ASD - POST ENROLLMENT _F/U Phone Call / Pregnancy Ref Form- (Mother)

STUDY TO EXPLORE EARLY DEVELOPMENT

SEED 3 Pregnancy Reference Form FAMID:__________/ DATE:________________/ TECHID:_____

Pregnancy Reference Form (PRF) - SCRIPT

This script will be used during the first Follow-up Call.

Read:

“I would like to ask you some questions now that will make the interview go faster when we next call you.”

ASK QUESTIONS 1-16 FROM PRF QUESTIONNAIRE

Read:

“Thank you. These are all the dates I need. We will confirm the dates during the interview call. We will also mail you a copy of the completed Pregnancy Reference Form for you to refer to during the telephone interview. This will help make the interview go faster.”

Fill out PRF Worksheet and PRF after the call ends.

PREGNANCY REFERENCE FORM QUESTIONS
	COPY CHILD’S BIRTHDAY FROM CIS TO Q1.
Q1.	Is (CHILD)’s birthday (READ DATE)?		CIS DATE - -
	IF INCORRECT, RECORD CORRECT DATE OF BIRTH.		CORRECT DATE - -
Q2.	During your pregnancy with (CHILD), what date did your doctor or health care provider first give you as your expected due date? (PROBE: This date may have been given during your first prenatal visit.)		ONE DATE GIVEN (RECORD BELOW) 01 NO DUE DATE GIVEN (SKIP TO Q11) 02 RF (SKIP TO Q11) 98 DK (SKIP TO Q11) 99 DATE - -
	NOTE: In case of questions, have the definition of due date available. If R is extremely unsure of the date but tries to give you one, do NOT record the date. Instead go to Q11 to help the R flesh out the information.
Q3.	Was this date based on last menstrual period (LMP) or ultrasound?		LAST MENSTRUAL PERIOD 01 ULTRASOUND 02 BOTH 03 RF 98 DK 99
Q4.	Approximately how far along were you in the pregnancy in weeks or months, when your doctor or health care provider gave you this due date? (PROBE: This date may have been given during your first prenatal visit.)		# WEEKS (SKIP TO Q6) # MONTHS (SKIP TO Q6) RF 98 DK 99
Q5.	Do you think the due date was calculated by your doctor or health care provider during your (READ ANSWERS)?		1st trimester (before 14 weeks) 01 2nd trimester (between 14 to 28 weeks) 02 3rd trimester (28 weeks and after) 03 RF 98 DK 99
Q6.	Did your doctor or health care provider ever change your due date because of an ultrasound that indicated the first date was inaccurate?		YES (RECORD VERBATIM) 01 NO (SKIP TO Q15) 02 RF 98 DK 99
	VERBATIM:
	NOTE: The woman may have been told unofficial due dates by the sonographer. In this instance, mark the answer NO, and do NOT record those instances as due dates.
Q7.	What was the final due date given to you by your doctor or health care provider? RECORD DATE AND VERBATIM.		DATE - - RF (SKIP TO Q11) 98 DK (SKIP TO Q11) 99
	VERBATIM:

	NOTE: If R is extremely unsure of the date but tries to give you one, do NOT record the date. Instead, go to Q11 to help flesh out the information.
Q8.	Was it based on an ultrasound?		YES 01 NO (SKIP TO Q15) 02 RF 98 DK 99
	NOTE: This is to confirm that the final due date was based on ultrasound for establishing due date and NOT for other reasons such as fetal distress, scheduled C-section, etc.
Q9.	When during your pregnancy in weeks or months was (that ultrasound performed/the final due date calculated)?		# WEEKS (SKIP TO Q15) # MONTHS (SKIP TO Q15) RF 98 DK 99
Q10.	Do you think (that ultrasound was during your/the final due date was calculated during your) (READ ANSWERS)?		1st trimester (before 14 weeks) 01 2nd trimester (between 14-28 weeks) 02 3rd trimester (28 weeks and after) 03 RF 98 DK 99
			SKIP TO Q15.
Q11.	Just before or after (CHILD) was born, did your doctor or health care provider tell you that (he/she) was born on time meaning that (he/she) was born at 40 weeks or 9.5 months from date of your last menstrual period?		YES (SKIP TO Q15) 01 NO 02 RF 98 DK 99
Q12.	Just before or after (CHILD) was born did your doctor or health care provider tell you that (he/she) was more than one week early or more than one week later than expected?		NO (SKIP TO Q15) 01 EARLY 02 LATE (SKIP TO Q14) 03 RF (SKIP TO Q15) 98 DK (SKIP TO Q15) 99
Q13.	How many weeks or days early was (CHILD)?		# WEEKS # DAYS RF 98 DK 99
			SKIP TO Q15.
	NOTE: If the answer is not in weeks, use the following equivalents: 1 MONTH = 4 WEEKS, 0.5 MONTHS = 2 WEEKS.
Q14.	How many weeks or days late was (CHILD)?		# WEEKS # DAYS RF 98 DK 99
	NOTE: If the answer is not in weeks, use the following equivalents: 1 MONTH = 4 WEEKS, 0.5 MONTHS = 2 WEEKS.

Q15.	Did you breastfeed (CHILD) even for a few days?		YES 01 NO (SKIP TO SCRIPT) 02 RF (SKIP TO SCRIPT) 98 DK (SKIP TO SCRIPT) 99
Q16.	How old was (CHILD) in days, weeks, or months when you completely stopped breastfeeding? Please include the time period where you continued to breastfeed while supplementing with other liquids or solids.		# DAYS # WEEKS # MONTHS RF 98 DK 99
	NOTE: If still breastfeeding, use child’s age at the time of interview.

INTERVIEWER ONLY:

Pregnancy form filled out using:

OPTION:

1. Exact due date given - used date given

2. More than one due date given - used worksheet

3. Due date not known – used date of birth as due date

(FLAG FOR ANALYSIS)

4. Due date not known – but knows child was born on time

– used date of birth as due date

5. Due date not known – but knows child was born early

– used worksheet

6. Due date not known – but knows child born late

– used worksheet

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