PRAMS Opioid Call-back Survey (English)

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

PRAMS Opioid Call Back Survey – Draft
PHONE Version – 4/2/2019

Public reporting of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (XXXX-XXXX)

The first questions are about you.

1. Are you currently working for pay?

(Don’t Read)	1	No	 Go to Question 4
	2	Yes
	8	Refused	 Go to Question 4
	9	Don’t know/Don’t Remember	 Go to Question 4

2. Please tell us about your MAIN job now. What is your job title and what are your usual activities or duties?

(Don’t Read)	Job Title: ________________________________________________________________ ___________________________________________________________________________
	Job Duties:_______________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
	8	Refused
	9	Don’t know/Don’t Remember

3. Thinking about your MAIN job now, what type of company do you work for or what does the company do or make?

(Don’t Read)	Type of Company:____________________________________________________________ ___________________________________________________________________________
	8	Refused
	9	Don’t know/Don’t Remember

4. What kind of health insurance do you have now? I’m going to read the list of types of health insurance. For each one, please tell me if you have this kind of health insurance now. Do you have ______?

(PROBE: What kind of health insurance do you have now?)

Health Insurance	(Don’t Read)
	No (1)			Yes (2)	Refused (8)	Don’t know (9)
Private health insurance from my job or the job of my husband or partner
Private health insurance from my parents
Private health insurance from the Health Insurance Marketplace or HealthCare.gov
Private health insurance that I or someone else purchase directly
Medicaid
TRICARE or other military health care
Do you have some other health insurance?
If YES, ask: What is that?
	↓
	If ALL No, ask option i
IF NONE OF ABOVE IS ‘YES’, ASK: Would you say that you do not have any health insurance now? INTERVIEWER: If the mother answered that she does not have any health insurance, check YES.

The next questions are about you and your health.

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

(PROBE: Do you currently have______?)

Condition	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Depression
Anxiety
Hepatitis B
Hepatitis C
Chronic Pain, which is pain lasting more than 12 weeks or 3 months

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

(Don’t Read)	1	Number of Visits [ _______ ]
	2	Have not had any health care visits since baby was born		 Go to Question 9
	8	Refused	 Go to Question 9
	9	Don’t know/Don’t Remember	 Go to Question 9

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

Types of Visits	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Postpartum checkup
Visit for problems I was having related to the delivery of my baby
Regular checkup at my family doctor’s or OB/GYN’s office
Visit for an illness or chronic condition
Visit for an injury
Visit for family planning or birth control
Visit for depression or anxiety
Visit to have my teeth cleaned by a dentist or dental hygienist
Prenatal care visit for a new pregnancy
Have you had another type of health care visit?
If YES, ask: What type of visit?

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

	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Talked to you about managing pain after the birth of your baby
Asked you, in person or on a form, if you drank alcoholic beverages
Asked you, in person or on a form, if you smoked cigarettes or used other tobacco products
Asked you if you were feeling down or depressed

The following questions are about your use of medications or other substances since your baby was born.

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

Prescription pain reliever	(Don’t Read)
	No (1)			Yes (2)	Refused (8)	Don’t know (9)
Hydrocodone like Vicodin®, Norco®, or Lortab®
Codeine like Tylenol® 3 or 4, these are not regular Tylenol®
Oxycodone like Percocet®, Percodan®, OxyContin®, or Roxicodone®
Tramadol like Ultram® or Ultracet®
Hydromorphone or meperidine like Demerol®, Exalgo®, or Dilaudid®
Oxymorphone like Opana®
Morphine like MS Contin®, Avinza®, or Kadian ®
Fentanyl like Duragesic®, Fentora®, or Actiq®
	↓
	If ALL No, go to question O10

INTERVIEWER: If mom said “Yes” for any of the options in Question 9, continue with the next question. If not, go to Question 13.

10. Where did you get the prescription pain relievers that you used since your baby was born? I’m going to read a list of options. For each one, please tell me if it applies to you. Were they ____________ ?

Receipt	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
In the hospital, right after the birth of your baby
OB-GYN, midwife, or prenatal care provider
Family doctor or primary care provider
Dentist or oral health care provider
Doctor in the emergency room
You had pain relievers left over from an old prescription
Friend or family member gave them to me
You got the pain relievers without a prescription some other way
Did you get them somewhere else?
If YES, ask: Where?

