Maternal Interview Call

The Study to Explore Early Development (SEED) - Phase 3 (Modified for COVID-19 Impact Assessment)

Attachment 6 Maternal Interview

Maternal Interview Call

OMB: 0920-1171

Document [docx]
Download: docx | pdf

Attachment 6

Study to Explore Early Development (SEED) Page A-0

Shape1


SECTION A: PRELIMINARY INFORMATION


TIME STARTED :




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.









A1*.

I would like to begin by asking you some basic questions. What is your full name?


FIRST NAME:

MIDDLE NAME:

LAST NAME:

SUFFIX:

MAIDEN NAME:





A2*.

What is your date of birth?


DOB - -

MM DD YYYY





A3*.

What is (CHILD)’s full name?


FIRST NAME:

MIDDLE NAME:

LAST NAME:

SUFFIX:





A4*.

What is (CHILD)’s date of birth? RECORD DATE HERE AND ON PREGNANCY REFERENCE FORM.


DOIB - -

MM DD YYYY





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.








A1.

I would like to begin by confirming some basic information about you and (CHILD). Is your full name (FULL NAME FROM CIS)?


YES 01

NO (UPDATE IN CIS) 02





A2.

Is your date of birth (MM/DD/YYYY DOB FROM CIS)?


YES 01

NO (UPDATE IN CIS) 02





A3.

Is (CHILD)’s full name (CHILD’S FULL NAME FROM CIS)?


YES 01

NO (UPDATE IN CIS) 02



MI SEED III Sect A Prelim Info doc 8/25/2016

Study to Explore Early Development (SEED) Page A-0

Shape2






A4.

Is (CHILD)’s date of birth (MM/DD/YYYY DOIB FROM CIS)?


YES 01

NO (UPDATE IN CIS) 02





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.



YES 01

NO (UPDATE IN CIS) 02






During the interview, occasionally I’ll ask you to refer to the booklet you received in the mail labeled “Maternal Interview Prep Guide.”





A6.

Do you have the guide in front of you now?


YES (SKIP TO B2) 01

NO 02

RF 98

DK 99














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.

































MI SEED III Sect A Prelim Info doc 8/25/2016



Study to Explore Early Development (SEED) Page B-0

Shape3


SECTION B: SOCIODEMOGRAPHICS








I am going to ask you some basic questions about your family background and education.





B1.

DELETED







B2.

Were you born in the US?


YES (SKIP TO B6) 01

NO 02

RF (SKIP TO B6) 98

DK (SKIP TO B6) 99





B3.

What country were you born in?


COUNTRY:

N/A (SKIP) 97

RF 98

DK 99





B4.

What year did you come to the US to live?


YEAR (SKIP TO B6)

N/A (SKIP) 9997

RF (SKIP TO B6) 9998

DK 9999





B5.

How old were you when you came to the US to live?


AGE: YEARS

AND/OR MONTHS

N/A (SKIP) 97 97

RF 98 98

DK 99 99





B6.

What language do you usually speak at home?


ENGLISH 01

SPANISH 02

OTHER (SPECIFY) 90

RF 98

DK 99


SPECIFY:





B7.

Do you consider yourself of Hispanic or Latina origin?


YES 01

NO (SKIP TO B8) 02

RF (SKIP TO B8) 98

DK (SKIP TO B8) 99






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.?)


GROUP:

N/A (SKIP) 97

RF 98

DK 99













MI SEED III Sect B Sociodemographics 8/25/2016

Study to Explore Early Development (SEED) Page B-0

Shape4


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.


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






IF B8 INCLUDES CODE 01, ASK B8A. OTHERWISE, SKIP TO B8B.






A. What tribe do you consider yourself a member of?


TRIBE:

N/A (SKIP) 97

RF 98

DK 99






IF B8 INCLUDES CODE 02 OR 04, ASK B8B. OTHERWISE, SKIP TO B9.






B. What is your country of ethnic origin? (PROMPT: Referring to Asian, Native Hawaiian or other Pacific Island countries.)


COUNTRY:

N/A (SKIP) 97

RF 98

DK 99





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.


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






IF B9 NOT EQUAL TO 02, SKIP TO B10.






A. How many years of school did you complete?


# OF YEARS

N/A (SKIP) 97

RF 98

DK 99





B10.

Is that the highest grade or year of school or college you have currently completed?


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-0

Shape5







B11.

What is the highest grade or year of school or college that you have currently completed? READ LIST. SELECT ONE.


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






IF B11 NOT EQUAL TO 02, SKIP TO B11B.




A. How many years of school did you complete?



# OF YEARS

N/A (SKIP) 97

RF 98

DK 99


B11B.

At the time of (CHILD’S) birth, were you married, living with a partner, separated, divorced, widowed, or never married?



Married……………………………..... 01

living with a partner 02

Separated……………. 03

Divorced………………. 04

Widowed………………. 05

Never Married………. 06

RF 98

DK…………………………………….………………………99





B11C.

Are you currently married, living with a partner, separated, divorced, widowed, or never married?



Married 01

living with a partner 02

Separated…………….. 03

Divorced………………. 04

Widowed………………. 05

Never Married………. 06

RF 98

DK…………………………………………………………….99

























MI SEED III Sect B Sociodemographics 8/25/2016

Study to Explore Early Development (SEED) Page B-0

Shape6


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.


