 Chorionic Gonadotrophin hCG 08 Fertinex 09 Follistim 10 Follitrophin Alpha 11 Follitrophin Beta 12 FSH 13 Gonal F 14 HCG 15 Humegon 16 Menotrophins: Follicle Stimulating Hormone + Luteinizing Hormone or Interstitial Cell Stimulating Hormone 17 Metrodin 18 Novarel 19 Ovidrel 20 Pergonal 21 |
Pregnyl 22 Profasi 23 Repronex 24 Urofollitrophin 25 Other male infertility medication Cabergoline 26 Danazol 27 Donocrine 28 Dostinex 29 Factrel 30 Gonadorelin 31 Leuprolide 32 Lupron 33 Lutrepulse 34 Synarel 35 Nafarelin 36 Medicine to reduce prolactine Bromocriptine 37 Parlodel 38 Steroid medications 39 Testosterone pill, injections or transdermal gel or patch 40 Other (SPECIFY) 90 N/A (SKIP) 97 RF 98 DK 99 |
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SPECIFY
MEDICINE 1: |
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SPECIFY
MEDICINE 2: |
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SPECIFY
MEDICINE 3: |
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D25. |
Prior to becoming pregnant with (CHILD), did (CHILD)’s father ever have any procedures or surgeries to help you become pregnant? |
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YES 01 NO (SKIP TO D27) 02 N/A (SKIP) 97 RF (SKIP TO D27) 98 DK (SKIP TO D27) 99 |
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D26. |
What was the procedure? READ LIST IF NEEDED. Are there any more procedures? CODE ALL THAT APPLY. |
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Vasectomy reversal 01 Surgery because of varicocele 02 Other (SPECIFY) 90 N/A (SKIP) 97 RF 98 DK 99 |
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SPECIFY: |
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SPECIFY: |
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MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
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D27. |
Prior to becoming pregnant with (CHILD), did you ever have any surgical procedures to help you become pregnant such as: to open or rejoin your fallopian tubes, to treat fibroids, or to remove endometriosis? |
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YES 01 NO (SKIP TO D29) 02 RF (SKIP TO D29) 98 DK (SKIP TO D29) 99 |
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D28. |
What was the procedure? Were there any more procedures? CODE ALL THAT APPLY. |
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OPEN FALLOPIAN TUBES 01 REJOIN FALLOPIAN TUBES 02 TREATMENT OF UTERINE FIBROIDS 03 REMOVAL OF ENDOMETRIOSIS 04 OTHER (SPECIFY) 90 N/A (SKIP) 97 RF 98 DK 99 |
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SPECIFY: |
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d29. |
Did you take any medications to help prevent miscarriage with your pregnancy with (CHILD)? |
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YES 01 NO (SKIP TO D31) 02 RF (SKIP TO D31) 98 DK (SKIP TO D31) 99 |
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D30. |
ASK R TO REFER TO LIST 4b IN THE PREP GUIDE. What medications did you take? READ LIST AND CODE ALL THAT APPLY. |
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Baby aspirin 01 Crinone vaginal gel 02 Gamma Globulin 03 Heparin 04 IVIg Therapy or Immunotherapy 05 Progesterone 06 Progesterone injection or implant 07 Prometrium or other progesterone capsules 08 Steroid treatment (SPECIFY) 09 Vaginal progesterone suppositories 10 Other (SPECIFY) 90 N/A (SKIP) 97 RF 98 DK 99 |
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SPECIFY: |
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SPECIFY: |
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D31. |
Within the two months prior to becoming pregnant with (CHILD),or just after you became pregnant, did you take any medications to help you become pregnant or to maintain the pregnancy in the early stages? Include medications that you took alone as well as medications that you took as part of a broader infertility treatment such as artificial insemination or assisted reproductive technology. |
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YES 01 NO (SKIP TO D33) 02 RF (SKIP TO D33) 98 DK (SKIP TO D33) 99 |
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
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D32. |
ASK R TO REFER TO LIST 4c IN PREP GUIDE. What medications did you take during those two months? READ BOLDED WORDS AND INDIVIDUAL MEDICATIONS IF NEEDED. CODE ALL THAT APPLY. |
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Injections or pills to stimulate your ovaries to produce eggs Bravelle 01 Clomid 02 Clomiphene citrate 03 Fertinex 04 Follistim 05 Follitrophin Alpha 06 Follitrophin Beta 07 FSH 08 Gonal F 09 Humegon 10 Menotrophins: Follicle Stimulating Hormone + Luteinizing Hormone or Interstitial Cell Stimulating Hormone 11 Metrodin 12 Milophene 13 Pergonal 14 Repronex 15 Serophene 16 Urofollitrophin 17
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Progesterone medication to prepare the uterine lining for pregnancy or help prevent an early pregnancy loss Crinone vaginal gel 18 Cyclogest cream 19 Microgest 20 Progesterone implant 21 Progesterone injection 22 Progesterone vaginal suppositories 23 Prometerium 24 Utrogestan 25 Injection to trigger ovulation once your ovaries had produced eggs Chorionic Gonadotrophin hCG 26 HCG 27 Novarel 28 Ovidrel 29 Pregnyl 30 Profasi 31 Medication to suppress your body’s natural hormone production, injection or nasal spray Abarelix 32 Antagon 33 Buserelin 34 Cetrotide 35 Deslorelin 36 Eligard 37 |
Ganirelix 38 Goserelin 39 Historelin 40 Leuprolide 41 Lupron 42 Nafarelin 43 Suprefact 44 Suprecor 45 Synarel 46 Tryptorelin 47 Zoladex 48 Other medications Bromocriptine 49 Cabaser 50 Cabergoline 51 Danazol 52 Danocrine 53 Dostinex 54 Estradiol patches 55 Estrace pills 56 Factrel 57 Gonadorelin 58 Lutrepulse 59 Parlodel 60 Other (SPECIFY) 90 N/A (SKIP) 97 RF 98 DK 99 |
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SPECIFY
MEDICINE 1: |
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SPECIFY
MEDICINE 2: |
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SPECIFY
MEDICINE 3: |
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D33. |
In the month you became pregnant with (CHILD), did you have any procedures such as artificial insemination or assisted reproductive technology to help you become pregnant with (CHILD)? |
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YES 01 NO (SKIP TO D37) 02 RF (SKIP TO D37) 98 DK (SKIP TO D37) 99 |
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MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
D34. |
ASK R TO REFER TO LIST 5 IN PREP GUIDE. I’m going to read you a list of procedures. Please tell me if you received any of these to help you get pregnant with (CHILD). READ ANSWERS AND CODE ALL THAT APPLY. (PROBE: Remember, these procedures would have been in the month you became pregnant.) |
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Artificial insemination or intrauterine insemination 01 In vitro fertilization (IVF) with vaginal embryo transfer 02 Intracytoplasmic sperm injection (ICSI) 03 Gamete intrafallopian transfer (GIFT)…………………….04 Zygote intrafallopian transfer (ZIFT), or tubal embryo transfer (TET), or pronuclear stage transfer (PROST) 05 Other fertility procedure….......(SPECIFY) 06 N/A (SKIP) 97 RF (SKIP TO D37) 98 DK (SKIP TO D37) 99 |
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SPECIFY: |
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COMPLETE ONE ROW (D35–D36) FOR EACH ANSWER IN D34. IF RESPONSE TO D34=01 ARTIFICIAL INSEMINATION AND NO OTHER RESPONSE WAS CHOSEN, ASK R ABOUT DONOR SPERM AND FROZEN SPERM AND MARK ALL OF THE FOLLOWING AS 97 NA: DONOR EGGS, DONOR EMBRYOS, FROZEN EMBRYOS. |
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D35. |
D36. |
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For (PROCEDURE), were (READ CHOICES) used? |
Were (READ CHOICES) used? |
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PROCEDURE #1: |
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YES |
NO |
NA |
RF |
DK |
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YES |
NO |
NA |
RF |
DK |
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Donor Eggs |
01 |
02 |
97 |
98 |
99 |
Frozen sperm |
01 |
02 |
97 |
98 |
99 |
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Donor sperm |
01 |
02 |
97 |
98 |
99 |
Frozen embryos |
01 |
02 |
97 |
98 |
99 |
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Donor embryos |
01 |
02 |
97 |
98 |
99 |
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PROCEDURE #2: |
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YES |
NO |
NA |
RF |
DK |
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YES |
NO |
NA |
RF |
DK |
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Donor Eggs |
01 |
02 |
97 |
98 |
99 |
Frozen sperm |
01 |
02 |
97 |
98 |
99 |
Donor sperm |
01 |
02 |
97 |
98 |
99 |
Frozen embryos |
01 |
02 |
97 |
98 |
99 |
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Donor embryos |
01 |
02 |
97 |
98 |
99 |
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PROCEDURE #3: |
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YES |
NO |
NA |
RF |
DK |
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YES |
NO |
NA |
RF |
DK |
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Donor Eggs |
01 |
02 |
97 |
98 |
99 |
Frozen sperm |
01 |
02 |
97 |
98 |
99 |
Donor sperm |
01 |
02 |
97 |
98 |
99 |
Frozen embryos |
01 |
02 |
97 |
98 |
99 |
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Donor embryos |
01 |
02 |
97 |
98 |
99 |
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# OF
ASSISTED REPRODUCTION PROCEDURE SUPPLEMENTS 
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
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MORNING SICKNESS |
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Now I have some more detailed questions about your pregnancy with (CHILD). Please have the Pregnancy Reference Form handy.
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D37.
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During the pregnancy with (CHILD), did you have any nausea? |
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YES 01 NO (SKIP TO D40) 02 RF (SKIP TO D40) 98 DK (SKIP TO D40) 99
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D38A was deleted |
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D38B. |
D38C. |
D38D. |
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Would you say the nausea occurred in the first trimester, from (1) to (3)? |
Would you say the nausea occurred in the second trimester, from (4) to (6)? |
Would you say the nausea occurred in the third trimester, from (7) to (10)? |
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YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
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01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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COMPLETE ONE ROW FOR EACH TRIMESTER INDICATED. |
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d39. |
How often during (TRIMESTER) did you have nausea? Would you say it was (READ ANSWERS)? |
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TRIMESTER |
Less than once a week |
Once a week |
A few times a week |
Every day |
N/A (SKIP) |
RF |
DK |
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1.________________________________ |
01 |
02 |
03 |
04 |
97 |
98 |
99 |
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2. ________________________________ |
01 |
02 |
03 |
04 |
97 |
98 |
99 |
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3. ________________________________ |
01 |
02 |
03 |
04 |
97 |
98 |
99 |
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
D40. |
During the pregnancy with (CHILD), did you have any vomiting? |
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YES 01 NO (SKIP TO D43) 02 RF (SKIP TO D43) 98 DK (SKIP TO D43) 99 |
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D41A was deleted |
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D41B. |
D41C. |
D41D. |
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Would you say the vomiting occurred in the first trimester, from (1) to (3)? |
Would you say the vomiting occurred in the second trimester, from (4) to (6)? |
Would you say the vomiting occurred in the third trimester, from (7) to (10)? |
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YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
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01 |
02 |
97 |
98 |
99
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01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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COMPLETE ONE ROW FOR EACH TRIMESTER INDICATED. |
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d42. |
How often during (TRIMESTER) did you have vomiting? Would you say it was (READ ANSWERS)? |
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TRIMESTER |
Less than once a week |
Once a week |
A few times a week |
Every day |
N/A (SKIP) |
RF |
DK |
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1.________________________________ |
01 |
02 |
03 |
04 |
97 |
98 |
99 |
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2. ________________________________ |
01 |
02 |
03 |
04 |
97 |
98 |
99 |
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3. ________________________________ |
01 |
02 |
03 |
04 |
97 |
98 |
99 |
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IF NO NAUSEA OR VOMITING (BOTH D37 AND D40 = 02, 98, OR 99), SKIP TO D45. |
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d43. |
Did you ever require medical treatment for the nausea or vomiting? |
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YES 01 NO (SKIP TO D45) 02 N/A (SKIP) 97 RF (SKIP TO D45) 98 DK (SKIP TO D45) 99 |
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
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D44. |
What medicine did you take? Was it (READ ANSWERS AND CODE ALL THAT APPLY)? |
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Vitamin B6 or pyridoxine 01 Unisom or doxylamine 02 Emetrol 03 Ginger 04 Other (SPECIFY) 90 NONE 00 N/A (SKIP) 97 RF 98 DK 99 |
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SPECIFY: |
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SPECIFY: |
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D44A. |
Did you require any other medical treatments for the nausea such as Sea Bands or bed rest? |
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YES (SPECIFY) 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
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SPECIFY: |
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PRENATAL CARE |
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D45. |
Between (-3) and (DOIB/END BF), did you take any prenatal vitamins? A prenatal vitamin is a special vitamin supplement sometimes taken by pregnant women or women trying to get pregnant. |
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YES 01 NO 02 RF 98 DK 99 |
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D46. |
Between (-3) and (DOIB/END BF), did you take any other vitamins or minerals? |
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YES 01 NO (SKIP TO D48) 02 RF (SKIP TO D48) 98 DK (SKIP TO D48) 99 |
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D47. |
Did you take (READ ANSWERS AND CODE ALL THAT APPLY)? |
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Multivitamins 01 Vitamin A 02 Folic Acid 03 Iron 04 Other (SPECIFY) 90 N/A (SKIP) 97 RF 98 DK 99 |
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SPECIFY: |
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SPECIFY: |
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D48. |
During your pregnancy with (CHILD), how many ultrasounds did you have? |
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NONE (SKIP TO D52) 00 #
OF ULTRASOUNDS RF (SKIP TO D52) 98 DK 99 |
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MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
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D49. |
Did you have any ultrasounds which showed any problems or confirmed abnormalities with the fetus, placenta, amniotic fluid, or any other problems? |
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YES 01 NO (SKIP TO D52) 02 N/A (SKIP) 97 RF (SKIP TO D52) 98 DK (SKIP TO D52) 99 |
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D50. |
Was the problem or abnormality with (READ ANSWERS AND CODE ALL THAT APPLY)? |
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Fetal growth (SPECIFY) 01 Placenta (SPECIFY) 02 Biophysical profile or BPP (SPECIFY) 03 Decreased fetal movement (SPECIFY) 04 Amniotic fluid volume (SPECIFY) 05 A fetal malformation or defect (SPECIFY) 06 Other (SPECIFY) 90 N/A (SKIP) 97 RF 98 DK 99 |
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SPECIFY: |
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SPECIFY: |
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SPECIFY: |
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D51A was deleted. |
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D51B. |
D51C. |
D51D. |
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Would you say the first ultrasound that showed an abnormality occurred in the first trimester, from (1) to (3)? |
Would you say the first ultrasound that showed an abnormality occurred in the second trimester, from (4) to (6)? |
Would you say the first ultrasound that showed an abnormality occurred in the third trimester, from (7) to (10)? |
|
|
|||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|||||
|
|
|
|
|
|
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MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
BLOOD TESTS |
|
|
|
||||||||||||||
D52. |
D53. |
D54. |
|
||||||||||||||
I am now going to ask about blood tests. When you were pregnant with (CHILD), did you have (READ LIST)? |
Were the results of the test normal or abnormal? |
Were the results high or low? |
|||||||||||||||
|
YES |
NO |
RF |
DK |
N |
AB |
NA |
RF |
DK |
H |
L |
NA |
RF |
DK |
|
||
|
(ASK D53) |
|
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|
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|
|
||
MSAFP or maternal serum alpha fetoprotein |
01 |
02 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
||
|
|
|
|
|
|
(ASK D54) |
|
|
|
|
|
|
|
|
|
||
Double screen |
01 |
02 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
|
||
Triple screen |
01 |
02 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
|
||
Quad screen |
01 |
02 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
|
||
AFP TEST, UNKNOWN VERSION |
01 |
02 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
|
||
D55. |
D56. |
D57. |
||||||||
Did you have an Amniocentesis or amnio? |
Were the results of the test normal or abnormal? |
What was the abnormality? SPECIFY. |
||||||||
|
YES |
NO |
RF |
DK |
N |
AB |
NA |
RF |
DK |
|
|
(ASK D56) |
|
|
|
|
(ASK D57) |
|
|
|
|
Amnio |
01 |
02 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
N/A (SKIP) 97 RF 98 DK 99 |
|
|
|
|
|
NOT ENOUGH FLUID 03 |
|
||||
D58. |
D59. |
D60. |
||||||||
Did you have a Chorionic Villus Sampling or CVS? |
Did the test show any abnormalities? |
What was the abnormality? SPECIFY. |
||||||||
|
YES |
NO |
RF |
DK |
YES |
NO |
NA |
RF |
DK |
|
|
(ASK D59) |
|
|
|
(ASK D60) |
|
|
|
|
|
CVS |
01 |
02 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
N/A (SKIP) 97 RF 98 DK 99 |
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
PAGE INTENTIONALLY LEFT BLANK.