11. I’m going to read a list of reasons for using prescription pain relievers. For each one, please tell me if it was a reason for you during your most recent pregnancy. Was it ________?

Reasons	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
To relieve pain associated with my baby’s birth, such as pain at the site of the incision or a tear
To relieve pain from an injury, condition, or surgery I had before pregnancy
To relieve pain from an injury, condition, or surgery that happened during my pregnancy
To relax or relieve tension or stress
To help me with my feelings or emotions
To help me sleep
To feel good or get high
Because I was “hooked” or I had to have them
Was there some other reason?
If YES, ask: What was it?

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

(Don’t Read)	1	Number of weeks ___________	(Range: 1-45 weeks)
		OR
	2	Number of months ___________	(Range: 1-10 months)
	3	Less than a week
	8	Refused
	9	Don’t know/Don’t Remember

13. Since your baby was born, did you take or use any of the following medications or drugs for any reason? I’m going to read a list of options. For each one, please tell me if you took or used it since your baby was born. Did you take or use _______?

(PROBE: Since your baby was born, did you take or use ____________________________?)

Medications/Drugs	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Over-the-counter pain medication such as aspirin, Tylenol®, Tylenol PM®, Tylenol Extra Strength®, Advil®, Motrin®, or Aleve®
Medication for depression such as Prozac®, Zoloft®, Lexapro®, Paxil®, or Celexa®
Medication for anxiety such as Valium®, Xanax®, Ativan®, Klonopin®, or other benzodiazepines, also known as “benzos”
Methadone, Subutex®, Suboxone®, or buprenorphine
Naloxone
Cannabidiol or CBD products
Adderall®, Ritalin®, or another stimulant
Marijuana or hash
Synthetic marijuana, or K2 or Spice
Heroin, also known as smack, junk, Black Tar, or Chiva
Amphetamines, also known as uppers, speed, crystal meth, crank, ice, or agua
Cocaine, also known as crack, rock, coke, blow, snow, or nieve
Tranquilizers, also known as downers or ludes
Hallucinogens, such as LSD/acid, PCP/angel dust, Ecstasy, Molly, mushrooms, or bath salts
Sniffing gasoline, glue, aerosol spray cans, or paint to get high, also known as huffing

The next questions are about tobacco products.

14. Since your baby was born, how many cigarettes have you smoked on an average day? A pack has 20 cigarettes. Did you smoke _________________?

(PROBE: Since your baby was born, about how many cigarettes have you smoked on an average day?)

(Don’t Read)	1	41 cigarettes or more
	2	21 to 40 cigarettes
	3	11 to 20 cigarettes
	4	6 to 10 cigarettes
	5	1 to 5 cigarettes
	6	Less than 1 cigarette
	7	Had not smoked since baby was born
	8	Refused
	9	Don’t know/Don’t Remember

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

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

Tobacco Products	(Don’t Read)
	Every day (1)	Some Days (2)	Never (3)	Refused (8)	Don’t know (9)
E-cigarettes or other electronic vaping products with nicotine
Hookah
Chewing tobacco, snuff, snus, or dip
Cigars, cigarillos, or little filtered cigars

INTERVIEWER: If mom Never used any tobacco products go to Question 17. Otherwise, continue with Question 16.

16. Since your baby was born, has a doctor, nurse or other health care worker advised you to quit smoking or stop using tobacco products?

(Don’t Read)	1	No
	2	Yes
	8	Refused
	9	Don’t know/Don’t Remember

The next questions are about alcohol use.

17. Have you had any alcoholic drinks since your baby was born? A drink is 1 glass of wine, wine cooler, can or bottle of beer, shot of liquor, or mixed drink.

(Don’t Read)	1	No	 Go to Question 22
	2	Yes
	8	Refused	 Go to Question 22
	9	Don’t know/Don’t Remember	 Go to Question 22

18. Since your baby was born, how many alcoholic drinks did you have in an average week? Was it ________?

(PROBE: Since your baby was born, how many alcoholic drinks did you have in an average week?)

	1	14 drinks or more a week
	2	8 to 13 drinks a week
	3	4 to 7 drinks a week
	4	1 to 3 drinks a week
	5	Less than 1 drink a week
(Don’t Read)	8	Refused
	9	Don’t know/Don’t Remember

19. Since your baby was born, how many times did you drink 4 alcoholic drinks or more in a 2 hour time span? Would you say that it was ________________?