DK FATHER (SKIP TO B34) 01

KNOWS FATHER 02

N/A (SKIP) 97

RF (SKIP TO B34) 98





B13.

What is (CHILD)’s biological father’s birthdate?


DOB - -

MM DD YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999





B14.

Was he born in the US?


YES (SKIP TO B18) 01

NO 02

N/A (SKIP) 97

RF (SKIP TO B18) 98

DK (SKIP TO B18) 99





B15.

What country was he born in?


COUNTRY:

N/A (SKIP) 97

RF 98

DK 99





B16.

What year did he come to the US to live?


YEAR (SKIP TO B18)

N/A (SKIP) 9997

RF (SKIP TO B18) 9998

DK 9999





B17.

How old was he when he came to the US to live?


AGE: YEARS

AND/OR MONTHS

N/A (SKIP) 97 97

RF 98 98

DK 99 99





B18.

What language does he usually speak at home?


ENGLISH 01

SPANISH 02

OTHER (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99



SPECIFY:









B19.

Does he consider himself of Hispanic or Latino origin?


YES 01

NO (SKIP TO B20) 02

NA (SKIP) 97

RF (SKIP TO B20) 98

DK (SKIP TO B20) 99










MI SEED III Sect B Sociodemographics 8/25/2016

Study to Explore Early Development (SEED) Page B-0

Shape7



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.?)


GROUP:


N/A (SKIP) 97

RF 98

DK 99









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.


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






IF B20 INCLUDES CODE 01, ASK B20A. OTHERWISE, SKIP TO B20B.






A. What tribe does he consider himself a member of?


TRIBE:

N/A (SKIP) 97

RF 98

DK 99






IF B20 INCLUDES CODE 02 OR 04, ASK B20B. OTHERWISE, SKIP TO B21.






B. What is his country of ethnic origin? (PROMPT: Referring to Asian, Native Hawaiian or other Pacific Island countries.)


COUNTRY:

N/A (SKIP) 97

RF 98

DK 99





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.


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






IF B21 NOT EQUAL TO 02, SKIP TO B22.






A. How many years of school did he complete?


# OF YEARS

N/A (SKIP) 97

RF 98

DK 99



MI SEED III Sect B Sociodemographics 8/25/2016

Study to Explore Early Development (SEED) Page B-0

Shape8






B22.

Is that the highest grade or year of school or college he has currently completed?


YES (SKIP TO B23B) 01

NO 02

N/A (SKIP) 97

RF (SKIP TO B23B) 98

DK (SKIP TO B23B) 99





B23.

What is the highest grade or year of school or college that he has currently completed? READ LIST. SELECT ONE.


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






IF B23 NOT EQUAL TO 02, SKIP TO B23B.






A. How many years of school did he complete?


# OF YEARS

N/A (SKIP) 97

RF 98

DK 99


B23b.

At the time of (CHILD’s) birth, did he live in the home with you and (CHILD)?


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






b23c.

Is he currently living in the home with you and (CHILD)?


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


B24–B33.

DELETED.















MI SEED III Sect B Sociodemographics 8/25/2016



Study to Explore Early Development (SEED) Page B-0

Shape9

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)?


YES 01

NO (SKIP TO NEXT SECTION) 02

RF (SKIP TO NEXT SECTION) 98

DK (SKIP TO NEXT SECTION) 99






A. What is that person’s relationship to (CHILD)?



NONBIOLOGICAL FATHER …………………………...…00

STEPMOTHER 01

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

DAD’S PARTNER 12

OTHER (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:




B35.

What is (CAREGIVER)’s birthdate?


DOB - -

MM DD YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999








B36.

Was (CAREGIVER) born in the US?


YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99





B37-B39

DELETED







B40.

What language does (CAREGIVER) usually speak at home?


ENGLISH 01

SPANISH 02

OTHER (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:



MI SEED III Sect B Sociodemographics 8/25/2016



Study to Explore Early Development (SEED) Page B-0

Shape10




B41.

Does (he consider himself/she consider herself) of Hispanic or (Latino/Latina) origin?


YES 01

NO (SKIP TO B42) 02

N/A (SKIP) 97

RF (SKIP TO B42) 98

DK (SKIP TO B42) 99







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.?)


GROUP:

N/A (SKIP) 97

RF 98

DK 99





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.


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






IF B42 INCLUDES CODE 01, ASK B42A. OTHERWISE, SKIP TO B42B.






A. What tribe does (he/she) consider (himself/herself) a member of?


TRIBE:

N/A (SKIP) 97

RF 98

DK 99






IF B42 INCLUDES CODE 02 OR 04, ASK B42B. OTHERWISE, SKIP TO B43.






B. What is (his/her) country of ethnic origin? (PROMPT: Referring to Asian, Native Hawaiian or other Pacific Island countries.)


COUNTRY:

N/A (SKIP) 97

RF 98

DK 99


B43-44

DELETED



B45.

What is the highest grade or year of school or college that (CAREGIVER) has currently completed?

READ ANSWERS. SELECT ONE.