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
D61. |
Did you have any other prenatal diagnostic test? What was the test? (PROBE: Fetal echocardiography or fetal dye studies?) Any other tests? |
|
YES (SPECIFY IN GRID) 01 NO (SKIP TO D64) 02 RF (SKIP TO D64) 98 DK (SKIP TO D64) 99 |
|||||||||||
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|||||||||||
D62A was deleted. |
D62B. |
D62C. |
|
|||||||||||
COMPLETE ONE ROW (D62–D63) FOR EACH TEST NAMED. |
Would you say you had (TEST) done in your first trimester, from (1) to (3)? |
|
|
|||||||||||
TEST: |
|
|||||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#1:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#2:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#3:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
D62. |
Did you have any other prenatal diagnostic test? PROBE: Fetal echocardiography or fetal dye studies? PROBE: Any other tests? |
|
YES (SPECIFY IN GRID) 01 NO (SKIP TO D65) 02 RF (SKI PTO D65) 98 DK (SKIP TO D65) 99 |
||||||
|
|
|
|
||||||
D62D. |
D63. |
|
|||||||
Would you say you had (TEST) done in your third trimester, from (7) to (10)? |
Why was (TEST) done? SPECIFY.
N/A (SKIP) 97 RF 98 DK 99 |
|
|||||||
YES |
NO |
N/A |
RF |
DK |
|
||||
01
|
02 |
97 |
98 |
99 |
|
||||
|
|
|
|||||||
YES |
NO |
N/A |
RF |
DK |
N/A (SKIP) 97 RF 98 DK 99 |
|
|||
01
|
02 |
97 |
98 |
99 |
|
||||
|
|
|
|||||||
YES |
NO |
N/A |
RF |
DK |
N/A (SKIP) 97 RF 98 DK 99 |
|
|||
01
|
02 |
97 |
98 |
99 |
|
||||
|
|
|
|||||||
# OF
PRENATAL TEST SUPPLEMENTS
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
D64. |
Did you or (CHILD) have any other prenatal medical procedures such as blood transfusions or fetal surgery? What was the procedure? Did you have any other procedures? |
|
YES (SPECIFY IN GRID) 01 NO (SKIP TO D67) 02 RF (SKIP TO D67) 98 DK (SKIP TO D67) 99 |
|||||||||||
|
|
|
|
|||||||||||
D65A was deleted. |
D65B. |
D65C. |
|
|||||||||||
COMPLETE ONE ROW (D65–D66) FOR EACH PROCEDURE NAMED. |
Would you say you had (PROCEDURE) done in your first trimester, from (1) to (3)? |
Would you say you had (PROCEDURE) done in your second trimester, from (4) to (6)? |
|
|||||||||||
PROCEDURE: |
|
|||||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#1:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#2:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#3:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
D62. |
Did you have any other prenatal diagnostic test? PROBE: Fetal echocardiography or fetal dye studies? PROBE: Any other tests? |
|
YES (SPECIFY IN GRID) 01 NO (SKIP TO D65) 02 RF (SKI PTO D65) 98 DK (SKIP TO D65) 99 |
||||||
|
|
|
|
||||||
D65D. |
D66. |
|
|||||||
Would you say you had (PROCEDURE) done in your third trimester, from (7) to (10)? |
Why was (PROCEDURE) done? SPECIFY.
N/A (SKIP) 97 RF 98 DK 99 |
|
|||||||
YES |
NO |
N/A |
RF |
DK |
|
||||
01
|
02 |
97 |
98 |
99 |
|
||||
|
|
|
|||||||
YES |
NO |
N/A |
RF |
DK |
N/A (SKIP) 97 RF 98 DK 99 |
|
|||
01
|
02 |
97 |
98 |
99 |
|
||||
|
|
|
|||||||
YES |
NO |
N/A |
RF |
DK |
N/A (SKIP) 97 RF 98 DK 99 |
|
|||
01
|
02 |
97 |
98 |
99 |
|
||||
|
|
|
|||||||
# OF
PRENATAL MEDICAL PROCEDURE SUPPLEMENTS
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
D67. |
Were you told that there was “Rhesus” or “Rh” incompatibility between you and (CHILD)? |
|
YES 01 NO (SKIP TO D70) 02 RF (SKIP TO D70) 98 DK (SKIP TO D70) 99 |
|
|
|
|
D68. |
If your blood type was RH negative when you were pregnant with (CHILD), you might have been given injections of Rhogam. Did you receive any Rhogam injections while you were pregnant or soon after you gave birth? |
|
YES, WHILE PREGNANT 01 YES, SOON AFTER GIVING BIRTH 02 YES, BOTH TIMES 03 NO 04 N/A (SKIP) 97 RF 98 DK 99 |
|
|
|
|
D69A. |
Were there any problems with (CHILD) because of the rhesus incompatibility? |
|
YES 01 NO (SKIP TO D70) 02 N/A (SKIP) 97 RF (SKIP TO D70) 98 DK (SKIP TO D70) 99 |
|
|
|
|
D69B. |
What were the problems? SPECIFY. |
|
PROBLEMS:
N/A (SKIP) 97 RF 98 DK 99 |
|
|
|
|
|
IF ONLY ONE PREGNANCY (C3 = 1), SKIP TO D71. |
|
|
|
|
|
|
D70. |
Did you receive Rhogam injections for any pregnancy other than your pregnancy with (CHILD)? |
|
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
|
|
|
|
|
VAGINAL DOUCHING |
|
|
D71. |
Did you ever douche between (-3) and (DOIB/END BF)? |
|
YES 01 NO (SKIP TO E1) 02 RF (SKIP TO E1) 98 DK (SKIP TO E1) 99 |
|
|
|
|
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
D72A was deleted. |
D72B. |
D72C. |
|
||||||||||||
|
Did you douche in the three months before you became pregnant, from (-3) to (-1)? |
Did you douche in your first trimester, from (1) to (3)? |
|
||||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
||||
|
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
|
||||
|
|
|
|
||||||||||||
|
|
IF R DID NOT BREASTFEED, SKIP TO D73. |
|||||||||||||
|
|
|
|
||||||||||||
D72D. |
D72E. |
D72F. |
|
||||||||||||
Did you douche in your second trimester, from (4) to (6)? |
Did you douche in your third trimester, from (7) to (10)? |
Did you douche during the months you breastfed, from (DOIB/10) to (END BF)? |
|
||||||||||||
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
||||||||||||
COMPLETE ONE ROW FOR EACH TRIMESTER INDICATED. |
|
|
|
|
|
|
|
|||||
|
|
|
|
|
||||||||
d73. |
How often during (TRIMESTER) did you douche? Would you say it was (READ ANSWERS)? |
|
||||||||||
|
TRIMESTER |
More than once a week |
Once a week |
Once every 2-3 weeks |
Once a month or less |
N/A (SKIP) |
RF |
DK |
||||
|
1. |
01 |
02 |
03 |
04 |
97 |
98 |
99 |
||||
|
2. |
01 |
02 |
03 |
04 |
97 |
98 |
99 |
||||
|
3. |
01 |
02 |
03 |
04 |
97 |
98 |
99 |
||||
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
D-
BLANK PAGE FOR END OF SECTION
MI SEED III Sect D Index Pregnancy 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
SECTION E: MATERNAL MEDICAL CONDITIONS, SURGERIES, PROCEDURES, AND MEDICATION USE |
|
||||||||
Now, I am going to ask you about some illnesses, surgeries and other procedures that you might have had during your pregnancy with (CHILD). I’m going to ask you about the time period from three months before you became pregnant with (CHILD) until ([his/her] delivery/you stopped breastfeeding completely). |
|
||||||||
|
|
|
|
|
|||||
REPRODUCTIVE AND MAJOR PERINATAL INFECTIONS AND CONDITIONS |
|
||||||||
I am going to start off by asking you about some infections or conditions that you might have had during the time period from three months before you became pregnant with (CHILD) until ([his/her] delivery/you stopped breastfeeding completely). Please refer to list 6 in your preparatory guide and follow along. |
|
||||||||
|
|
|
|
|
|||||
E1. |
Between (-3) and (DOIB/END BF) did you have any of the following illnesses? READ LIST AND CODE ALL THAT APPLY. |
|
|||||||
|
|
|
|
|
|||||
Bacterial Vaginosis 01 Candidiasis or Yeast Infection 02 Chicken Pox 03 Chlamydia 04 Cystitis NOS 05 Cytomegalovirus 06 Encephalitis 07 Endocarditis 08 Endometriosis 09 Fibroids 10 Genital Herpes 11 Group B Streptococcal infection 12 |
Hepatitis (PROBE): HEPATITIS A 13 HEPATITIS B 14 HEPATITIS C 15 HEPATITIS NOS 16 HIV/AIDS 17 Human Papilloma Virus or HPV or Genital warts or venereal warts 18 Influenza or flu 19 Meningitis 20 Mononucleosis or mono 21 Myocarditis 22
|
Parvovirus or Fifth disease 23 Pelvic Inflammatory Disease or PID 24 Pneumonia 25 Pyelonephritis or kidney infection 26 Rubella or German measles 27 Septicemia or blood infection 28 Shingles 29 Staphylococcal infection or cysts 30 Syphilis 31
|
Toxoplasmosis 32 Trichomoniasis or trich 33 Upper respiratory infection 34 Urinary tract infection 35 Vaginitis NOS 36
Other
conditions RF 98 DK 99 NO CONDITIONS 00 |
||||||
|
|
|
|
|
|||||
|
SPECIFY:
|
|
|||||||
|
SPECIFY:
|
|
|||||||
|
SPECIFY:
|
|
|||||||
|
|
|
|
|
|||||
|
IF E1 = 00, 98 OR 99, SKIP TO E8. |
|
|
|
|||||
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
COMPLETE E2–E7 FOR EACH CONDITION IN E1. |
|
|
|||||||||||||||||||||||||||
IF E1 = 11 (HERPES) OR 18 (VENEREAL WARTS), ASK E2 ABOUT OUTBREAKS. CODE E2B N/A IF NO OUTBREAKS AND SKIP TO E3. |
|
||||||||||||||||||||||||||||
E2A was deleted. |
E2B. |
|
|
|
|||||||||||||||||||||||||
CONDITION 1: |
Would you say (CONDITION) occurred in the 3 months before you became pregnant, from (-3) to (-1)? |
Would you say (CONDITION) occurred in your first trimester, from (1) to (3)? |
|
|
|||||||||||||||||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||||||||||||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
||||||||||||||||||
|
|
|
|
||||||||||||||||||||||||||
|
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|||||||||||||||||
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||||||||||||||||||||||||||
E3. |
Did you take any medicine for (CONDITION) between (-3) and (DOIB/END BF)? (IF YES: ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine did you take? The medications in the list have been organized as best as possible by condition so please look for the heading and find your medication under that. If you do not see your medication, please look under the “other medications” category. If your medication is not listed at all, we still want you to tell us about it. Medications can be in pill form, nasal spray, patches, creams, injections, shots, etc. Any others?) |
||||||||||||||||||||||||||||
E4A was deleted. |
E4B. |
|
|
|
|
|
|||||||||||||||||||||||
MEDICINE: |
Would you say you took (MED) in the three months before you became pregnant, from (-3) to (-1)? |
Would you say you took (MEDICINE) in your first trimester, from (1) to (3)? |
|
|
|||||||||||||||||||||||||
#1:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||||||||||||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
||||||||||||||||||
|
|
|
|
||||||||||||||||||||||||||
|
|
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|
|
|
|
|
|
|
|
|
|
|||||||||||||||||
|
|
|
|
|
|
||||||||||||||||||||||||
#2:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||||||||||||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
||||||||||||||||||
|
|
|
|
||||||||||||||||||||||||||
|
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||||||||||||||||||||||||||
E5. |
Did
you have a fever from (CONDITION)
between |
|
YES 01 NO (SKIP TO NEXT CONDITION/E8) 02 N/A (SKIP) 97 RF (SKIP TO NEXT CONDITION/E8) 98 DK (SKIP TO NEXT CONDITION/E8) 99 |
||||||||||||||||||||||||||
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|
|
|
||||||||||||||||||||||||||
|
E6B. |
E6C. |
|
|
|||||||||||||||||||||||||
|
Would you say the fever occurred in the 3 months before you became pregnant, from (-3) to (-1)? |
Would you say the fever occurred in your first trimester, from (1) to (3)? |
|
|
|||||||||||||||||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||||||||||||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
||||||||||||||||||
|
|
|
|
||||||||||||||||||||||||||
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|||||||||||||
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
IF
R DID NOT BREASTFEED, SKIP TO E3. |
E2E. |
E2F. |
|
|
|
|
|
|||||||||||||||
Would you say (CONDITION) occurred in your second trimester, from (4) to (6)? |
Would you say (CONDITION) occurred in your third trimester, from (7) to (10)? |
Would you say (CONDITION) occurred during the months you breastfed, from (DOIB/10) to (END BF)? |
|
|
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|
|
|
|||
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
|||
|
IF DK, ASK B-F. |
|
|
|
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|||||||||||||||||||
YES (SPECIFY IN GRID) 01 NO (SKIP TO E5) 02
IF
R DID NOT BREASTFEED, RF (SKIP TO E5) 98 DK (SKIP TO E5) 99
|
|
|
||||||||||||||||||||
E4D. |
E4E. |
E4F. |
|
|
|
|
|
|||||||||||||||
Would you say you took (MEDICINE) in your second trimester, from (4) to (6)? |
Would you say you took (MEDICINE) in your third trimester, from (7) to (10)? |
Would you say you took (MEDICINE) during the months you breastfed, from (DOIB/10) to (END BF)?