	1	6 or more times
	2	4 to 5 times
	3	2 to 3 times
	4	1 time
	5	You didn’t have 4 drinks or more in a 2 hour time span
(Don’t Read)	8	Refused
	9	Don’t know/Don’t Remember

20. Since your baby was born, has a doctor, nurse, or other health care worker talked to about what level of drinking alcohol is harmful or risky for your health?

(Don’t Read)	1	No
	2	Yes
	8	Refused
	9	Don’t know/Don’t Remember

21. Since your baby was born, have you been advised to reduce or quit your drinking alcohol by a doctor, nurse, or other health care worker?

(Don’t Read)	1	No
	2	Yes
	8	Refused
	9	Don’t know/Don’t Remember

The next questions are about things you may have experienced since your baby was born.

22. Since your baby was born, have you felt that your use of any medication, drug, or alcohol interfered with important activities in your life such as working, going to school, taking care of children, enjoying hobbies, or spending time with friends and family?

(Don’t Read)	1	No
	2	Yes
	3	Mom has not used any medication, drugs or consumed alcohol since her baby was born	 Go to Question 30
	8	Refused	 Go to Question 30
	9	Don’t know/Don’t Remember	 Go to Question 30

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

Substances	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Prescription pain relievers
Drugs or medications other than pain relievers
Alcohol
Cigarettes or other tobacco products
Did you need treatment or counseling for your use of any other substance?
If YES, ask: For what?

INTERVIEWER: If mom marked “No” for all the options in Question 23, go to Question 30. Otherwise, continue with the next question.

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

Substances	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Prescription pain relievers
Drugs or medications other than pain relievers
Alcohol
Cigarettes or other tobacco products
Did you need treatment or counseling for your use of any other substance?
If YES, ask: For what?

INTERVIEWER: If mom received the treatment or counseling she needed for her use of any substance, please go to Question 26. If she did not receive all the treatment or counseling she needed, please continue with the next question.

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

Reasons	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
You could not get an appointment or were put on a waiting list
You was able to cut down or stop using without help
You didn’t think I needed help
You didn’t have enough money or insurance to pay for services
You didn’t know where to go for help
You didn’t have transportation
You didn’t want people to think you had a problem
Your partner did not want me to get help
You were afraid to lose custody of your baby or children
You had too many other things going on
Was there another reason?
If YES, ask: What was it?

INTERVIEWER: If mom has not receive any type of treatment or counseling, go to Question 30.

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

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

Types of Treatment or Counseling	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Individual counseling with a behavioral health professional
Group counseling with a behavioral health professional
Counseling with a clergy member or other religious or community counselor
Self-help or recovery group meetings (such as Alcoholics Anonymous, Self-Management and Recovery Training (SMART), Moderation Management (MM))
Medication-assisted treatment (MAT) using medicines such as methadone, buprenorphine, Suboxone®, Subutex® or naltrexone (Vivitrol®).
Tobacco cessation counseling or treatment
Did you receive another type of treatment or counseling?
If YES, ask: What did you receive?

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

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

Places	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Self-help group meetings
A private doctor’s office
An emergency room
A hospital as an inpatient where I stayed at night
A treatment facility as an outpatient where I did not stay at night
A residential treatment facility where I stayed at night
A prison or jail
Did you receive treatment somewhere else?
If YES, ask: Where?

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

	1	You are still in treatment	 Go to Question 30
	2	You completed treatment, or	 Go to Question 30
	3	You did not finish treatment
(Don’t Read)	8	Refused	 Go to Question 30
	9	Don’t know/Don’t Remember	 Go to Question 30

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

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

Reasons	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
You had a problem with the program
You could not afford to continue treatment
Your family needed you
You began using medications, drugs, or alcohol again
Was there another reason?
If YES, ask: What was it?

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

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

(Don’t Read)	1	No	 Go to Question 33
	2	Yes
	8	Refused	 Go to Question 33
	9	Don’t know/Don’t Remember	 Go to Question 33

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

Items	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Your baby’s doctor, nurse, or other health care worker
Your doctor, nurse, or other health care worker
Your husband or partner
Your mother, father, or in-laws
Other family member or relative
Your friends
Did someone else suggest you do not breastfeed your baby?
IF YES, ask: Who?

INTERVIEWER: If a doctor, nurse or other health care worker recommended she NOT breastfeed her baby go to the next question, otherwise go to Question 33.