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






MI SEED III Sect B Sociodemographics 8/25/2016


Study to Explore Early Development (SEED) Page B-0

Shape11



IF B45 NOT EQUAL TO 02, SKIP TO B46.






A. How many years of school did (he/she) complete?


# OF YEARS

N/A (SKIP) 97

RF 98

DK 99





B46.

Are there any (other) adults living with you who have major caregiving responsibilities for (CHILD)?


YES 01

NO (SKIP TO NEXT SECTION) 02

RF (SKIP TO NEXT SECTION) 98

DK (SKIP TO NEXT SECTION) 99






A. What is the relationship of that person or persons to (CHILD)? (Check all that apply)



NONBIOLOGICAL FATHER …………………………...…00

STEPMOTHER 01

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

DAD’S PARTNER 12

OTHER (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:


SPECIFY:























MI SEED III Sect B Sociodemographics 8/25/2016



Study to Explore Early Development (SEED) Page C-0

Shape12


SECTION C: MATERNAL REPRODUCTIVE AND PREGNANCY HISTORY





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?


AGE IN YEARS AND MONTHS (SKIP TO C2)

YRS MOS

RF (SKIP TO C2) 98 98

DK 99 99






A. What grade were you in when you had your first menstrual period?


GRADE

N/A (SKIP) 97

RF 98

DK 99





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.


# OF DAYS

IRREGULAR PERIOD 90

RF 98

DK 99





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).


# OF PREGNANCIES

RF 98

DK 99





C4.

How many babies were you carrying during your (1st/2nd/3rd) pregnancy? (PROBE: Did you have a single baby, twins, or more babies?)






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.







# OF BABIES

N/A (SKIP)

RF

DK


PREGNANCY 1


98

99


PREGNANCY 2

97

98

99


PREGNANCY 3

97

98

99


PREGNANCY 4

97

98

99


PREGNANCY 5

97

98

99


PREGNANCY 6

97

98

99


PREGNANCY 7

97

98

99


PREGNANCY 8

97

98

99


BABY COUNT


98




(IF ALL PREGS=RF, SKIP TO C18)


NUMBER OF BABIES/PREGNANCY SUPPLEMENTS


IF C3 = 1 AND C4 = 1, READ: This baby must be (CHILD). CODE C5 = 1 AND C6 = 1, AND SKIP TO C10.





OTHERWISE, READ: I would now like to ask you a few questions about the outcomes of each of your pregnancies. COMPLETE ONE ROW OF BABY TABLE (C5–C14) FOR EACH BABY.





MI SEED III Sect C Maternal History 8/25/2016

Study to Explore Early Development (SEED) Page C-0

Shape13


C5.

C6.

C7.

C8.

Shape14 C9A.

BABY COUNT:


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)?



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?




What is (BABY)’s birthdate?

BABY:






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






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.







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






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.







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-0

Shape15

C9B.

C10.

C11.

C12.

Shape16 C13A.

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,
SKIP TO C14.






-

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,
SKIP TO C14.






-

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,
SKIP TO C14.






-

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,
SKIP TO C14.





MI SEED III Sect C Maternal History 8/25/2016

Study to Explore Early Development (SEED) Page C-0

Shape17

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
retardation 15

Movement or coordination problems 16

Neurofibromatosis 17

Obsessive compulsive disorder 18

Pervasive Developmental Disorder
not otherwise specified 19

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
(
SPECIFY) 31

N/A(SKIP) 97

RF 98

DK 99

NONE 00

Shape18


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-0

Shape19

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-0

Shape20



IF C3 = 1 AND C4 = 1, SKIP TO C18.







COMPLETE ONE ROW (C15–C17) FOR EACH PREGNANCY IN C3.







I have just a few more questions about each of your pregnancies.








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.








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.









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.









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.









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-0

Shape21


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-0

Shape22















BLANK PAGE FOR END OF SECTION


















































MI SEED III Sect C Maternal History 8/25/2016

Study to Explore Early Development (SEED) Page D-0

Shape23


SECTION D: INDEX PREGNANCY



INTERVIEWER NOTE: ASK R TO TAKE OUT PREGNANCY REFERENCE FORM SENT WITH THE PREP GUIDE.






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-0

Shape24






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





D3.

What is your height without your shoes?


FEET

INCHES

OR

M

CM

RF 998

DK 999





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-0

Shape25


















PAGE INTENTIONALLY LEFT BLANK.














































MI SEED III Sect D Index Pregnancy 8/25/2016

Study to Explore Early Development (SEED) Page D-0

Shape26


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





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.






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)?

Shape27 Would you say you were using the pill in your first trimester, from (1) to (3)?

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
























MI SEED III Sect D Index Pregnancy 8/25/2016

Study to Explore Early Development (SEED) Page D-0

Shape28






















Shape29

IF R DID NOT BREASTFEED,
SKIP TO NEXT PILL/D8.




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-0

Shape30


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)?

Shape31 Would you say you were using (METHOD) in your first trimester, from (1) to (3)?

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-0

Shape32






































Shape33

IF R DID NOT BREASTFEED,
SKIP TO NEXT METHOD/D11A.