|
|
|
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
|||
|
|
|
|
|||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
|||
#
OF PERINATAL CONDITION 1 MEDICINE SUPPLEMENTS 
IF
R DID NOT BREASTFEED,
SKIP TO E7.
E6D. |
E6E. |
E6F. |
E7. |
||||||||||||
Would you say the fever occurred in your second trimester, from (4) to (6)? |
Would you say the fever occurred in your third trimester, from (7) to (10)? |
Would you say the fever occurred during the months you breastfed, from (DOIB/10) to (END BF)? |
C F |
||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
TEMP |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
NA (SKIP) 997 RF 998 DK 999
|
.
C
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
|
E2B. |
E2C. |
|
|||||||||||||||||||||||
CONDITION 2: |
Would you say (CONDITION) occurred in the 3 months before you became pregnant, from (-3) to (-1)? |
Would you say (CONDITION) occurred in your first trimester, from (1) to (3)? |
|
|||||||||||||||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||||||||||||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
||||||||||||||||
|
|
|
||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||||
|
|
|
|
|||||||||||||||||||||||
E3. |
Did you take any medicine for (CONDITION) between (-3) and (DOIB/END BF)? (IF YES: ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine did you take? The medications in the list have been organized as best as possible by condition so please look for the heading and find your medication under that. If you do not see your medication, please look under the “other medications” category. If your medication is not listed at all, we still want you to tell us about it. Medications can be in pill form, nasal spray, patches, creams, injections, shots, etc. Any others?) |
|||||||||||||||||||||||||
|
E4B. |
|
|
|
||||||||||||||||||||||
MEDICINE: |
Would you say you took (MED) in the three months before you became pregnant, from (-3) to (-1)? |
Would you say you took (MEDICINE) in your first trimester, from (1) to (3)? |
|
|||||||||||||||||||||||
#1:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||||||||||||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
||||||||||||||||
|
|
|
||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||||
|
|
|
|
|||||||||||||||||||||||
#2:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||||||||||||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
||||||||||||||||
|
|
|
||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||||
|
|
|
|
|||||||||||||||||||||||
E5. |
Did
you have a fever from (CONDITION)
between |
|
YES 01 NO (SKIP TO NEXT CONDITION/E8) 02 N/A (SKIP) 97 RF (SKIP TO NEXT CONDITION/E8) 98 DK (SKIP TO NEXT CONDITION/E8) 99 |
|||||||||||||||||||||||
|
|
|
|
|||||||||||||||||||||||
|
E6B. |
E6C. |
|
|||||||||||||||||||||||
|
Would you say the fever occurred in the 3 months before you became pregnant, from (-3) to (-1)? |
Would you say the fever occurred in your first trimester, from (1) to (3)? |
|
|||||||||||||||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||||||||||||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
||||||||||||||||
|
|
|
||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
IF
R DID NOT BREASTFEED, SKIP TO E3. |
E2E. |
E2F. |
|
|
|
|
|
|||||||||||||||
Would you say (CONDITION) occurred in your second trimester, from (4) to (6)? |
Would you say (CONDITION) occurred in your third trimester, from (7) to (10)? |
Would you say (CONDITION) occurred during the months you breastfed, from (DOIB/10) to (END BF)? |
|
|
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|
|
|
|||
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
|||
|
IF DK, ASK B-F. |
|
|
|
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|||||||||||||||||||
YES (SPECIFY IN GRID) 01 NO (SKIP TO E5) 02
IF
R DID NOT BREASTFEED, RF (SKIP TO E5) 98 DK (SKIP TO E5) 99
|
|
|
||||||||||||||||||||
E4D. |
E4E. |
E4F. |
|
|
|
|
|
|||||||||||||||
Would you say you took (MEDICINE) in your second trimester, from (4) to (6)? |
Would you say you took (MEDICINE) in your third trimester, from (7) to (10)? |
Would you say you took (MEDICINE) during the months you breastfed, from (DOIB/10) to (END BF)?
|
|
|
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
|||
|
|
|
|
|||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
|||
#
OF PERINATAL CONDITION 2 MEDICINE SUPPLEMENTS
IF
R DID NOT BREASTFEED,
SKIP TO E7.
E6D. |
E6E. |
E6F. |
E7. |
||||||||||||
Would you say the fever occurred in your second trimester, from (4) to (6)? |
Would you say the fever occurred in your third trimester, from (7) to (10)? |
Would you say the fever occurred during the months you breastfed, from (DOIB/10) to (END BF)? |
C F |
||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
TEMP |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
NA (SKIP) 997 RF 998 DK 999
|
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
|
E2B. |
E2C. |
|
|
||||||||||||||||||||||
CONDITION 3: |
Would you say (CONDITION) occurred in the 3 months before you became pregnant, from (-3) to (-1)? |
Would you say (CONDITION) occurred in your first trimester, from (1) to (3)? |
|
|
||||||||||||||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
||||||||||||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|||||||||||||||
|
|
|
|
|||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||
|
|
|
|
|||||||||||||||||||||||
E3. |
Did you take any medicine for (CONDITION) between (-3) and (DOIB/END BF)? (IF YES: ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine did you take? The medications in the list have been organized as best as possible by condition so please look for the heading and find your medication under that. If you do not see your medication, please look under the “other medications” category. If your medication is not listed at all, we still want you to tell us about it. Medications can be in pill form, nasal spray, patches, creams, injections, shots, etc. Any others?) |
|||||||||||||||||||||||||
|
E4B. |
|
|
|||||||||||||||||||||||
MEDICINE: |
Would you say you took (MED) in the three months before you became pregnant, from (-3) to (-1)? |
Would you say you took (MEDICINE) in your first trimester, from (1) to (3)? |
|
|
||||||||||||||||||||||
#1:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
||||||||||||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|||||||||||||||
|
|
|
|
|||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||
|
|
|
|
|||||||||||||||||||||||
#2:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
||||||||||||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|||||||||||||||
|
|
|
|
|||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||
|
|
|
|
|||||||||||||||||||||||
E5. |
Did
you have a fever from (CONDITION)
between |
|
YES 01 NO (SKIP TO NEXT CONDITION/E8) 02 N/A (SKIP) 97 RF (SKIP TO NEXT CONDITION/E8) 98 DK (SKIP TO NEXT CONDITION/E8) 99 |
|||||||||||||||||||||||
|
|
|
|
|||||||||||||||||||||||
|
E6B. |
E6C. |
|
|
||||||||||||||||||||||
|
Would you say the fever occurred in the 3 months before you became pregnant, from (-3) to (-1)? |
Would you say the fever occurred in your first trimester, from (1) to (3)? |
|
|
||||||||||||||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
||||||||||||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|||||||||||||||
|
|
|
|
|||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
IF
R DID NOT BREASTFEED, SKIP TO E3. |
E2E. |
E2F. |
|
|
|
|
|
|||||||||||||||
Would you say (CONDITION) occurred in your second trimester, from (4) to (6)? |
Would you say (CONDITION) occurred in your third trimester, from (7) to (10)? |
Would you say (CONDITION) occurred during the months you breastfed, from (DOIB/10) to (END BF)? |
|
|
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|
|
|
|||
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
|||
|
IF DK, ASK B-F. |
|
|
|
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|||||||||||||||||||
YES (SPECIFY IN GRID) 01 NO (SKIP TO E5) 02
IF
R DID NOT BREASTFEED, RF (SKIP TO E5) 98 DK (SKIP TO E5) 99
|
|
|
||||||||||||||||||||
E4D. |
E4E. |
E4F. |
|
|
|
|
|
|||||||||||||||
Would you say you took (MEDICINE) in your second trimester, from (4) to (6)? |
Would you say you took (MEDICINE) in your third trimester, from (7) to (10)? |
Would you say you took (MEDICINE) during the months you breastfed, from (DOIB/10) to (END BF)?
|
|
|
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
|||
|
|
|
|
|||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
|||
#
OF PERINATAL CONDITION 3 MEDICINE SUPPLEMENTS
IF
R DID NOT BREASTFEED,
SKIP TO E7.
E6D. |
E6E. |
E6F. |
E7. |
||||||||||||
Would you say the fever occurred in your second trimester, from (4) to (6)? |
Would you say the fever occurred in your third trimester, from (7) to (10)? |
Would you say the fever occurred during the months you breastfed, from (DOIB/10) to (END BF)? |
C F |
||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
TEMP |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
NA (SKIP) 997 RF 998 DK 999
|
#
OF PERINATAL CONDITION SUPPLEMENTS
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study
to Explore Early Development (SEED) Page
E-
|
ORAL/DENTAL DISEASE |
|
|
|
|
|
|
E8. |
Between (-3) and (DOIB/END BF) did a doctor or dentist ever tell you that you had gingivitis or periodontitis? |
|
YES 01 NO (SKIP TO E15) 02 RF (SKIP TO E15) 98 DK (SKIP TO E15) 99 |
|
|
|
|
E9. |
Did you take any medication for gingivitis or periodontitis between (-3) and (DOIB/END BF)? |
|
YES 01 NO (SKIP TO E12) 02 N/A (SKIP) 97 RF (SKIP TO E12) 98 DK (SKIP TO E12) 99 |
|
|
|
|
E10. |
ASK R TO REFER TO LIST 7a IN PREP GUIDE. What medicine did you take? Anything else? IF R CAN’T RECALL, READ ANSWERS AND CODE ALL THAT APPLY. |
|
Clindamycin 01 Doxycycline 02 Metronidazole 03 Minocycline 04 Penicillin 05 Other (SPECIFY IN GRID) 90 N/A (SKIP) 97 RF 98 DK 99 |
E11A was deleted. |
E11B. |
|
|
|||||||||||
COMPLETE ONE ROW FOR EACH MEDICINE. |
Would you say you took (MED) in the 3 months before you became pregnant, from (-3) to (-1)? |
Would you say you took (MED) in your first trimester, from (1) to (3)? |
|
|||||||||||
|
|
|||||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#1:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#2:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#3:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
|
ORAL/DENTAL DISEASE |
|
|
|||||||||||
|
|
|
|
|||||||||||
E11. |
Between (-3) and (DOIB/END BF) did a doctor or dentist ever tell you that you had gingivitis or periodontitis? |
|
YES 01 NO (SKIP TO E18) 02 RF (SKIP TO E18) 98 DK (SKIP TO E18) 99 |
|||||||||||
|
|
|
|
|||||||||||
E12. |
Did you take any medication for gingivitis or periodontitis between (-3) and (DOIB/END BF)? |
|
YES 01 NO (SKIP TO E15) 02 N/A (SKIP) 97 RF (SKIP TO E15) 98 DK (SKIP TO E15) 99 |
|||||||||||
|
|
|
|
|||||||||||
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study
to Explore Early Development (SEED) Page
E-
E13.