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

Reasons	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
You had a medical condition that made breastfeeding a problem for you
You had a medical condition that made breastfeeding unsafe for your baby
There was concern that drugs or medications you were using would pass to the baby through your milk
Your baby had a medical condition and breastfeeding was not recommended
Was there another reason?
If YES, ask: What was the reason?

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

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

(Don’t Read)	1	No	 Go to Question 36
	2	Yes
	8	Refused	 Go to Question 36
	9	Don’t know/Don’t Remember	 Go to Question 36

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

Reasons	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Medications such as morphine, methadone, or buprenorphine
Fluids through an IV
Skin-to-skin care or Kangaroo Care
Sleeping in quiet, dimly lit room
High calorie formula
Breastfeeding or pumped breast milk
Donor breast milk
Did your baby receive other treatment?
If YES, ask: What did your baby receive?

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

	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Talk to me about why my baby had drug withdrawal
Talk to me about treatment for babies with drug withdrawal
Talk to me about how long my baby’s withdrawal signs may last
Talk to me about the things my baby could experience
Talk to me about my baby’s behavior
Talk to me about when my baby would be able to go home
Ask me about medications I was taking or took during pregnancy
Suggest I receive counseling or treatment for my use of medications, drugs or alcohol
Suggest I receive services for my baby such as early intervention or home visiting programs
Did a blood test or scoring test to evaluate my baby for neonatal abstinence syndrome

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

	1	In the hospital room with you, sometimes known as “rooming-in”
	2	In the regular newborn nursery
	3	In a specialized nursery for babies that need extra care such as a Special Care Nursery (SCN) or Neonatal Intensive Care Unit (NICU)
(Don’t Read)	4	Baby was not born in a hospital	 Go to Question 43
	8	Refused  Go to Question 43
	9	Don’t know/Don’t Remember  Go to Question 43

37. During your hospital stay when your baby was born, did you feel you were treated poorly because of any of the following things? I’m going to read the list of things. For each one, please tell me if you felt you were treated poorly because of it or not.

(PROBE: Did you feel you were treated poorly because of _____?)

Things	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Your age
Your weight
Your income
Your education level
Your race or ethnicity
Your cultural background or language
Your sexual orientation or gender identity
Your type of health insurance or your lack of health insurance
Your use of substances such as alcohol or drugs during pregnancy
Differing opinions with medical staff about how to care for yourself
Differing opinion with medical staff about how to care for your baby
Did you feel you were treated poorly because of something else?
If YES, ask: For what?

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

Things	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
How to soothe your baby
How to respond to your baby’s needs
Feeling a bond with your baby
Feeding your baby at home
Having a safe place for your baby to sleep
Having someone that can help you take care of your baby
Taking your baby to doctors’ visits
Keeping your baby safe in your home
Recognizing signs or symptoms in my baby that require medical attention

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

	1	No
	2	Yes
	3	You didn’t have any questions about your baby’s health
(Don’t Read)	8	Refused
	9	Don’t know/Don’t Remember

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

	1	No
	2	Yes, you were discharged at the same time, and your baby went home with you
	3	Yes, you were discharged at the same time, but your baby did not go home with you
(Don’t Read)	8	Refused
	9	Don’t know/Don’t Remember

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

(Don’t Read)	1	No	 Go to Question 43
	2	Yes
	8	Refused	 Go to Question 43
	9	Don’t know/Don’t Remember	 Go to Question 43

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

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

Reasons	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Breathing problems
Feeding difficulties
Dehydration
Surgery
Injury
Drug withdrawal
Jaundice
Fever
Respiratory or other infections
Audiology screening or rescreening
Did they have to go back to the hospital for another reason?
If YES, ask: What was it?

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

	1	No, he or she is living with his or her biological father		 Go to Question 51
	2	No, he or she is living with another family member		 Go to Question 51
	3	No, he or she is in foster care		 Go to Question 51
	4	No, he or she has been adopted by someone else		 Go to Question 51
	5	No, he or she passed away	 We are very sorry for your loss. Go to Question 51
	6	Yes
(Don’t Read)	8	Refused		 Go to Question 51
	9	Don’t know/Don’t Remember		 Go to Question 51

The following questions are about your baby’s health.

44. Do you have someone you think of as your baby’s personal doctor or nurse? A personal doctor or nurse is a health professional who knows your baby well and is familiar with your baby’s health history. This can be a family doctor, a pediatrician, a specialist doctor, a nurse practitioner, or a physician assistant. Would you say __________ ?