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-0

Shape34


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 OR THIRD TRIMESTER AND THUS, DID NOT USE CONTRACEPTION DURING 3 MONTHS BEFORE PREGNANCY OR FIRST TRIMESTER (NONE OF THE FOLLOWING ARE CODED AS 01 YES: D7B, D7C, D10B, D10C).

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)


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





D11A.

Did you (READ ANSWERS)?


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








SKIP TO D12.





D11B.

Did you (READ ANSWERS)?


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





D11C.

Did you (READ ANSWERS)?


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











MI SEED III Sect D Index Pregnancy 8/25/2016

Study to Explore Early Development (SEED) Page D-0

Shape35






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.


YES 01

NO (SKIP TO D14) 02

RF (SKIP TO D14) 98

DK …………………….(SKIP TO D14) 99






IF FATHER UNKNOWN (B12 = 01), SKIP TO D14.







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?


YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99





D14.

Before getting pregnant with (CHILD), were you trying to get pregnant?


YES 01

NO (SKIP TO D16) 02

RF (SKIP TO D16) 98

DK (SKIP TO D16) 99





D15.

How long had you been trying to get pregnant?


MONTHS

AND/OR

YEARS

N/A (SKIP) 97 97

RF 98 98

DK 99 99





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.


YES 01

NO (SKIP TO D18) 02

RF (SKIP TO D18) 98

DK (SKIP TO D18) 99






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)?


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


SPECIFY:



MI SEED III Sect D Index Pregnancy 8/25/2016

Study to Explore Early Development (SEED) Page D-0


Shape36





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.


YES 01

NO (SKIP TO D21) 02

RF (SKIP TO D21) 98

DK (SKIP TO D21) 99






D19.

Were you ever told by a doctor or health care provider that you had (READ ANSWERS AND CODE ALL THAT APPLY)?


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


SPECIFY:






IF FATHER UNKNOWN (B12 = 01), SKIP TO D23.








IF D19 NOT EQUAL TO 08, SKIP TO D21.







D20.

Were the anti-sperm antibodies associated with (CHILD)’s father or a different partner?


(CHILD’S) FATHER 01

DIFFERENT PARTNER 02

N/A (SKIP) 97

RF 98

DK 99





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?


YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99





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?


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 D-0

Shape37





DK 99



































































MI SEED III Sect D Index Pregnancy 8/25/2016

Study to Explore Early Development (SEED) Page D-0

Shape38



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).






IF FATHER UNKNOWN (B12 = 01), SKIP TO D27.







D23.

Prior to becoming pregnant with (CHILD), did (CHILD)’s father take any medications to help you become pregnant with (him/her)?


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 D-0

Shape39






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.


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


SPECIFY MEDICINE 1:


SPECIFY MEDICINE 2:


SPECIFY MEDICINE 3:





D25.

Prior to becoming pregnant with (CHILD), did (CHILD)’s father ever have any procedures or surgeries to help you become pregnant?


YES 01

NO (SKIP TO D27) 02

N/A (SKIP) 97

RF (SKIP TO D27) 98

DK (SKIP TO D27) 99





D26.

What was the procedure? READ LIST IF NEEDED. Are there any more procedures? CODE ALL THAT APPLY.


Vasectomy reversal 01

Surgery because of varicocele 02

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:


SPECIFY:







MI SEED III Sect D Index Pregnancy 8/25/2016

Study to Explore Early Development (SEED) Page D-0

Shape40







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?


YES 01

NO (SKIP TO D29) 02

RF (SKIP TO D29) 98

DK (SKIP TO D29) 99





D28.

What was the procedure? Were there any more procedures? CODE ALL THAT APPLY.


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


SPECIFY:





d29.

Did you take any medications to help prevent miscarriage with your pregnancy with (CHILD)?


YES 01

NO (SKIP TO D31) 02

RF (SKIP TO D31) 98

DK (SKIP TO D31) 99





D30.

ASK R TO REFER TO LIST 4b IN THE PREP GUIDE. What medications did you take? READ LIST AND CODE ALL THAT APPLY.


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


SPECIFY:


SPECIFY:





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.


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 D-0

Shape41







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.


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


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


SPECIFY MEDICINE 1:


SPECIFY MEDICINE 2:


SPECIFY MEDICINE 3:





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)?


YES 01

NO (SKIP TO D37) 02

RF (SKIP TO D37) 98

DK (SKIP TO D37) 99

















MI SEED III Sect D Index Pregnancy 8/25/2016

Study to Explore Early Development (SEED) Page D-0

Shape42



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.)


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


SPECIFY:










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.



D35.

D36.


For (PROCEDURE), were (READ CHOICES) used?

Were (READ CHOICES) used?

PROCEDURE #1:


YES

NO

NA

RF

DK


YES

NO

NA

RF

DK



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

Donor embryos

01

02

97

98

99








PROCEDURE #2:


YES

NO

NA

RF

DK


YES

NO

NA

RF

DK



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

Donor embryos

01

02

97

98

99








PROCEDURE #3:


YES

NO

NA

RF

DK


YES

NO

NA

RF

DK



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

Donor embryos

01

02

97

98

99







# OF ASSISTED REPRODUCTION PROCEDURE SUPPLEMENTS









MI SEED III Sect D Index Pregnancy 8/25/2016

Study to Explore Early Development (SEED) Page D-0

Shape43




MORNING SICKNESS




Now I have some more detailed questions about your pregnancy with (CHILD). Please have the Pregnancy Reference Form handy.