|
What medicine did you take? PROBE: Anything else? IF R CAN’T RECALL, READ LIST AND CODE ALL THAT APPLY. IF THESE MEDICATIONS WERE NOT GIVEN, ASK R TO REFER TO LIST 8a IN PREP GUIDE UNDER AN
IF
R DID NOT BREASTFEED,
TIBIOTICS AND RECORD MEDICATION BELOW. |
|
Penicillin 01 Clindamycin 02 Metronidazole 03 Minocycline 04 Doxycycline 05 Other (SPECIFY IN GRID) 90 N/A (SKIP) 97 RF 98 DK 99 |
E11D. |
E11E. |
E11F. |
|
|||||||||||||||
Would you say you took (MED) in your second trimester, from (4) to (6)? |
Would you say you took (MED) in your third trimester, from (7) to (10)? |
Would you say you took (MED) during the months you breastfed, from (DOIB/10) to (END BF)? |
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
#
OF DENTAL MEDICINE SUPPLEMENTS 
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
E12. |
Did you have any treatment other than medicine or antibiotics for gingivitis or periodontitis between (-3) and (DOIB/END BF)? |
|
YES 01 NO (SKIP TO E15) 02 N/A (SKIP) 97 RF (SKIP TO E15) 98 DK (SKIP TO E15) 99 |
|
|
|
|
E13. |
What treatments did you have? Was it (READ ANSWERS AND CODE ALL THAT APPLY)? |
|
Root planing and scaling 01 Gingival curettage 02 Splinting 03 Other (SPECIFY IN GRID) 90 N/A (SKIP) 97 RF 98 DK 99 |
E14A was deleted. |
E14B. |
|
|
|||||||||||
COMPLETE ONE ROW FOR EACH TREATMENT. |
Would you say you got (TREATMENT) in the 3 months before you became pregnant, from (-3) to (-1)? |
Would you say you got (TREATMENT) in your first trimester, from (1) to (3)? |
|
|||||||||||
|
|
|||||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#1:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#2:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#3:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
|
ORAL/DENTAL DISEASE |
|
|
|||||||||||
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
E15. |
Did you have any treatment other than medicine or antibiotics for gingivitis or periodontitis between (-3) and (DOIB/END BF)? |
|
YES 01 NO (SKIP TO E18) 02 N/A (SKIP) 97 RF (SKIP TO E18) 98 DK (SKIP TO E18) 99 |
|
|
|
|
E16. |
IF
R DID NOT BREASTFEED, |
|
Root planning and scaling 01 Gingival curettage 02 Splinting 03 Other (SPECIFY IN GRID) 90 N/A (SKIP) 97 RF 98 DK 99 |
E14D. |
E14E. |
E14F. |
|
|||||||||||||||
Would you say you got (TREATMENT) in your second trimester, from (4) to (6)? |
Would you say you got (TREATMENT) in your third trimester, from (7) to (10)? |
Would you say you got (TREATMENT) during the months you breastfed, from (DOIB/10) to (END BF)?
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
#
OF DENTAL TREATMENT SUPPLEMENTS
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
|
INJURIES |
|
|
|
|
The next few questions are about any injuries that you might have had during the time period from three months prior to conception of (CHILD) through (DOIB/the time until you completely stopped breastfeeding). |
|
||
|
|
|
|
|
E15. |
Between (-3) and (DOIB/END BF) did you have any injuries that required medical attention? |
|
YES 01 NO (SKIP TO E21) 02 RF (SKIP TO E21) 98 DK (SKIP TO E21) 99 |
|
|
|
|
|
|
E16. |
What were the injuries you had? SPECIFY. |
|||
|
INJURY
1:
|
|||
|
INJURY
2:
|
|||
|
INJURY
3:
|
|||
|
|
|
N/A (SKIP) 97 RF 98 DK 99 |
|
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
|
COMPLETE E17-E20 FOR EACH INJURY. |
|
E17A was deleted. |
E17B. |
E17C. |
||||||||
INJURY 1: |
Would you say (INJURY) occurred in the three months before you became pregnant, from (-3) to (-1)? |
Would you say (INJURY) occurred in your first trimester, from (1) to (3)? |
||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|||||||||
|
|
|
|
|
|
|
|
|
|
|
IF
R DID NOT BREASTFEED,
SKIP TO E18.
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
|
E17B. |
E17C. |
||||||||
INJURY 2: |
Would you say (INJURY) occurred in the three months before you became pregnant, from (-3) to (-1)? |
Would you say (INJURY) occurred in your first trimester, from (1) to (3)? |
||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|||||||||
|
|
|
|
|
|
|
|
|
|
|
IF
R DID NOT BREASTFEED,
SKIP TO E18.
E17D. |
E17E |
E17F. |
E18. |
|
|||||||||||||||||||
Would you say (INJURY) occurred in your second trimester, from (4) to (6)? |
Would you say (INJURY) occurred in your third trimester, from (7) to (10)? |
Would you say (INJURY) occurred during the months you breastfed, from (DOIB/10) to (END BF)?
|
Did you ever lose consciousness because of (INJURY)? |
|
|||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
||||||||||||||||||||
E19. |
Did you take any medications or receive injections because of (INJURY)? |
|
YES 01 NO (SKIP TO NEXT INJURY/E21) 02 N/A (SKIP) 97 RF (SKIP TO NEXT INJURY/E21) 98 DK (SKIP TO NEXT INJURY/E21) 99 |
||||||||||||||||||||
|
|
|
|
||||||||||||||||||||
E20. |
ASK R TO LOOK AT LIST 7a THROUGH 7p PAYING CLOSE ATTENTION TO 7a AND 7b IN PREP GUIDE. What medicines or injections did you take for (INJURY)? Anything else? |
||||||||||||||||||||||
|
MEDICINE
1:
|
|
|||||||||||||||||||||
|
MEDICINE
2:
|
|
|||||||||||||||||||||
|
MEDICINE
3:
|
|
|||||||||||||||||||||
|
|
|
N/A (SKIP) 97 RF 98 DK 99 |
||||||||||||||||||||
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
|
E17B. |
E17C. |
||||||||
INJURY 3: |
Would you say (INJURY) occurred in the three months before you became pregnant, from (-3) to (-1)? |
Would you say (INJURY) occurred in your first trimester, from (1) to (3)? |
||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|||||||||
|
|
|
|
|
|
|
|
|
|
|
IF
R DID NOT BREASTFEED,
SKIP TO E18.
E17D. |
E17E. |
E17F. |
E18. |
|
|||||||||||||||||||
Would you say (INJURY) occurred in your second trimester, from (4) to (6)? |
Would you say (INJURY) occurred in your third trimester, from (7) to (10)? |
Would you say (INJURY) occurred during the months you breastfed, from (DOIB/10) to (END BF)?
|
Did you ever lose consciousness because of (INJURY)? |
|
|||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
||||||||||||||||||||
E19. |
Did you take any medications or receive injections because of (INJURY)? |
|
YES 01 NO (SKIP TO NEXT INJURY/E21) 02 N/A (SKIP) 97 RF (SKIP TO NEXT INJURY/E21) 98 DK (SKIP TO NEXT INJURY/E21) 99 |
||||||||||||||||||||
|
|
|
|
||||||||||||||||||||
E20. |
ASK R TO LOOK AT LIST 7a THROUGH 7p PAYING CLOSE ATTENTION TO 7a AND 7b IN PREP GUIDE. What medicines or injections did you take for (INJURY)? Anything else? |
||||||||||||||||||||||
|
MEDICINE
1:
|
|
|||||||||||||||||||||
|
MEDICINE
2:
|
|
|||||||||||||||||||||
|
MEDICINE
3:
|
|
|||||||||||||||||||||
|
|
|
N/A (SKIP) 97 RF 98 DK 99 |
||||||||||||||||||||
#
OF PERINATAL INJURY SUPPLEMENTS 
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
|
SURGERY |
|
|
|
|||
|
Now I’m going to ask you about any surgeries or procedures not related to pregnancy or delivery that you might have had during the time period from three months before becoming pregnant with (CHILD) through the time until (DOIB/you completely stopped breastfeeding). |
|
|||||
|
|
|
|
|
|||
E21. |
Between (-3) and (DOIB/END BF) did you have any dental, medical, or surgical procedures that required the use of general or local anesthesia? (PROBE: What procedures did you have done?) |
|
YES (SPECIFY IN GRID) 01 NO (SKIP TO E24) 02 RF (SKIP TO E24) 98 DK (SKIP TO E24) 99 |
|
|||
|
|
|
|
|
|||
|
COMPLETE E22–E23 FOR EACH PROCEDURE. |
|
|
||||
|
E22. E23A was deleted |
E23B. |
||||
PROCEDURE: |
For (PROCEDURE) did you have general anesthesia or local anesthesia? |
Would you say you received the anesthesia in the three months before you became pregnant, from (-3) to (-1)? |
||||
#1:
|
GENERAL 01 LOCAL 02 N/A (SKIP) 97 RF 98 DK 99 |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99 |
||
|
||||||
|
IF E22 = 98, SKIP TO NEXT PROCEDURE/E24. |
|
|
|
|
|
|
|
|
|
|
|
|
#2:
|
GENERAL 01 LOCAL 02 N/A (SKIP) 97 RF 98 DK 99 |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99 |
||
|
||||||
|
IF E22 = 98, SKIP TO NEXT PROCEDURE/E24. |
|
|
|
|
|
|
|
|
|
|
|
|
#3:
|
GENERAL 01 LOCAL 02 N/A (SKIP) 97 RF 98 DK 99 |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99 |
||
|
||||||
|
IF E22 = 98, SKIP TO NEXT PROCEDURE/E24. |
|
|
|
|
|
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
|
SURGERY |
|
|
|
Now I’m going to ask you about any surgeries or procedures not related to pregnancy or delivery that you might have had during the time period from three months before becoming pregnant with (CHILD) through the time until (DOIB/you completely stopped breastfeeding). |
||
|
|
|
|
E24. |
Between (-3) and (DOIB/END BF) did you have any dental, medical, or surgical procedures that required the use of general or local anesthesia? |
|
YES 01 NO (SKIP TO E28) 02 RF (SKIP TO E28) 98 DK (SKIP TO E28) 99 |
|
|
|
IF
R DID NOT BREASTFEED, |
E23C. |
E23D. |
E23E. |
E23F. |
||||||||||||||||
Would you say you received the anesthesia in your first trimester, from (1) to (3)? |
Would you say you received the anesthesia in your second trimester, from (4) to (6)? |
Would you say you received the anesthesia in your third trimester, from (7) to (10)? VERBATIM:
|
Would you say you received the anesthesia during the months you breastfed, from (DOIB/10) to (END BF)? |
||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
||||||||||||||||
|
IF E26 = 98, SKIP TO NEXT PROCEDURE/E28. |
IF DK, ASK B-F. |
|
|
|
|
|
||||||||||||
|
|
VERBATIM:
|
|
|
|
|
|
||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
||||||||||||||||
|
IF E26 = 98, SKIP TO NEXT PROCEDURE/E28. |
IF DK, ASK B-F. |
|
|
|
|
|
||||||||||||
|
|
VERBATIM:
|
|
|
|
|
|
||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
||||||||||||||||
|
IF E26 = 98, SKIP TO NEXT PROCEDURE/E28. |
IF DK, ASK B-F. |
|
|
|
|
|
||||||||||||
#
OF NON-PREGNANCY PROCEDURE SUPPLEMENTS 
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
|
OTHER PROCEDURES |
|
|
|||||||
|
|
|
|
|||||||
E24. |
Between (-3) and (DOIB/END BF) did you have any of the following procedures not related to your pregnancy with (CHILD)? READ ANSWERS AND CODE ALL THAT APPLY. |
|
X-rays, including dental 01 Mammogram 02 CT/CAT scans 03 MRI or magnetic resonance imaging 04 Radionuclide study or scan 05 Radiation treatments 06 Other x-rays or scans 07 Other (SPECIFY IN GRID) 90 NONE (SKIP TO E27) 00 RF (SKIP TO E27) 98 DK (SKIP TO E27) 99 |
|||||||
|
|
|
|
|||||||
|
|
|
|
|||||||
|
IF E24 = 02, SKIP TO E26. |
|
|
|||||||
|
E25. |
|
|
|||||||
COMPLETE ONE ROW FOR EACH TEST/TREATMENT. |
What part of your body was tested or treated?