	1	No
	2	Yes, one person
	3	Yes, more than one person
(Don’t Read)	8	Refused
	9	Don’t know/Don’t Remember

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

	1	Age in months [ _______ ]	[Range: 0 – 10]
(Don’t Read)	2	My baby has never had a health care visit	 Go to Question 47
	8	Refused	 Go to Question 47
	9	Don’t know/Don’t Remember	 Go to Question 47

46. I’m going to read a list of things that the doctors, nurses, or health care workers might do during your baby’s check-ups. For each one, please tell me how often they did it during his or her check-ups.

(PROBE: Would you say they would always, sometimes, or never _________________?)

Actions	(Don’t Read)
	Always (1)	Sometimes (2)	Never (3)	Refused (8)	Don’t know (9)
Spend enough time with you and your baby
Listen carefully to you
Show sensitivity to your family’s values and customs
Provide the information you needed concerning your baby
Help you feel like a partner in your baby’s care
Ask you if you had concerns about your baby’s development

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

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

Actions	(Don’t Read)
	Not at all (1)	Some-what (2)	Very Much (3)	Refused (8)	Don’t know (9)
Does your baby have a hard time being with new people?
Does your baby have a hard time in new places?
Does your baby have a hard time with change?
Does your baby mind being held by other people?
Does your baby cry a lot?
Does your baby have a hard time calming down?
Is your baby fussy or irritable?
Is it hard to comfort your baby?
Is it hard to keep your baby on a schedule or routine?
Is it hard to put your baby to sleep?
Is it hard for you to get enough sleep because of your baby?
Does your baby have trouble staying asleep?

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

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

Actions	(Don’t Read)
	Not at all (1)	Some-what (2)	Very Much (3)	Refused (8)	Don’t know (9)
Holds up arms to be picked up
Gets into a sitting position by him or herself
Picks up food and eats it
Pulls up to standing
Plays games like "peek-a-boo" or "pat-a-cake"
Calls parents "mama" or "dada" or similar name
Looks around when people say things like "Where's your bottle?" or "Where's your blanket?"
Copies sounds that other people make
Walks across a room without help
Follows directions like "Come here" or "Give me the ball"

49. Has a doctor, nurse, or other health care worker told you that your baby has any developmental delays?

(Don’t Read)	1	No
	2	Yes	 Go to Question 51
	8	Refused	 Go to Question 51
	9	Don’t know/Don’t Remember	 Go to Question 51

50. Have you received any referrals or services to support your baby’s early learning and development? I’m going to read a list of services. For each one, please tell me if you have received the referral service or not.

Services	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Referral to a developmental specialist
Referral to a physical therapist
Services from the Early Head Start program
Services from the Healthy Start program
Services from an early intervention program for babies and children
Services such as parenting programs or support groups
Services such as home visitation
Have you received any other referrals or services for your baby?
If YES, ask: What were they?

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

Services	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
WIC
SNAP
Parenting groups
Housing assistance
Financial assistance
Transportation assistance
Emergency child care

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

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

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

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

	1	Often true
	2	Sometimes true
	3	Never true
(Don’t Read)	8	Refused
	9	Don’t know/Don’t Remember

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

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

	1	Often true
	2	Sometimes true
	3	Never true
(Don’t Read)	8	Refused
	9	Don’t know/Don’t Remember

54. In the past 30 days, how often have you felt down, depressed, or hopeless? Would you say it has been always, often, sometimes, rarely, or never?

(PROBE: How often have you felt down, depressed, or hopeless in the past 30 days?)

	1	Always
	2	Often
	3	Sometimes
	4	Rarely
	5	Never
(Don’t Read)	8	Refused
	9	Don’t know/Don’t Remember

55. In the past 30 days, how often have you had little interest or little pleasure in doing things you usually enjoyed? Would you say it has been always, often, sometimes, rarely, or never?

(PROBE: How often have you had little interest or little pleasure in doing things you usually enjoyed in the past 30 days?)

	1	Always
	2	Often
	3	Sometimes
	4	Rarely
	5	Never
(Don’t Read)	8	Refused
	9	Don’t know/Don’t Remember

56. In the past 30 days, who would help you if a problem came up? For example, who would help you if you needed to borrow $50 or if you got sick and had to be in bed for several weeks? Would ________ help you?

(PROBE: In the past 30 days, would ______ help you if a problem came up?)