D37.


During the pregnancy with (CHILD), did you have any nausea?


YES 01

NO (SKIP TO D40) 02

RF (SKIP TO D40) 98

DK (SKIP TO D40) 99









D38A was deleted





D38B.

D38C.

D38D.



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)?



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.







d39.

How often during (TRIMESTER) did you have nausea? Would you say it was (READ ANSWERS)?






TRIMESTER

Less than once a week

Once a week

A few times a week

Every day

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-0

Shape44


D40.

During the pregnancy with (CHILD), did you have any vomiting?


YES 01

NO (SKIP TO D43) 02

RF (SKIP TO D43) 98

DK (SKIP TO D43) 99


D41A was deleted



D41B.

D41C.

D41D.


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)?


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.







d42.

How often during (TRIMESTER) did you have vomiting? Would you say it was (READ ANSWERS)?





TRIMESTER

Less than once a week

Once a week

A few times a week

Every day

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





IF NO NAUSEA OR VOMITING (BOTH D37 AND D40 = 02, 98, OR 99), SKIP TO D45.





d43.

Did you ever require medical treatment for the nausea or vomiting?


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 D-0

Shape45








D44.

What medicine did you take? Was it (READ ANSWERS AND CODE ALL THAT APPLY)?


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



SPECIFY:


SPECIFY:






D44A.

Did you require any other medical treatments for the nausea such as Sea Bands or bed rest?


YES (SPECIFY) 01

NO 02

N/A (SKIP) 97

RF 98

DK 99



SPECIFY:






PRENATAL CARE




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.


YES 01

NO 02

RF 98

DK 99







D46.

Between (-3) and (DOIB/END BF), did you take any other vitamins or minerals?


YES 01

NO (SKIP TO D48) 02

RF (SKIP TO D48) 98

DK (SKIP TO D48) 99







D47.

Did you take (READ ANSWERS AND CODE ALL THAT APPLY)?


Multivitamins 01

Vitamin A 02

Folic Acid 03

Iron 04

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99



SPECIFY:


SPECIFY:





D48.

During your pregnancy with (CHILD), how many ultrasounds did you have?


NONE (SKIP TO D52) 00

# OF ULTRASOUNDS

RF (SKIP TO D52) 98

DK 99




MI SEED III Sect D Index Pregnancy 8/25/2016

Study to Explore Early Development (SEED) Page D-0

Shape46







D49.

Did you have any ultrasounds which showed any problems or confirmed abnormalities with the fetus, placenta, amniotic fluid, or any other problems?


YES 01

NO (SKIP TO D52) 02

N/A (SKIP) 97

RF (SKIP TO D52) 98

DK (SKIP TO D52) 99







D50.

Was the problem or abnormality with (READ ANSWERS AND CODE ALL THAT APPLY)?


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



SPECIFY:


SPECIFY:


SPECIFY:







D51A was deleted.




D51B.

D51C.

D51D.



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






























MI SEED III Sect D Index Pregnancy 8/25/2016

Study to Explore Early Development (SEED) Page D-0

Shape47



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)















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-0

Shape48











PAGE INTENTIONALLY LEFT BLANK.


























































MI SEED III Sect D Index Pregnancy 8/25/2016

Study to Explore Early Development (SEED) Page D-0

Shape49



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





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)?

Shape50 Would you say you had (TEST) done in your second trimester, from (4) to (6)?


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-0

Shape51



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-0

Shape52



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




Shape53

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-0

Shape54



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-0

Shape55



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-0

Shape56



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-0

Shape57
















BLANK PAGE FOR END OF SECTION
















































MI SEED III Sect D Index Pregnancy 8/25/2016

Study to Explore Early Development (SEED) Page E-0

Shape58



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
(SPECIFY) 90

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-0

Shape59


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.

Shape60 E2C.



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
























E3.

Shape61

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.

Shape62 E4C.





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
(-3) and (
DOIB/END BF)?


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




Shape63


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-0

Shape64



Shape65

IF R DID NOT BREASTFEED, SKIP TO E3.

E2D.

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

Shape66

IF R DID NOT BREASTFEED,
SKIP TO NEXT MED/NEXT COND/E5

N/A (SKIP) 97

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




Shape67

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)?

Shape68

C

F

What was the highest temperature recorded using a thermometer during your fever?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

TEMP . C

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-0

Shape69

Shape70

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.

Shape71

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.

Shape72 E4C.



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
(-3) and (
DOIB/END BF)?


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




Shape73


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-0

Shape74

Shape75

IF R DID NOT BREASTFEED, SKIP TO E3.

E2D.

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

Shape76

IF R DID NOT BREASTFEED,
SKIP TO NEXT MED/NEXT COND/E5

N/A (SKIP) 97

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




Shape77

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)?

Shape78

C

F

What was the highest temperature recorded using a thermometer during your fever?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

TEMP . C

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-0

Shape79


Shape80

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.

Shape81

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.