#1:
#2:
|
Would you say the (TEST/ TREATMENT) was done in the three months before you became pregnant, from (-3) to (-1)? |
|
|||||||
TEST/TREATMENT: |
|
|||||||||
#1:
|
N/A (SKIP) 97 RF 98 DK 99 |
YES |
NO |
N/A |
RF |
DK |
|
|||
01 |
02 |
97 |
98 |
99 |
|
|||||
|
|
|||||||||
|
|
|
|
|
|
|
|
|||
|
#1:
#2:
|
|
|
|
|
|
#2:
|
N/A (SKIP) 97 RF 98 DK 99 |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99 |
||
|
||||||
|
|
|
|
|
|
|
|
#1:
#2:
|
|
|
|
|
|
#3:
|
N/A (SKIP) 97 RF 98 DK 99 |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99 |
||
|
||||||
|
|
|
|
|
|
|
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
|
|
|
|
||||||||||||||||||||
E28. |
Between (-3) and (DOIB/END BF) did you have any of the following procedures not related to your pregnancy with (CHILD)? READ ANSWERS AND CODE ALL THAT APPLY. |
|
X-rays, including dental 01 Mammogram 02 CT/CAT scans 03 MRI/magnetic resonance 04 Imaging 05 Radionuclide study or scan 06 Radiation treatments 07 Other x-rays or scans 08 Other (SPECIFY IN GRID) 90 NONE 00 RF 98 DK 99 |
||||||||||||||||||||
|
|
|
|
||||||||||||||||||||
|
IF E28 = 02, SKIP TO E30. |
|
|
||||||||||||||||||||
|
|
|
|
IF R DID NOT BREASTFEED, SKIP TO NEXT TEST/E27. |
|||||||||||||||||||
E26C. |
E26D. |
E26E. |
E26F. |
||||||||||||||||||||
Would you say the (TEST/ TREATMENT) was done in your first trimester, from (1) to (3)? |
Would you say the (TEST/ TREATMENT) was done in your second trimester, from (4) to (6)? |
Would you say the (TEST/ TREATMENT) was done in your third trimester, from (7) to (10)? VERBATIM:
|
Would you say the (TEST/ TREATMENT) was done during the months you breastfed, from (DOIB/10) to (END BF)? |
||||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
||||
|
|
|
|
||||||||||||||||||||
|
|
|
|
|
|
|
|
||||||||||||||||
|
|
VERBATIM:
|
|
|
|
|
|
||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
||||||||||||||||
|
IF E26 = 98, SKIP TO NEXT PROCEDURE/E28. |
IF DK, ASK B-F. |
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VERBATIM:
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YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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IF E26 = 98, SKIP TO NEXT PROCEDURE/E28. |
IF DK, ASK B-F. |
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#
OF NON-PREGNANCY TEST/TREATMENT SUPPLEMENTS
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
|
MEDICATION USE |
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I will ask you about medications that you might have taken for specific conditions and symptoms from (-3) through (DOIB/END BF). |
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E27. |
Between (-3) and (DOIB/END BF) did you take any medications or have any other type of treatment such as counseling, behavioral therapy, or physical therapy for the following conditions? READ ANSWERS AND CODE ALL THAT APPLY. DESCRIBE EACH CONDITION WHERE INDICATED. |
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Acne 01
Allergy
1:
Allergy
2: Anxiety disorder 04 Arthritis 05 Asthma 06 Attention Deficit Hyperactivity Disorder 07 Autoimmune disorders (see List 8 in prep guide):
1:
2:
Back pain 09 Bipolar disorder 10 Cancer 11
Cardiovascular
condition 1:
Cardiovascular
condition 2: Cold or cough 14 Constipation 15 Depression 16 Diabetes 17 Dieting 18
Eating
disorder 1:
Eating
disorder 2: Eczema or Psoriasis 21
Endocrine
disorder 1:
Endocrine
disorder 2:
|
Gastrointestinal
disorder 1:
Gastrointestinal
disorder 2: General headaches 26 Heartburn 27 High blood pressure 28 Migraine headaches 29
Neuromuscular
disorder 1:
Neuromuscular
disorder 2: Nicotine addiction 32 Obesity 33 Obsessive compulsive disorder 34 Personality disorder 35
Respiratory
condition 1:
Respiratory
condition 2: Schizophrenia 38 Seizures 39 Sickle cell anemia 40 Sleep disorder 41 Thyroid disease 42 Other (SPECIFY) 90 NONE (SKIP TO E30) 00 RF (SKIP TO E30) 98 DK (SKIP TO E30) 99 |
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SPECIFY:
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SPECIFY:
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SPECIFY:
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ANSWER E28–E29 FOR EACH CONDITION. |
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02
03
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
PAGE INTENTIONALLY LEFT BLANK
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
CONDITION 1:
E28. |
ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine or other treatment were you given for (CONDITION)? RECORD NAME OF MEDS/TREATMENTS IN GRID BELOW. Anything else? |
|
PROVIDED NAME OF MED(S)/TREATMENT(S) 01 N/A (SKIP) 97 RF 98 DK 99 |
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E29A was deleted. |
E29B. |
E29C. |
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MEDICINE/TREATMENT: |
Would you say you (took [MED] / had [TREAT]) in the three months before you became pregnant, from (-3) to (-1)? |
Would you say you (took [MED] / had [TREAT]) in your first trimester, from (1) to (3)? |
|
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#1:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
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|||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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#2:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
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|||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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CONDITION 2:
E28. |
ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine or other treatment were you given for (CONDITION)? RECORD NAME OF MEDS/TREATMENTS IN GRID BELOW. Anything else? |
|
PROVIDED NAME OF MED(S)/TREATMENT(S) 01 N/A (SKIP) 97 RF 98 DK 99 |
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MEDICINE/TREATMENT: |
E29B. |
E29C. |
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#1:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
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|||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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#2:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
IF
R DID NOT BREASTFEED, SKIP TO
NEXT MED/NEXT CONDITION/E30.
E29D. |
E29E. |
E29F. |
|
|||||||||||||
Would you say you (took [MED] / had [TREAT]) in your second trimester, from (4) to (6)? |
Would you say you (took [MED] / had [TREAT]) in your third trimester, from (7) to (10)? |
Would you say you (took [MED] / had [TREAT]) during the months you breastfed, from (DOIB/10) to (END BF)?
|
|
|||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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|
#
OF NON-PREGNANCY CONDITION 1 MEDICINE SUPPLEMENTS
|
|||||||||||||||
IF
R DID NOT BREASTFEED, SKIP TO
NEXT MED/NEXT CONDITION/E30.
E29D. |
E29E. |
E29F. |
|
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YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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|||
|
#
OF NON-PREGNANCY CONDITION 2 MEDICINE SUPPLEMENTS |
|||||||||||||||||
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
CONDITION 3:
E28. |
ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine or other treatment were you given for (CONDITION)? RECORD NAME OF MEDS/TREATMENTS IN GRID BELOW. Anything else? |
|
PROVIDED NAME OF MED(S)/TREATMENT(S) 01 N/A (SKIP) 97 RF 98 DK 99 |
||||||||||||||
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E29B. |
|
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|||||||||||||
MEDICINE/TREATMENT: |
Would you say you (took [MED] / had [TREAT]) in the three months before you became pregnant, from (-3) to (-1)? |
Would you say you (took [MED] / had [TREAT]) in your first trimester, from (1) to (3)? |
|
|
|||||||||||||
#1:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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#2:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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CONDITION 4:
E28. |
ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine or other treatment were you given for (CONDITION)? RECORD NAME OF MEDS/TREATMENTS IN GRID BELOW. Anything else? |
|
PROVIDED NAME OF MED(S)/TREATMENT(S) 01 N/A (SKIP) 97 RF 98 DK 99 |
||||||||||||||
|
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|||||||||||||||
MEDICINE/TREATMENT: |
E29B. |
E29C. |
|
|
|||||||||||||
#1:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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|||||||
#2:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
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||||||
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||||||||||||||
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
IF
R DID NOT BREASTFEED, SKIP TO
NEXT MED/NEXT CONDITION/E30.
E29D. |
E29E. |
E29F. |
|
|
|||||||||||||||
Would you say you (took [MEDICINE] / had [TREATMENT]) in your second trimester, from (4) to (6)? |
Would you say you (took [MEDICINE] / had [TREATMENT]) in your third trimester, from (7) to (10)? |
Would you say you (took [MEDICINE] / had [TREATMENT]) during the months you breastfed, from (DOIB/10) to (END BF)?
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
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|||
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|
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|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|||
|
#
OF NON-PREGNANCY CONDITION 3 MEDICINE SUPPLEMENTS |
||||||||||||||||||
IF
R DID NOT BREASTFEED, SKIP TO
NEXT MED/NEXT CONDITION/E30.
E29D. |
E29E. |
E29F. |
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|||
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|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|||
|
#
OF NON-PREGNANCY CONDITION 4 MEDICINE SUPPLEMENTS |
||||||||||||||||||
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
CONDITION 5:
E28. |
ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine or other treatment were you given for (CONDITION)? RECORD NAME OF MEDS/TREATMENTS IN GRID BELOW. Anything else? |
|
PROVIDED NAME OF MED(S)/TREATMENT(S) 01 N/A (SKIP) 97 RF 98 DK 99 |
||||||||||||||
|
|
|
|||||||||||||||
|
E29B. |
|
|
|
|||||||||||||
MEDICINE/TREATMENT: |
Would you say you (took [MEDICINE] / had [TREATMENT]) in the three months before you became pregnant, from (-3) to (-1)? |
Would you say you (took [MEDICINE] / had [TREATMENT]) in your first trimester, from (1) to (3)? |
|
|
|||||||||||||
#1:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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|||||||
#2:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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||||||||||||||||
CONDITION 6:
E28. |
ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine or other treatment were you given for (CONDITION)? RECORD NAME OF MEDS/TREATMENTS IN GRID BELOW. Anything else? |
|
PROVIDED NAME OF MED(S)/TREATMENT(S) 01 N/A (SKIP) 97 RF 98 DK 99 |
||||||||||||||
|
|
|
|||||||||||||||
MEDICINE/TREATMENT: |
E29B. |
E29C. |
|
|
|||||||||||||
#1:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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|||||||
#2:
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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|||||
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||||||||||||||
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
IF
R DID NOT BREASTFEED, SKIP TO
NEXT MED/NEXT CONDITION/E30.
E29D. |
E29E. |
E29F. |
|
|
|||||||||||||||
Would you say you (took [MEDICINE] / had [TREATMENT]) in your second trimester, from (4) to (6)? |
Would you say you (took [MEDICINE] / had [TREATMENT]) in your third trimester, from (7) to (10)? |
Would you say you (took [MEDICINE] / had [TREATMENT]) during the months you breastfed, from (DOIB/10) to (END BF)?
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|||
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|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|||
|
#
OF NON-PREGNANCY CONDITION 5 MEDICINE SUPPLEMENTS |
||||||||||||||||||
IF
R DID NOT BREASTFEED, SKIP TO
NEXT MED/NEXT CONDITION/E30.
E29D. |
E29E. |
E29F. |
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|||
|
|
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|||
|
#
OF NON-PREGNANCY CONDITION 6 MEDICINE SUPPLEMENTS |
||||||||||||||||||
|
#
OF NON-PREGNANCY CONDITION SUPPLEMENTS |
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
|
VACCINATIONS |
|
|
E30. |
Now I am going to ask you a few questions about vaccinations. During the time from (-3) to (DOIB/END BF) did you have any vaccinations or shots? |
|
YES 01 NO (SKIP TO F1) 02 RF (SKIP TO F1) 98 DK (SKIP TO F1) 99 |
|
|
|
|
E31. |
What vaccination did you receive? Was it (READ ANSWERS AND CODE ALL THAT APPLY)? |
|
Combined measles, mumps and rubella vaccine, or MMR 01 Single rubella vaccine 02 Single mumps vaccine 03 Single measles vaccine 04 Tetanus 05 Influenza or flu vaccine 06 Hepatitis A 07 Hepatitis B 08 Allergy shots 09 Other (SPECIFY IN GRID) 90 N/A (SKIP) 97 RF 98 DK 99 |
E32A was deleted. |
E32B. |
E32C. |
|
|||||||||||
COMPLETE ONE ROW FOR EACH VACCINATION. |
Would you say you received (SHOT) in the 3 months before you became pregnant, from (-3) to (-1)? |
Would you say you received (SHOT) in your first trimester, from (1) to (3)? |
|
|||||||||||
|
|
|||||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#1:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#2:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
#3:
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||
|
ORAL/DENTAL DISEASE |
|
|
|||||||||||
|
|
|
|
|||||||||||
E11. |
Between (-3) and (DOIB/END BF) did a doctor or dentist ever tell you that you had gingivitis or periodontitis? |
|