People	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Your husband or partner
Your mother, father or in-laws
Another family member or relative
A friend
A religious community
Who else would help you?
If YES, ask: Who?
IF NONE OF ABOVE IS ‘YES’ ASK: Would you say that no one would help you if a problem came up?

The next questions are about you and your family.

57. I’m going to read a list of people who might live in the same house with you. For each one, please tell me if they have lived with you since your baby was born.

(PROBE: Did ________ live in the same house with you since your baby was born?)

People	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Your husband or partner
Children less than 12 months old  IF YES, ASK:     How many? _______ (Range: 0-20)
Children 1 year to 5 years old  IF YES, ASK:     How many? _______ (Range: 0-20)
Children 6 years old and over  IF YES, ASK:     How many? _______ (Range: 0-20)
Your mother
Your father
Your husband’s or partner’s parents
A friend or roommate
Other family member or relative
Does someone else live with you?
If YES, ask: Who?
IF NONE OF ABOVE IS ‘YES’, ASK: Did you live alone?

58. Are you pregnant now?

(Don’t Read)	1	No	 Go to Question 60
	2	Yes
	8	Refused	 Go to Question 60
	7	Don’t know/Don’t Remember	 Go to Question 60

59. Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant? I’m going to read a list of options. Please choose the one that best describes how you felt.

(PROBE: Just before you got pregnant with your new baby, how did you feel about becoming pregnant?)

	1	You wanted to be pregnant later
	2	You wanted to be pregnant sooner
	3	You wanted to be pregnant then
	4	You did not want to be pregnant then or at any time in the future
	5	You were not sure what you wanted
(Don’t Read)	8	Refused
	9	Don’t know/Don’t Remember

INTERVIEWER: If the mom is currently pregnant, go to Question 63.

60. Are you or your husband or partner doing anything now to keep from getting pregnant? Some things people do to keep from getting pregnant include having their tubes tied, using birth control pills, condoms, withdrawal, or natural family planning.

(Don’t Read)	1	No
	2	Yes	 Go to Question 62
	8	Refused	 Go to Question 63
	9	Don’t know/Don’t Remember	 Go to Question 63

61. I’m going to read a list of reasons some women or their husbands or partners have for not doing anything to keep from getting pregnant. For each one, please tell me if it is one of the reasons for you or your husband or partner now. Is it because______?

(PROBE: Is one of the reasons you aren’t doing anything to keep from getting pregnant now because______?)

Reasons	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
You want to get pregnant
You had your tubes tied or blocked
You don’t want to use birth control
You are worried about side effects from birth control
You are not having sex
Your husband or partner doesn’t want to use anything
You have problems paying for birth control
Is there any other reason you’re not doing anything to keep from getting pregnant now?
If YES, ask: What is the reason?

INTERVIEWER: If the mom and partner are not doing anything to avoid getting pregnant, go to Question 63.

62. I’m going to read a list of birth control methods. For each one, please tell me if you or your husband or partner is using this method now.

(PROBE: What are you or your husband or partner using now to keep from getting pregnant?)

Reasons	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Tubes tied or blocked, female sterilization, or Essure®
Vasectomy or male sterilization
Birth control pills
Condoms
Shots, injections or Depo-Provera®
Contraceptive patch or OrthoEvra® or vaginal ring or NuvaRing®
IUD, including Mirena®, ParaGard®, Liletta®, or Skyla®
Contraceptive implant in the arm, including Nexplanon® or Implanon®
Natural family planning including rhythm method
Withdrawal or pulling out
Not having sex or abstinence
Are you or your husband or partner using anything else to keep from getting pregnant now?
If YES, ask: What are you or your husband or partner using?

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

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

Questions	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Were your parents ever separated or divorced?
Was your mom less than 18 years old when she had you?
Was your dad less than 18 years old when you were born?
Did you live with anyone who was a problem drinker or alcoholic?
Did you live with anyone who was depressed, mentally ill, or suicidal?
Did you live with anyone who used illegal drugs or who abused prescription medications?
Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?
Did you frequently have to move houses or leave the places where you were living?
Did you like going to school?
Did you drop out of school before you were able to graduate?
Were you ever bullied?

Thank you for answering these questions!

Your answers will help us understand how to improve the health of mothers and babies.

Is there anything else you would like to say about your experiences around pregnancy, taking care of your baby, or the health of mothers and babies in <state>?

PRAMS Opioids Call-Back Survey – ENGLISH PHONE | Page 24