Shape82 E4C.


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
(-3) and (
DOIB/END BF)?


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




Shape83


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-0

Shape84




Shape85

IF R DID NOT BREASTFEED, SKIP TO E3.

E2D.

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

Shape86

IF R DID NOT BREASTFEED,
SKIP TO NEXT MED/NEXT COND/E5

N/A (SKIP) 97

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




Shape87

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)?

Shape88

C

F

What was the highest temperature recorded using a thermometer during your fever?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

TEMP . C

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-0

Shape89


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.

Shape90 E11C.


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-0

Shape91

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















Shape92

IF R DID NOT BREASTFEED,
SKIP TO NEXT MED/E12.



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-0

Shape93



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.

Shape94 E14C.


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-0

Shape95


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.

Shape96

IF R DID NOT BREASTFEED,
SKIP TO NEXT TREATMENT/E15.

What treatments did you have? Was it (READ ANSWERS AND CODE ALL THAT APPLY)?


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-0

Shape97



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-0

Shape98



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














Shape99

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-0

Shape100



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














Shape101

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-0

Shape102



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














Shape103

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-0

Shape104



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.



Shape105


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-0

Shape106



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




Shape107

IF R DID NOT BREASTFEED,
SKIP TO NEXT PROC/E24.





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-0

Shape108



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.

Shape109 E26A was deleted. E26B.


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-0

Shape110






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.









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 TEST/TREATMENT SUPPLEMENTS





MI SEED III Sect E Maternal Medical Conditions 8/25/2016

Study to Explore Early Development (SEED) Page E-0

Shape111


MEDICATION USE








I will ask you about medications that you might have taken for specific conditions and symptoms from (-3) through (DOIB/END BF).







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.








Acne 01

Allergy 1: 02

Allergy 2: 03

Anxiety disorder 04

Arthritis 05

Asthma 06

Attention Deficit Hyperactivity Disorder 07

Autoimmune disorders (see List 8 in prep guide):

1: 08

2: 43

Back pain 09

Bipolar disorder 10

Cancer 11

Cardiovascular condition 1: 12

Cardiovascular condition 2: 13

Cold or cough 14

Constipation 15

Depression 16

Diabetes 17

Dieting 18

Eating disorder 1: 19

Eating disorder 2: 20

Eczema or Psoriasis 21

Endocrine disorder 1: 22

Endocrine disorder 2: 23



Gastrointestinal disorder 1: 24

Gastrointestinal disorder 2: 25

General headaches 26

Heartburn 27

High blood pressure 28

Migraine headaches 29

Neuromuscular disorder 1: 30

Neuromuscular disorder 2: 31

Nicotine addiction 32

Obesity 33

Obsessive compulsive disorder 34

Personality disorder 35

Respiratory condition 1: 36

Respiratory condition 2: 37

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


SPECIFY:


SPECIFY:


SPECIFY:





ANSWER E28–E29 FOR EACH CONDITION.










MI SEED III Sect E Maternal Medical Conditions 8/25/2016

Study to Explore Early Development (SEED) Page E-0

Shape112















PAGE INTENTIONALLY LEFT BLANK


















































MI SEED III Sect E Maternal Medical Conditions 8/25/2016

Study to Explore Early Development (SEED) Page E-0

Shape113


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


Shape114



E29A was deleted.

E29B.

E29C.



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































#2:


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK



01

02

97

98

99

01

02

97

98

99





















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


Shape115



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































#2:


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-0

Shape116




Shape117

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




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 1 MEDICINE SUPPLEMENTS



Shape118

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 2 MEDICINE SUPPLEMENTS











MI SEED III Sect E Maternal Medical Conditions 8/25/2016

Study to Explore Early Development (SEED) Page E-0

Shape119

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





E29B.

Shape120 E29C.



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































#2:


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK



01

02

97

98

99

01

02

97

98

99





















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


Shape121



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































#2:


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-0

Shape122





Shape123

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









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




Shape124

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 4 MEDICINE SUPPLEMENTS










MI SEED III Sect E Maternal Medical Conditions 8/25/2016

Study to Explore Early Development (SEED) Page E-0

Shape125

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.

Shape126 E29C.



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































#2:


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK



01

02

97

98

99

01

02

97

98

99























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


Shape127



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































#2:


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-0

Shape128





Shape129

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









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





Shape130

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-0

Shape131



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

Shape132

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






MI SEED III Sect E Maternal Medical Conditions 8/25/2016

Study to Explore Early Development (SEED) Page E-0

Shape133

E13.

Shape134

IF R DID NOT BREASTFEED,
SKIP TO NEXT SHOT/E33.

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 ANTIBIOTICS 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




















































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-0

Shape135





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-0

Shape136


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-0

Shape137




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-0

Shape138






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-0

Shape139


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-0

Shape140






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-0




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











# 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-0

Shape141





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 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-0

Shape142



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





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


SPECIFY





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
(SPECIFY) 04

Emergency cesarean section 05

RF 98

DK 99


SPECIFY






IF F10 NOT EQUAL TO 01, SKIP TO F13.







F11.

Were forceps used or was vacuum extraction done to aide delivery?