YES 01 NO (SKIP TO E18) 02 RF (SKIP TO E18) 98 DK (SKIP TO E18) 99 |
|||||||||||
|
|
|
|
|||||||||||
E12. |
Did you take any medication for gingivitis or periodontitis between (-3) and (DOIB/END BF)? |
|
YES 01 NO (SKIP TO E15) 02 N/A (SKIP) 97 RF (SKIP TO E15) 98 DK (SKIP TO E15) 99 |
|||||||||||
|
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|
|
|||||||||||
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study
to Explore Early Development (SEED) Page
E-
E13. |
IF
R DID NOT BREASTFEED, |
|
Penicillin 01 Clindamycin 02 Metronidazole 03 Minocycline 04 Doxycycline 05 Other (SPECIFY IN GRID) 90 N/A (SKIP) 97 RF 98 DK 99 |
|
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|||||||||||||||
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|||||||||||||||
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|||||||||||||||
E32D. |
E32E. |
E32F. |
|
|||||||||||||||
Would you say you received (SHOT) in your second trimester, from (4) to (6)? |
Would you say you received (SHOT) in your third trimester, from (7) to (10)? |
Would you say you received (SHOT) during the months you breastfed, from (DOIB/10) to (END BF)? |
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
|
|
|
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|||
#
OF VACCINATION SUPPLEMENTS
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
E-
|
|
|
|
E33. |
Did you have any reactions to the vaccinations that required medical attention? |
|
YES 01 NO (SKIP TO F1) 02 N/A (SKIP) 97 RF (SKIP TO F1) 98 DK (SKIP TO F1) 99 |
|
COMPLETE ONE ROW FOR EACH REACTION. |
|
|
|
E34. |
|
E35. |
|
Which vaccine(s) caused the reaction? SPECIFY. |
|
What was the reaction? SPECIFY. |
#1 |
N/A (SKIP) 97 RF 98 DK 99 |
|
N/A (SKIP) 97 RF 98 DK 99 |
|
|
|
|
#2 |
N/A (SKIP) 97 RF 98 DK 99 |
|
N/A (SKIP) 97 RF 98 DK 99 |
|
|
|
|
#3 |
N/A (SKIP) 97 RF 98 DK 99 |
|
N/A (SKIP) 97 RF 98 DK 99 |
|
|
|
|
#
OF VACCINATION REACTION SUPPLEMENTS
MI SEED III Sect E Maternal Medical Conditions 8/25/2016
Study to Explore Early Development
(SEED) Page
F-
SECTION F: OBSTETRIC AND DELIVERY COMPLICATIONS |
|||
OBSTETRIC COMPLICATIONS |
|||
We are interested in learning about any obstetric and pregnancy conditions that you might have had during your pregnancy with (CHILD). |
|||
|
|
|
|
F1. |
ASK R TO LOOK AT LIST 9 IN PREP GUIDE. I am going to read you a list of obstetric and pregnancy conditions. Please tell me if you had any of these conditions during your pregnancy with (CHILD). Did you have (READ ANSWERS AND CODE ALL THAT APPLY)? |
|
Anemia 01 Chorioamnionitis 02 Eclampsia 03 Gestational diabetes 04 HELLP or H-E-L-L-P syndrome 05 Hyperemesis 06 Incompetent cervix 07 Low blood pressure that required medical treatment 08 Pregnancy-induced hypertension or preeclampsia 09 Premature rupture of your membranes 10 Pre-term or early labor 11 Vaginal bleeding 12 Other (SPECIFY) 90 NONE (SKIP TO F8) 00 RF (SKIP TO F8) 98 DK (SKIP TO F8) 99 |
|
|
|
|
|
SPECIFY:
|
||
|
SPECIFY:
|
||
|
|
|
|
|
ANSWER F2–F6 FOR EACH COMPLICATION. |
|
|
MI SEED III Sect F Obstetric and Delivery 8/25/2016
Study to Explore Early Development
(SEED) Page
F-
COMPLICATION 1:
|
|
||||||||||||||||||||||
F2A was deleted. F2B. |
F2C. |
F2D. |
|
||||||||||||||||||||
Would you say you had (COMPLICATION) in your first trimester, from (1) to (3)? |
Would you say you had (COMPLICATION) in your second trimester, from (4) to (6)? |
Would you say you had (COMPLICATION) in your third trimester, from (7) to (10)? |
|
||||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
||||||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
|
||||||||
|
|
|
|
||||||||||||||||||||
|
|
|
|
||||||||||||||||||||
|
|
|
|
||||||||||||||||||||
F3. |
Did you take any medicine for (COMPLICATION)? (IF YES: ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine did you take? Any others?) |
|
YES (SPECIFY IN GRID) 01 NO (SKIP TO F5) 02 N/A (SKIP) 97 RF (SKIP TO F5) 98 DK (SKIP TO F5) 99 |
||||||||||||||||||||
|
|
|
|
||||||||||||||||||||
MEDICINE
1:
|
|
||||||||||||||||||||||
F4A was deleted. F4B. |
F4C. |
F4D. |
|
||||||||||||||||||||
Would you say you took (MEDICINE) in your first trimester, from (1) to (3)? |
Would you say you took (MEDICINE) in your second trimester, from (4) to (6)? |
Would you say you took (MEDICINE) in your third trimester, from (7) to (10)? |
|
||||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
||||||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
|
||||||||
|
|
|
|
||||||||||||||||||||
|
|
|
|
||||||||||||||||||||
MEDICINE
2:
|
|
||||||||||||||||||||||
F4B. |
F4C. |
F4C. |
|
||||||||||||||||||||
Would you say you took (MEDICINE) in your first trimester, from (1) to (3)? |
Would you say you took (MEDICINE) in your second trimester, from (4) to (6)? |
Would you say you took (MEDICINE) in your third trimester, from (7) to (10)? |
|
||||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
||||||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
|
||||||||
|
|
|
|
||||||||||||||||||||
|
|
|
|
||||||||||||||||||||
#
OF PREGNANCY COMPLICATION 1 MEDICINE SUPPLEMENTS 
MI SEED III Sect F Obstetric and Delivery 8/25/2016
Study to Explore Early Development
(SEED) Page
F-
|
|
|
|
||||||||||||||||
F5. |
Did you have any treatments for (COMPLICATION)? This could include bed rest, home remedies, medical procedures, acupuncture, or chiropractic treatment. (IF YES: ASK R TO REFER TO LIST 7p IN PREP GUIDE. What treatment did you have? Any others?) |
|
YES (SPECIFY IN GRID) 01 NO (SKIP TO NEXT COMPLICATION/F8) 02 N/A (SKIP) 97 RF (SKIP TO NEXT COMPLICATION/F8) 98 DK (SKIP TO NEXT COMPLICATION/F8) 99 |
||||||||||||||||
|
|
||||||||||||||||||
TREATMENT
1:
|
|
||||||||||||||||||
F6A was deleted. F6B. |
F6C. |
F6D. |
|
||||||||||||||||
Would you say you had (TREATMENT) in your first trimester, from (1) to (3)? |
Would you say you had (TREATMENT) in your second trimester, from (4) to (6)? |
Would you say you had (TREATMENT) in your third trimester, from (7) to (10)? |
|
||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
|
||||
|
|
|
|
||||||||||||||||
|
|
|
|
||||||||||||||||
|
|
||||||||||||||||||
TREATMENT
2:
|
|
||||||||||||||||||
F6B. |
F6C. |
F6D. |
|
||||||||||||||||
Would you say you had (TREATMENT) in your first trimester, from (1) to (3)? |
Would you say you had (TREATMENT) in your second trimester, from (4) to (6)? |
Would you say you had (TREATMENT) in your third trimester, from (7) to (10)? |
|
||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
|
||||
|
|
|
|
||||||||||||||||
|
|
|
|
||||||||||||||||
#
OF PREGNANCY COMPLICATION 1 TREATMENT SUPPLEMENTS
MI SEED III Sect F Obstetric and Delivery 8/25/2016
Study to Explore Early Development
(SEED) Page
F-
COMPLICATION 2:
|
|
||||||||||||||||||||||||
F2B. |
F2C. |
F2D. |
|
|
|||||||||||||||||||||
Would you say you had (COMPLICATION) in your first trimester, from (1) to (3)? |
Would you say you had (COMPLICATION) in your second trimester, from (4) to (6)? |
Would you say you had (COMPLICATION) in your third trimester, from (7) to (10)? |
|
|
|||||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
|
|
|||||||||
|
|
|
|
|
|||||||||||||||||||||
|
|
|
|
|
|||||||||||||||||||||
|
|
|
|
||||||||||||||||||||||
F3. |
Did you take any medicine for (COMPLICATION)? (IF YES: ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine did you take? Any others?) |
|
YES (SPECIFY IN GRID) 01 NO (SKIP TO F5) 02 N/A (SKIP) 97 RF (SKIP TO F5) 98 DK (SKIP TO F5) 99 |
||||||||||||||||||||||
|
|
|
|
||||||||||||||||||||||
MEDICINE
1:
|
|
||||||||||||||||||||||||
F4B. |
F4C. |
F4D. |
|
|
|||||||||||||||||||||
Would you say you took (MEDICINE) in your first trimester, from (1) to (3)? |
Would you say you took (MEDICINE) in your second trimester, from (4) to (6)? |
Would you say you took (MEDICINE) in your third trimester, from (7) to (10)? |
|
|
|||||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
|
|
|||||||||
|
|
|
|
|
|||||||||||||||||||||
|
|
|
|
|
|||||||||||||||||||||
MEDICINE
2:
|
|
||||||||||||||||||||||||
F4B. |
F4C. |
F4D. |
|
||||||||||||||||||||||
Would you say you took (MEDICINE) in your first trimester, from (1) to (3)? |
Would you say you took (MEDICINE) in your second trimester, from (4) to (6)? |
Would you say you took (MEDICINE) in your third trimester, from (7) to (10)? |
|
||||||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
||||||||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
|
||||||||||
|
|
|
|
||||||||||||||||||||||
|
|
|
|
||||||||||||||||||||||
#
OF PREGNANCY COMPLICATION 2 MEDICINE SUPPLEMENTS
MI SEED III Sect F Obstetric and Delivery 8/25/2016
Study to Explore Early Development
(SEED) Page
F-
|
|
|
|
||||||||||||||||
F5. |
Did you have any treatments for (COMPLICATION)? This could include bed rest, home remedies, medical procedures, acupuncture, or chiropractic treatment. (IF YES: ASK R TO REFER TO LIST 7p IN PREP GUIDE. What treatment did you have? Any others?) |
|
YES (SPECIFY IN GRID) 01 NO (SKIP TO NEXT COMPLICATION/F8) 02 N/A (SKIP) 97 RF (SKIP TO NEXT COMPLICATION/F8) 98 DK (SKIP TO NEXT COMPLICATION/F8) 99 |
||||||||||||||||
|
|
||||||||||||||||||
TREATMENT
1:
|
|
||||||||||||||||||
F6B. |
F6C. |
F6D. |
|
||||||||||||||||
Would you say you had (TREATMENT) in your first trimester, from (1) to (3)? |
Would you say you had (TREATMENT) in your second trimester, from (4) to (6)? |
Would you say you had (TREATMENT) in your third trimester, from (7) to (10)? |
|
||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
|
||||
|
|
|
|
||||||||||||||||
|
|
|
|
||||||||||||||||
|
|
||||||||||||||||||
TREATMENT
2:
|
|
||||||||||||||||||
F6B. |
F6C. |
F6D. |
|
||||||||||||||||
Would you say you had (TREATMENT) in your first trimester, from (1) to (3)? |
Would you say you had (TREATMENT) in your second trimester, from (4) to (6)? |
Would you say you had (TREATMENT) in your third trimester, from (7) to (10)? |
|
||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
|
||||
|
|
|
|
||||||||||||||||
|
|
|
|
||||||||||||||||
#
OF PREGNANCY COMPLICATION 2 TREATMENT SUPPLEMENTS
MI SEED III Sect F Obstetric and Delivery 8/25/2016
Study to Explore Early Development
(SEED) Page
F-
COMPLICATION 3:
|
|
||||||||||||||||||||||||
F2B. |
F2C. |
F2D. |
|
|
|||||||||||||||||||||
Would you say you had (COMPLICATION) in your first trimester, from (1) to (3)? |
Would you say you had (COMPLICATION) in your second trimester, from (4) to (6)? |
Would you say you had (COMPLICATION) in your third trimester, from (7) to (10)? |
|
|
|||||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
|
|
|||||||||
|
|
|
|
|
|||||||||||||||||||||
|
|
|
|
|
|||||||||||||||||||||
|
|
|
|
||||||||||||||||||||||
F3. |
Did you take any medicine for (COMPLICATION)? (IF YES: ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine did you take? Any others?) |
|
YES (SPECIFY IN GRID) 01 NO (SKIP TO F5) 02 N/A (SKIP) 97 RF (SKIP TO F5) 98 DK (SKIP TO F5) 99 |
||||||||||||||||||||||
|
|
|
|
||||||||||||||||||||||
MEDICINE
1:
|
|
||||||||||||||||||||||||
F4B. |
F4C. |
F4D. |
|
|
|||||||||||||||||||||
Would you say you took (MEDICINE) in your first trimester, from (1) to (3)? |
Would you say you took (MEDICINE) in your second trimester, from (4) to (6)? |
Would you say you took (MEDICINE) in your third trimester, from (7) to (10)? |
|
|
|||||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
|
|
|||||||||
|
|
|
|
|
|||||||||||||||||||||
|
|
|
|
|
|||||||||||||||||||||
MEDICINE
2:
|
|
||||||||||||||||||||||||
F4B. |
F4C. |
F4D. |
|
||||||||||||||||||||||
Would you say you took (MEDICINE) in your first trimester, from (1) to (3)? |
Would you say you took (MEDICINE) in your second trimester, from (4) to (6)? |
Would you say you took (MEDICINE) in your third trimester, from (7) to (10)? |
|
||||||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
||||||||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
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#
OF PREGNANCY COMPLICATION 3 MEDICINE SUPPLEMENTS
MI SEED III Sect F Obstetric and Delivery 8/25/2016
Study to Explore Early Development
(SEED) Page
F-
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F5. |
Did you have any treatments for (COMPLICATION)? This could include bed rest, home remedies, medical procedures, acupuncture, or chiropractic treatment. (IF YES: ASK R TO REFER TO LIST 7p IN PREP GUIDE. What treatment did you have? Any others?) |
|
YES (SPECIFY IN GRID) 01 NO (SKIP TO NEXT COMPLICATION/F8) 02 N/A (SKIP) 97 RF (SKIP TO NEXT COMPLICATION/F8) 98 DK (SKIP TO NEXT COMPLICATION/F8) 99 |
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TREATMENT
1:
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F6B. |
F6C. |
F6D. |
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Would you say you had (TREATMENT) in your first trimester, from (1) to (3)? |
Would you say you had (TREATMENT) in your second trimester, from (4) to (6)? |
Would you say you had (TREATMENT) in your third trimester, from (7) to (10)? |
|
||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
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||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
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TREATMENT
2:
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F6B. |
F6C. |
F6D. |
|
||||||||||||||||
Would you say you had (TREATMENT) in your first trimester, from (1) to (3)? |
Would you say you had (TREATMENT) in your second trimester, from (4) to (6)? |
Would you say you had (TREATMENT) in your third trimester, from (7) to (10)? |
|
||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
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||||
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
01 |
02 |
97 |
98 |
98 |
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#
OF PREGNANCY COMPLICATION 3 TREATMENT SUPPLEMENTS
#
OF PREGNANCY COMPLICATION SUPPLEMENTS
F7 was deleted.