YES

NO

N/A
(SKIP)

RF

DK


a. Forceps

01

02

97

98

99


b. Vacuum extraction

01

02

97

98

99





F12.

Was the baby breech?


YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99





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-0

Shape143


SPECIFY



































































MI SEED III Sect F Obstetric and Delivery 8/25/2016

Study to Explore Early Development (SEED) Page F-0

Shape144



IF F13 NOT EQUAL TO 02, SKIP TO F15.






Shape145

C

F


F14.

What was the highest temperature recorded during your fever?


TEMPERATURE .

N/A (SKIP) 997

RF 998

DK 999





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:






IF F15 NOT EQUAL TO 09, SKIP TO SECTION H.







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-0

Shape146

















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-0

Shape147


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

DK (SKIP TO H2B) 99




Shape148 H1D. What was your major field of study? SPECIFY



MAJOR:

N/A (SKIP) 97

RF 98

DK 99



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-0

Shape149





IF HAD A JOB (H1A=01), SKIP TO H4 BOX




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

Disabled 02

Unemployed or between jobs (ASK H3B) 03

Incarcerated 04


Something else? (SPECIFY) 90


N/A (SKIP) 97


RF 98


DK 99

SPECIFY: ______________________________________________________________________



IF H3A NOT EQUAL TO 03, SKIP TO SECTION J




H3B. What was your usual job or job title?

SPECIFY:


N/A (SKIP) 97


RF 98


DK 99




SKIP TO SECTION J



H4 INSTRUCTION BOX:

Shape150

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

Shape151 Study to Explore Early Development (SEED) Page H-0


ASK H4A-C FOR ALL JOBS, THEN ANSWER H5-H9 FOR EACH JOB

Shape152

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:

Shape154 1.


N/A (SKIP) 97

RF 98

DK 99





Shape155


N/A (SKIP) 97

RF 98

DK 99


Shape156

Shape157

N/A (SKIP) .97 97

RF 98 98

DK 99 99




/


N/A (SKIP) .97 97

RF 98 9998

DK 99 9999


Shape158 2.


N/A (SKIP) 97

RF 98

DK 99




Shape159


N/A (SKIP) 97

RF 98

DK 99


Shape160

Shape161

N/A (SKIP) .97 97

RF 98 98

DK 99 99



/


N/A (SKIP) .97 97

RF 98 9998

DK 99 9999


Shape162 3.


N/A (SKIP) 97

RF 98

DK 99





Shape163


N/A (SKIP) 97

RF 98

DK 99


Shape164

Shape165

N/A (SKIP) .97 97

RF 98 98

DK 99 99



/


N/A (SKIP) .97 97

RF 98 9998

DK 99 9999


Shape166 4.


N/A (SKIP) 97

RF 98

DK 99




Shape167


N/A (SKIP) 97

RF 98

DK 99


Shape168

Shape169

N/A (SKIP) .97 97

RF 98 98

DK 99 99



/


N/A (SKIP) .97 97

RF 98 9998

DK 99 9999


Shape170 5.


N/A (SKIP) 97

RF 98

DK 99



Shape171


N/A (SKIP) 97

RF 98

DK 99


Shape172

Shape173

N/A (SKIP) .97 97

RF 98 98

DK 99 99


/


N/A (SKIP) .97 97

RF 98 9998

DK 99 9999


MI SEED III Sect H Occupational History 8/25/2016

Study to Explore Early Development (SEED) Page H-0

Shape174








































































MI SEED III Sect H Occupational History 8/25/2016

Study to Explore Early Development (SEED) Page H-0

Shape175





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



Shape176


N/A (SKIP) 97

RF 98

DK 99



Shape177


Shape178

Shape179

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



Shape180


N/A (SKIP) 97

RF 98

DK 99



Shape181


Shape182

Shape183

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



Shape184


N/A (SKIP) 97

RF 98

DK 99



Shape185


Shape186

Shape187

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



Shape188


N/A (SKIP) 97

RF 98

DK 99



Shape189


Shape190

Shape191

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



Shape192


N/A (SKIP) 97

RF 98

DK 99



Shape193


Shape194

Shape195

N/A (SKIP) 97

RF 98

DK 99

Shape197 Shape196

Shape198 # OF JOB SUPPLEMENTS


MI SEED III Sect H Occupational History 8/25/2016

Study to Explore Early Development (SEED) Page H-0

Shape199






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-0

Shape200


0SECTION J: TOBACCO, ALCOHOL, AND OTHER DRUGS







TOBACCO







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





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





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










IF R DID NOT BREASTFEED, SKIP TO J4.







J3D.

J3E.

J3F.



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






























MI SEED III Sect J Tobacco 8/25/2016

Study to Explore Early Development (SEED) Page J-0

Shape201



COMPLETE ONE ROW FOR EACH TRIMESTER INDICATED.















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







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









































MI SEED III Sect J Tobacco 8/25/2016

Study to Explore Early Development (SEED) Page J-0

Shape202



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







IF R DID NOT BREASTFEED, SKIP TO J8.





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













































MI SEED III Sect J Tobacco 8/25/2016

Study to Explore Early Development (SEED) Page J-0

Shape203



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










IF R DID NOT BREASTFEED, SKIP TO J10.







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.



