MI SEED III Sect F Obstetric and Delivery 8/25/2016
Study to Explore Early Development
(SEED) Page
F-
|
DELIVERY COMPLICATIONS |
|
|
||||
F8. |
Now I am going to ask you a few questions about the labor and delivery with (CHILD). Were you given medications to help start or augment labor such as pitocin or oxytocin? |
|
YES 01 NO 02 RF 98 DK 99 |
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||||
F9. |
Did you receive (READ ANSWERS)? CODE ALL THAT APPLY. |
|
General anesthesia 01 A spinal 02 An epidural 03 Other anesthesia (SPECIFY) 90 No anesthesia 00 RF 98 DK 99 |
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|
SPECIFY |
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F10. |
What was the method of delivery? READ ANSWERS. |
|
Vaginal (ASK F11) 01 Scheduled cesarean section because you had a previous cesarean section 02 Scheduled cesarean section because your baby was breech 03
Scheduled
cesarean section for another reason Emergency cesarean section 05 RF 98 DK 99 |
||||
|
SPECIFY |
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|
IF F10 NOT EQUAL TO 01, SKIP TO F13. |
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F11. |
Were forceps used or was vacuum extraction done to aide delivery? |
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YES |
NO |
N/A |
RF |
DK |
|
a. Forceps |
01 |
02 |
97 |
98 |
99 |
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b. Vacuum extraction |
01 |
02 |
97 |
98 |
99 |
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||||
F12. |
Was the baby breech? |
|
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
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||||
F13. |
Did you experience any of the following events during the labor or delivery of (CHILD)? READ ANSWERS AND CODE ALL THAT APPLY. |
|
Adverse reaction to anesthesia 01 High fever (ASK F14) 02 Hemorrhage 03 Uterine rupture 04 Low blood pressure 05 Other (SPECIFY) 90 NONE 00 RF 98 DK 99 |
||||
MI SEED III Sect F Obstetric and Delivery 8/25/2016
Study to Explore Early Development
(SEED) Page
F-
|
SPECIFY |
MI SEED III Sect F Obstetric and Delivery 8/25/2016
Study to Explore Early Development
(SEED) Page
F-
|
IF F13 NOT EQUAL TO 02, SKIP TO F15. |
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C F |
F14. |
What was the highest temperature recorded during your fever? |
|
TEMPERATURE N/A (SKIP) 997 RF 998 DK 999 |
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F15. |
During or after delivery of (CHILD), did any of the following occur to (CHILD)? READ ANSWERS AND CODE ALL THAT APPLY. |
|
Cord wrapped around neck 01 Prolonged or dysfunctional labor (also sometimes called “failure to progress”) 02 Fever in (CHILD) 03 Fetal distress 04 Resuscitation needed 05 Sent to neonatal intensive care unit or NICU 06 Needed transfusion 07 Antibiotics given 08 Jaundice (ASK F16) 09 Meconium aspiration 10 Other (SPECIFY) 90 NONE 00 RF 98 DK 99 |
|
SPECIFY:
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|
IF F15 NOT EQUAL TO 09, SKIP TO SECTION H. |
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F16. |
Did (CHILD) receive phototherapy or bili lights, bili blanket, or special lights? |
|
YES 01 NO 02 N/A (SKIP) 97 RF 98 DK 99 |
.
MI SEED III Sect F Obstetric and Delivery 8/25/2016
Study to Explore Early Development
(SEED) Page
F-
BLANK PAGE FOR END OF SECTION
MI SEED III Sect F Obstetric and Delivery 8/25/2016
Study to Explore Early Development
(SEED) Page
H-
SECTION H: OCCUPATIONAL HISTORY
Now, I am going to ask you about your work experience during the 3 months before you became pregnant until (CHILD) was born/time you stopped breastfeeding (CHILD), so that would include (-3) to (DOIB/END BF). As we discuss your jobs, please include jobs that were paid, volunteer, or military service, which lasted one month or more for 10 or more hours per week. I will also ask you about stay-at-home parenting and education activities, so do not include those as a job.
H1A. Between (-3) and (DOIB/END BF) did you have a job? |
Yes 01 |
|
No 02 |
|
RF 98 |
|
DK 99 |
|
|
H1B. During that time, were you enrolled as a regular full-time student? That is, not just taking 1 class or community classes. |
Yes 01 |
|
No (SKIP TO H3A) 02 |
|
RF (SKIP TO H3A) 98 |
|
DK (SKIP TO H3A) 99 |
|
|
H1C. At what level or grade were you enrolled? |
HS OR VOCATIONAL SCHOOL (SKIP TO H2B) 01 |
|
COLLEGE OR UNDERGRAD 02 |
|
GRAD OR PROFESSIONAL SCHOOL 03 |
|
N/A (SKIP) 97 |
|
RF (SKIP TO H2B) 98 |
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DK (SKIP TO H2B) 99 |
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MAJOR:
|
|
N/A (SKIP) 97 |
|
RF 98 |
|
DK 99 |
|
|
H1D. What
was your major field of study? SPECIFY H2A was deleted. H2B. H2C. H2D.
Would you say you were a regular student in the three months before you became pregnant, from (-3) to (-1)?
YES NO N/A RF DK |
Would you say you were a regular student in your first trimester, from (1) to (3)?
YES NO N/A RF DK |
Would you say you were a regular student in your second trimester, from (4) to (6)?
YES NO N/A RF DK |
01 02 97 98 99
|
01 02 97 98 99 |
01 02 97 98 99 |
-
IF R DID NOT BREASTFEED, SKIP TO H4 BOX
H2E. H2F.
Would you say you were a regular student in your third trimester, from (7) to (10)?
YES NO N/A RF DK |
Would you say you were a regular student during the months you breastfed, from (DOIB/10) to (END BF)? YES NO N/A RF DK |
01 02 97 98 99 |
01 02 97 98 99 |
MI SEED III Sect H Occupational History 8/25/2016
Study to Explore Early Development
(SEED) Page
H-
|
|
||
H3A. Which of the following describes what you were doing during this time? Were you (READ ANSWERS AND CODE ALL THAT APPLY)? |
A stay at home parent or caregiver 01 |
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|
Disabled 02 |
||
|
Unemployed or between jobs (ASK H3B) 03 |
||
|
Incarcerated 04 |
||
|
Something else? (SPECIFY) 90 |
||
|
N/A (SKIP) 97 |
||
|
RF 98 |
||
|
DK 99 |
SPECIFY:
______________________________________________________________________
|
|
|
H3B. What was your usual job or job title? |
SPECIFY:
|
|
|
N/A (SKIP) 97 |
|
|
RF 98 |
|
|
DK 99 |
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|
SKIP TO SECTION J |
H4 INSTRUCTION BOX:
IF
STUDENT ONLY (H1A = 02, 98, OR 99, SKIP TO SECTION J
I would like to know more about the jobs that you held between (-3) and (DOIB/END BF) that lasted one month or more at 10 or more hours a week. I am interested in types of jobs, so if you worked different jobs with the same employer, please tell me about those as separate jobs. But if you were self-employed or a contractor doing similar work for different companies, include that as one job. Think about all the jobs you had between (-3) and (DOIB/END BF) starting with the most recent.
|
MI SEED III Sect H Occupational History 8/25/2016
PAGE INTENTIONALLY LEFT BLANK
MI SEED III Sect H Occupational History 8/25/2016
Study
to Explore Early Development (SEED) Page
H-
-
ASK H4A-C FOR ALL JOBS, THEN ANSWER H5-H9 FOR EACH JOB
H4A. H4B. H4C. H5.
Can you please tell me your title for the most recent job? If you had another job between (-3) and (DOIB/END BF), what was your title for that job?
JOB TITLE: |
Please tell me the name of the company or organization you (work/worked) for, or whether you (are/were) self-employed, for this job.
EMPLOYER: |
Please tell me the city and state the job (is/was) located in, for this job.
CITY/STATE: |
Next, I’m going to ask you a few questions about each of those jobs. For your job as (JOB TITLE), when did you start working at this job? Please tell me the month and year. MONTH/YEAR: |
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) .97 97 RF 98 98 DK 99 99
|
N/A (SKIP) .97 97 RF 98 9998 DK 99 9999
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) .97 97 RF 98 98 DK 99 99
|
N/A (SKIP) .97 97 RF 98 9998 DK 99 9999
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) .97 97 RF 98 98 DK 99 99
|
N/A (SKIP) .97 97 RF 98 9998 DK 99 9999
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) .97 97 RF 98 98 DK 99 99
|
N/A (SKIP) .97 97 RF 98 9998 DK 99 9999
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) .97 97 RF 98 98 DK 99 99 |
N/A (SKIP) .97 97 RF 98 9998 DK 99 9999 |
1.
/
MI SEED III Sect H Occupational History 8/25/2016
Study
to Explore Early Development (SEED) Page
H-
|
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MI SEED III Sect H Occupational History 8/25/2016
Study to Explore Early Development
(SEED) Page
H-
H6. H7. H8. H9.
When did you stop working at this job? Please tell me the month and year.
MONTH/YEAR: |
How many hours per week (do/did) you work on the job?
HOURS PER WEEK: |
What type of business (is/was) this, or what (does/did) the company make or do?
BUSINESS: |
Please describe your main duties or activities for this job, that is, what you (do/did) it. PROBE: Anything else?
MAIN DUTIES: |
N/A (SKIP) .97 9997 RF 98 9998 DK 99 9999
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99 |
N/A (SKIP) .97 9997 RF 98 9998 DK 99 9999
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99 |
N/A (SKIP) .97 9997 RF 98 9998 DK 99 9999
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99 |
N/A (SKIP) .97 9997 RF 98 9998 DK 99 9999
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99 |
N/A (SKIP) .97 9997 RF 98 9998 DK 99 9999
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99
|
N/A (SKIP) 97 RF 98 DK 99 |
#
OF JOB SUPPLEMENTS
MI SEED III Sect H Occupational History 8/25/2016
Study
to Explore Early Development (SEED) Page
H-
H10-H12D were deleted.
BLANK PAGE FOR END OF SECTION
MI SEED III Sect H Occupational History 8/25/2016
Study to Explore Early Development
(SEED) Page
J-
0SECTION J: TOBACCO, ALCOHOL, AND OTHER DRUGS |
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TOBACCO |
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J1. |
The next several questions are about your lifestyle. Did you ever smoke cigarettes? |
|
YES 01 NO (SKIP TO J5) 02 RF (SKIP TO J5) 98 DK (SKIP TO J5) 99 |
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||||||||||||||||
J2. |
At any time from (-3) to (DOIB/END BF), did you smoke cigarettes? |
|
YES 01 NO (SKIP TO J5) 02 N/A (SKIP) 97 RF (SKIP TO J5) 98 DK (SKIP TO J5) 99 |
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J3A was deleted. |
J3B. |
J3C. |
|
|
|||||||||||||||
|
Did you smoke in the three months before you became pregnant, from (-3) to (-1)? |
Did you smoke in your first trimester, from (1) to (3)? |
|
|
|||||||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||||||
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
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|
IF R DID NOT BREASTFEED, SKIP TO J4. |
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J3D. |
J3E. |
J3F. |
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|
|||||||||||||||
Did you smoke in your second trimester, from (4) to (6)? |
Did you smoke in your third trimester, from (7) to (10)? |
Did you smoke during the months you breastfed, from (DOIB/10) to (END BF)? |
|
|
|||||||||||||||
|
|
||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
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|||
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|||||||||||||||
MI SEED III Sect J Tobacco 8/25/2016
Study to Explore Early Development
(SEED) Page
J-
|
COMPLETE ONE ROW FOR EACH TRIMESTER INDICATED. |
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|||||||||||||
|
J4. |
About how many cigarettes did you smoke a day during (TRIMESTER)? |
|||||||||||||||
|
TRIMESTER |
<1/ day |
1/day |
2-4/ day |
½ Pack (5-14) |
1 Pack (15-24) |
1½ Packs (25-34) |
2 Packs (35-44) |
>2 Packs |
N/A (SKIP) |
RF |
DK |
|||||
|
1. _____________________ |
01 |
02 |
03 |
04 |
05 |
06 |
07 |
08 |
97 |
98 |
99 |
|||||
|
2. _____________________ |
01 |
02 |
03 |
04 |
05 |
06 |
07 |
08 |
97 |
98 |
99 |
|||||
|
3. _____________________ |
01 |
02 |
03 |
04 |
05 |
06 |
07 |
08 |
97 |
98 |
99 |
|||||
|
4. _____________________ |
01 |
02 |
03 |
04 |
05 |
06 |
07 |
08 |
97 |
98 |
99 |
|||||
|
5. _____________________ |
01 |
02 |
03 |
04 |
05 |
06 |
07 |
08 |
97 |
98 |
99 |
|||||
|
|
|
|
|
|||||||||||||
|
J5. |
At any time from (-3) to (DOIB/END BF), did you use other tobacco products? (PROMPT: chewing tobacco, pipe tobacco, cigar smoking). |
|
YES 01 NO 02 RF 98 DK 99 |
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|||||||||||||
|
J6. |
Did anyone else smoke one or more cigarettes regularly in your home between (-3) and (DOIB/END BF)? |
|
YES 01 NO (SKIP TO J8) 02 RF (SKIP TO J8) 98 DK (SKIP TO J8) 99 |
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MI SEED III Sect J Tobacco 8/25/2016
Study to Explore Early Development
(SEED) Page
J-
J7A was deleted. |
J7B. |
J7C. |
|
||||||||||||
|
Would you say someone else smoked cigarettes in your home during the three months before you became pregnant, from (-3) to (-1)? |
Would you say someone else smoked cigarettes in your home during your first trimester, from (1) to (3)? |
|
||||||||||||
|
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
||||
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
||||
|
|
|
|
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|
|
IF R DID NOT BREASTFEED, SKIP TO J8. |
|||||||||||||
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|
|
|
||||||||||||
J7D. |
J7E. |
J7F. |
|
||||||||||||
Would you say someone else smoked cigarettes in your home during your second trimester, from (4) to (6)? |
Would you say someone else smoked cigarettes in your home during your third trimester, from (7) to (10)? |
Would you say someone else smoked cigarettes in your home during the months you breastfed, from (DOIB/10) to (END BF)? |
|
||||||||||||
|
|||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|
|
|
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MI SEED III Sect J Tobacco 8/25/2016
Study to Explore Early Development
(SEED) Page
J-
ALCOHOL |
|
|
|||||||||||||||||
J8. |
Did you have any alcoholic drinks between (-3) and (DOIB/END BF)? We define an alcoholic drink as one beer, one glass of wine, one mixed drink, or one shot of liquor. |
|
YES 01 NO (SKIP TO J13) 02 RF (SKIP TO J13) 98 DK (SKIP TO J13) 99 |
||||||||||||||||
|
|
|
|
||||||||||||||||
J9A was deleted. |
J9B. |
J9C. |
|
|
|||||||||||||||
|
Would you say you drank in the three months before you became pregnant, from (-3) to (-1)? |
Would you say you drank in your first trimester, from (1) to (3)? |
|
|
|||||||||||||||
|
|
|
|||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
||||||||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
||||||||
|
|
|
|
|
|||||||||||||||
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|
IF R DID NOT BREASTFEED, SKIP TO J10. |
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|
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|||||||||||||||
J9D. |
J9E. |
J9F. |
|
|
|||||||||||||||
Would you say you drank in your second trimester, from (4) to (6)? |
Would you say you drank in your third trimester, from (7) to (10)? |
Would you say you drank during the months you breastfed, from (DOIB/10) to (END BF)? |
|
|
|||||||||||||||
|
|
||||||||||||||||||
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
|
|||
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
|
|
|||
COMPLETE ONE ROW FOR EACH TRIMESTER INDICATED. |
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|||||||||||
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|
J10. |
During (TRIMESTER), on average, how many drinks did you have per week? |
||||||||||||||||||
|
|
MONTH/TRIMESTER |
<1/ week |
1 or 2 |
3 or 4 |
5 or 6 |
7 or 8 |
9 or 10 |
11 or more |
N/A (SKIP) |
RF |
DK |
|
|
|
||||||
|
|
1. _____________________ |
01 |
02 |
03 |
04 |
05 |
06 |
07 |
97 |
98 |
99 |
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2. _____________________ |
01 |
02 |
03 |
04 |
05 |
06 |
07 |
97 |
98 |
99 |
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3. _____________________ |
01 |
02 |
03 |
04 |
05 |
06 |
07 |
97 |
98 |
99 |
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4. _____________________ |
01 |
02 |
03 |
04 |
05 |
06 |
07 |
97 |
98 |
99 |
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5. _____________________ |
01 |
02 |
03 |
04 |
05 |
06 |
07 |
97 |
98 |
99 |
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MI SEED III Sect J Tobacco 8/25/2016
Study to Explore Early Development
(SEED) Page
J-
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J11. |
Were there times when you had five or more drinks on one occasion between (-3) and (DOIB/END BF)? |
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YES 01 NO (SKIP TO J13) 02 N/A (SKIP) 97 RF (SKIP TO J13) 98 DK (SKIP TO J13) 99 |
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J12A was deleted. |
J12B. |
J12C. |
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Would you say you drank five or more drinks on one occasion during the three months before you became pregnant, from (-3) to (-1)? |
Would you say you drank five or more drinks on one occasion during your first trimester, from (1) to (3)? |
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YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
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01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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IF R DID NOT BREASTFEED, SKIP TO J13. |
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J12D. |
J12E. |
J12F. |
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Would you say you drank five or more drinks on one occasion during your second trimester, from (4) to (6)? |
Would you say you drank five or more drinks on one occasion during your third trimester, from (7) to (10)? |
Would you say you drank five or more drinks on one occasion during the months you breastfed, from (DOIB/10) to (END BF)? |
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YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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OTHER DRUGS |
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J13. |
Now I would like to ask you about any recreational drugs you might have used. Between (-3) and (DOIB/BF) did you use any of the following recreational or street drugs, or any prescription drugs that were not prescribed to you? READ ANSWERS AND CODE ALL THAT APPLY. |
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Marijuana 01 Cocaine 02 Ecstasy 03 Methamphetamines or crank or ice 04 Other (SPECIFY) 90 NONE (SKIP TO K1) 00 RF (SKIP TO K1) 98 DK (SKIP TO K1) 99 |
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SPECIFY:
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MI SEED III Sect J Tobacco 8/25/2016
Study to Explore Early Development
(SEED) Page
J-
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J14A was deleted. J14B. |
J14C. |
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COMPLETE ONE ROW FOR EACH DRUG USED. |
Would you say you used or took (DRUG) in the three months before you became pregnant, from (-3) to (-1)? |
Would you say you used or took (DRUG) in your first trimester, from (1) to (3)? |
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DRUG: |
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YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
#1:
|
01 |
02 |
97 |
98 |
99
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01 |
02 |
97 |
98 |
99 |
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YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
#2:
|
01
|
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
#3:
|
01
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02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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MI SEED III Sect J Tobacco 8/25/2016
Study to Explore Early Development
(SEED) Page
J-
IF
R DID NOT BREASTFEED, SKIP TO NEXT DRUG/K1.
J14D. |
J14E. |
J14F. |
||||||||||||
Would you say you used or took (DRUG) in your second trimester, from (4) to (6)? |
Would you say you used or took (DRUG) in your third trimester, from (7) to (10)? |
Would you say you used or took (DRUG) during the months you breastfed, from (DOIB/10) to (END BF)? |
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YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
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YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
YES |
NO |
N/A |
RF |
DK |
01 |
02 |
97 |
98 |
99
|
01 |
02 |
97 |
98 |
99 |
01 |
02 |
97 |
98 |
99 |
#
OF DRUG SUPPLEMENTS
MI SEED III Sect J Tobacco 8/25/2016
Study to Explore Early Development
(SEED) Page
J-
BLANK PAGE FOR END OF SECTION
MI SEED III Sect J Tobacco 8/25/2016
Study to Explore Early Development
(SEED) Page
K-
SECTION K: INCOME AND CLOSING |
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K1. |
The final survey questions ask about household income. In the 12 months prior to when you were pregnant with (CHILD), what was your estimated total household income before taxes? Please include income such as Medicaid, Social Security, and Unemployment payments. Was it (READ ANSWERS)? |
|
Less than 10 Thousand Dollars per year 01 10 to 30 Thousand Dollars 02 30 to 50 Thousand Dollars 03 50 to 70 Thousand Dollars 04 70 to 90 Thousand Dollars 05 90 to 110 Thousand Dollars 06 More than 110 Thousand Dollars 07 RF 98 DK 99 |
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INTERVIEWER NOTE: If income is exactly as start/end point, round up to the high range. For example, if income = $30,000, round up to 30-50,000. |
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K2. |
At that time, how many people were living in the household, including both adults and children? |
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#
OF PEOPLE RF 98 DK 99 |
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K2A. How many of these were children under the age of 18? |
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#
OF CHILDREN RF 98 DK 99 |
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K3. |
Do you currently live with (CHILD)? (PROBE: How much of the time do you live with [CHILD])? |
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YES, ALL OF THE TIME 01 YES, PART OF THE TIME/SHARED CUSTODY (ASK A) 02 NO, NONE OF THE TIME 03 RF 98 DK 99 |
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IF K3 NOT EQUAL TO 02, SKIP TO K4. |
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A. On average, how many days does (CHILD) live with you? |
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NUMBER
OF DAYS PER WEEK 1 PER MONTH 2 PER YEAR 3 N/A (SKIP) 97 7 RF 98 8 DK 99 9 |
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K4. |
What was your estimated total household income for the last 12 months before taxes? Please include income such as Medicaid, Social Security, and Unemployment payments. Was it (READ ANSWERS)? |
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Less than 10 Thousand Dollars per year 01 10 to 30 Thousand Dollars 02 30 to 50 Thousand Dollars 03 50 to 70 Thousand Dollars 04 70 to 90 Thousand Dollars 05 90 to 110 Thousand Dollars 06 More than 110 Thousand Dollars 07 RF 98 DK 99 |
MI SEED III Sect K Income and Closing 8/25/2016
Study to Explore Early Development
(SEED) Page
K-
K5. |
At that time, how many people were living in the household, including both adults and children? |
|
#
OF PEOPLE RF 98 DK 99 |
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K5A. How many of these were children under the age of 18? |
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#
OF CHILDREN RF 98 DK 99 |
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K6. |
I’ve asked about some things we think might be associated with development. Is there anything, including some of the factors we’ve already talked about that you think might cause autism or other developmental problems? |
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YES 01 NO (SKIP TO K8) 02 RF (SKIP TO K8) 98 DK (SKIP TO K8) 99 |
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K7. |
Can you tell me about those factors? |
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VERBATIM:
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K8. |
Why did you decide to be in this study? |
||
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VERBATIM:
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K9. |
That completes this interview. In case we need to get in touch with you in the future for this study, would you be willing to give us the name, address, and phone number of someone who should always know where you are? This information will be kept separate from your questionnaire. It will be locked except when needed by the research team, and will be destroyed when the study is finished. RECORD CONTACT INFO IN CIS. |
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IF CIS NOT AVAILABLE:
NAME OF CONTACT: PREFIX: Ms. Mrs. Mr. Dr. First Name: Last Name: Street/Apartment: City/State: Home Phone: Work Phone: Relationship: |
||
MI SEED III Sect K Income and Closing 8/25/2016
Study
to Explore Early Development (SEED) Page
K-
|
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MI SEED III Sect K Income and Closing 8/25/2016
Study to Explore Early Development
(SEED) Page
K-
|
In closing, we would like to sincerely thank you for your time and effort and your contribution to this important study. Your answers to these questions will help us greatly in our efforts to better understand the causes of autism and other developmental problems. Thank you. |
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TIME
ENDED RECORD IN MILITARY TIME. |
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|
NOTE: IF DEMOGRAPHICS RECORDED IN INTERVIEW, ENTER NOW IN CIS. |
||
:
MI SEED III Sect K Income and Closing 8/25/2016
Study to Explore Early Development
(SEED) Page
K-
BLANK PAGE FOR END OF SECTION
MI SEED III Sect K Income and Closing 8/25/2016
Study to Explore Early Development
(SEED) Page
L-
SECTION L: INTERVIEWER STATUS |
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|||||||
|
NOTE: ANSWER QUESTIONS IN SECTIONS L AND M AFTER EACH SESSION OF INTERVIEWING EVEN IF INTERVIEW WAS NOT COMPLETE. |
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||||||
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||||
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L1. |
L2. |
L3. |
L4. |
||||
|
Interviewer ID |
Was the interview a phone or in-person interview? |
Status of the interview: |
Session date:
MM DD YYYY |
||||
SESSION #1 |
|
PHONE 01 IN-PERSON 02 |
Paused, not scheduled 03 Paused, scheduled 04 Finished, needs checking 05 Submitted, incomplete 08 Submitted, complete 09 |
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SESSION #2 |
|
PHONE 01 IN-PERSON 02 |
Paused, not scheduled 03 Paused, scheduled 04 Finished, needs checking 05 Submitted, incomplete 08 Submitted, complete 09 |
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SESSION #3 |
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PHONE 01 IN-PERSON 02 |
Paused, not scheduled 03 Paused, scheduled 04 Finished, needs checking 05 Submitted, incomplete 08 Submitted, complete 09 |
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||||
SESSION #4 |
|
PHONE 01 IN-PERSON 02 |
Paused, not scheduled 03 Paused, scheduled 04 Finished, needs checking 05 Submitted, incomplete 08 Submitted, complete 09 |
|
||||
-
-
MI SEED III Sect L Interviewer Status 8/25/2016
Study to Explore Early Development
(SEED) Page
L-
BLANK PAGE FOR END OF SECTION
MI SEED III Sect L Interviewer Status 8/25/2016
Study to Explore Early Development
(SEED) Page
M-
SECTION M: INTERVIEWER REMARKS |
||||
|
NOTE: ANSWER QUESTIONS IN SECTIONS L AND M AFTER EACH SESSION OF INTERVIEWING EVEN IF INTERVIEW WAS NOT COMPLETE. |
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CODES FOR M2: |
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||
|
Did not know enough information regarding the topic 01 Did not want to be more specific 02 Sounded bored or uninterested 03 Sounded upset, depressed, or angry 04 Had poor hearing or speech 05 Sounded confused or distracted by frequent interruptions 06 Sounded inhibited by others around him or her 07 |
Sounded embarrassed by the subject matter 08 Sounded emotionally unstable 09 Sounded physically ill 10 Not comfortable with English or Spanish language 11 Doesn’t have the time 12 Felt the interview was too long 13 Did not comprehend the questions 14 Other (SPECIFY IN GRID) 90 |
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M1. |
M2. |
M3. |
|
The overall quality of the interview in this session was: |
The main reason for questionable or unsatisfactory quality of information was because the respondent: |
Was the majority of the interview done today in English or in Spanish? |
SESSION #1 |
High
quality Generally
reliable Questionable 03 Unsatisfactory 04 |
SPECIFY: |
English 01 Spanish 02 Half English/half Spanish 03 |
SESSION #2 |
High
quality Generally
reliable Questionable 03 Unsatisfactory 04 |
SPECIFY: |
English 01 Spanish 02 Half English/half Spanish 03 |
SESSION #3 |
High
quality Generally
reliable Questionable 03 Unsatisfactory 04 |
SPECIFY: |
English 01 Spanish 02 Half English/half Spanish 03 |
SESSION #4 |
High
quality Generally
reliable Questionable 03 Unsatisfactory 04 |
SPECIFY: |
English 01 Spanish 02 Half English/half Spanish 03 |
M4. |
Additional comments. Use this space for any other comments you have which may affect the interpretation of this respondent’s answers. |
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MI SEED III Sect M Interviewer Remarks v1 8/25/2016
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | McKenzie, Charmaine (CDC/ONDIEH/NCBDDD) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |
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