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






2. _____________________

01

02

03

04

05

06

07

97

98

99






3. _____________________

01

02

03

04

05

06

07

97

98

99






4. _____________________

01

02

03

04

05

06

07

97

98

99






5. _____________________

01

02

03

04

05

06

07

97

98

99






























MI SEED III Sect J Tobacco 8/25/2016

Study to Explore Early Development (SEED) Page J-0

Shape204







J11.

Were there times when you had five or more drinks on one occasion between (-3) and (DOIB/END BF)?


YES 01

NO (SKIP TO J13) 02

N/A (SKIP) 97

RF (SKIP TO J13) 98

DK (SKIP TO J13) 99






J12A was deleted.

J12B.

J12C.



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)?



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 J13.





J12D.

J12E.

J12F.


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)?



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







OTHER DRUGS







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.


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







SPECIFY:













MI SEED III Sect J Tobacco 8/25/2016

Study to Explore Early Development (SEED) Page J-0

Shape205












Shape206

J14A was deleted. J14B.

J14C.

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)?

DRUG:


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 J Tobacco 8/25/2016

Study to Explore Early Development (SEED) Page J-0

Shape207



Shape208

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)?

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 DRUG SUPPLEMENTS
















MI SEED III Sect J Tobacco 8/25/2016

Study to Explore Early Development (SEED) Page J-0

Shape209
















BLANK PAGE FOR END OF SECTION












































MI SEED III Sect J Tobacco 8/25/2016

Study to Explore Early Development (SEED) Page K-0

Shape210


SECTION K: INCOME AND CLOSING





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






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.





K2.

At that time, how many people were living in the household, including both adults and children?


# OF PEOPLE

RF 98

DK 99






K2A. How many of these were children under the age of 18?


# OF CHILDREN

RF 98

DK 99





K3.

Do you currently live with (CHILD)? (PROBE: How much of the time do you live with [CHILD])?


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






IF K3 NOT EQUAL TO 02, SKIP TO K4.








A. On average, how many days does (CHILD) live with you?


NUMBER OF DAYS

PER WEEK 1

PER MONTH 2

PER YEAR 3

N/A (SKIP) 97 7

RF 98 8

DK 99 9





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)?


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-0

Shape211


K5.

At that time, how many people were living in the household, including both adults and children?


# OF PEOPLE

RF 98

DK 99






K5A. How many of these were children under the age of 18?


# OF CHILDREN

RF 98

DK 99





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?


YES 01

NO (SKIP TO K8) 02

RF (SKIP TO K8) 98

DK (SKIP TO K8) 99





K7.

Can you tell me about those factors?




VERBATIM:








K8.

Why did you decide to be in this study?


VERBATIM:









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.






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-0

Shape212









































































MI SEED III Sect K Income and Closing 8/25/2016

Study to Explore Early Development (SEED) Page K-0

Shape213



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.






TIME ENDED :

RECORD IN MILITARY TIME.




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-0

Shape214















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-0

Shape215

SECTION L: INTERVIEWER STATUS



NOTE: ANSWER QUESTIONS IN SECTIONS L AND M AFTER EACH SESSION OF INTERVIEWING EVEN IF INTERVIEW WAS NOT COMPLETE.








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

- -

SESSION #2

PHONE 01

IN-PERSON 02

Paused, not scheduled 03

Paused, scheduled 04

Finished, needs checking 05

Submitted, incomplete 08

Submitted, complete 09

- -

SESSION #3

PHONE 01

IN-PERSON 02

Paused, not scheduled 03

Paused, scheduled 04

Finished, needs checking 05

Submitted, incomplete 08

Submitted, complete 09

- -

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-0

Shape216














BLANK PAGE FOR END OF SECTION














































MI SEED III Sect L Interviewer Status 8/25/2016

Study to Explore Early Development (SEED) Page M-0

Shape217

SECTION M: INTERVIEWER REMARKS


NOTE: ANSWER QUESTIONS IN SECTIONS L AND M AFTER EACH SESSION OF INTERVIEWING EVEN IF INTERVIEW WAS NOT COMPLETE.






CODES FOR M2:



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





Shape218


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
(
SKIP TO M3) 01

Generally reliable
(
SKIP TO M3) 02

Questionable 03

Unsatisfactory 04



SPECIFY:

English 01

Spanish 02

Half English/half Spanish 03

SESSION #2

High quality
(
SKIP TO M3) 01

Generally reliable
(
SKIP TO M3) 02

Questionable 03

Unsatisfactory 04



SPECIFY:

English 01

Spanish 02

Half English/half Spanish 03

SESSION #3

High quality
(
SKIP TO M3) 01

Generally reliable
(
SKIP TO M3) 02

Questionable 03

Unsatisfactory 04



SPECIFY:

English 01

Spanish 02

Half English/half Spanish 03

SESSION #4

High quality
(
SKIP TO M3) 01

Generally reliable
(
SKIP TO M3) 02

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.







MI SEED III Sect M Interviewer Remarks v1 8/25/2016

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMcKenzie, Charmaine (CDC/ONDIEH/NCBDDD)
File Modified0000-00-00
File Created2021-02-19

© 2024 OMB.report | Privacy Policy