PRAMS Opioid Call-back Survey (English)

Pregnancy Risk Assessment Monitoring System (PRAMS)

Att 11a-PRAMS Opioid Call Back Survey_DRAFT_PHONE_ENGLISH_040819

OMB: 0920-1273

Document [docx]
Download: docx | pdf

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx



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

Shape1

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


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


(Don’t Read)

  1. Job Title: ________________________________________________________________

___________________________________________________________________________



  1. Job Duties:_______________________________________________________________

___________________________________________________________________________

___________________________________________________________________________






8

Refused



9

Don’t know/Don’t Remember



  1. 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


















  1. 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)

  1. Private health insurance from my job or the job of my husband or partner






  1. Private health insurance from my parents






  1. Private health insurance from the Health Insurance Marketplace or HealthCare.gov






  1. Private health insurance that I or someone else purchase directly






  1. Medicaid






  1. TRICARE or other military health care






  1. Do you have some other health insurance?






  1. If YES, ask: What is that?





If ALL No, ask option i

  1. 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.


  1. 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)

  1. Depression





  1. Anxiety





  1. Hepatitis B





  1. Hepatitis C





  1. Chronic Pain, which is pain lasting more than 12 weeks or 3 months












  1. 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


  1. 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)

  1. Postpartum checkup





  1. Visit for problems I was having related to the delivery of my baby





  1. Regular checkup at my family doctor’s or OB/GYN’s office





  1. Visit for an illness or chronic condition





  1. Visit for an injury





  1. Visit for family planning or birth control





  1. Visit for depression or anxiety





  1. Visit to have my teeth cleaned by a dentist or dental hygienist





  1. Prenatal care visit for a new pregnancy





  1. Have you had another type of health care visit?





  1. If YES, ask: What type of visit?



  1. 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)

  1. Talked to you about managing pain after the birth of your baby





  1. Asked you, in person or on a form, if you drank alcoholic beverages





  1. Asked you, in person or on a form, if you smoked cigarettes or used other tobacco products





  1. 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.


  1. 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)

  1. Hydrocodone like Vicodin®, Norco®, or Lortab®






  1. Codeine like Tylenol® 3 or 4, these are not regular Tylenol®






  1. Oxycodone like Percocet®, Percodan®, OxyContin®, or Roxicodone®






  1. Tramadol like Ultram® or Ultracet®






  1. Hydromorphone or meperidine like Demerol®, Exalgo®, or Dilaudid®






  1. Oxymorphone like Opana®






  1. Morphine like MS Contin®, Avinza®, or Kadian ®






  1. 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.


  1. 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)

  1. In the hospital, right after the birth of your baby





  1. OB-GYN, midwife, or prenatal care provider





  1. Family doctor or primary care provider





  1. Dentist or oral health care provider





  1. Doctor in the emergency room





  1. You had pain relievers left over from an old prescription





  1. Friend or family member gave them to me





  1. You got the pain relievers without a prescription some other way





  1. Did you get them somewhere else?





  1. If YES, ask: Where?








  1. 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)

  1. To relieve pain associated with my baby’s birth, such as pain at the site of the incision or a tear





  1. To relieve pain from an injury, condition, or surgery I had before pregnancy





  1. To relieve pain from an injury, condition, or surgery that happened during my pregnancy





  1. To relax or relieve tension or stress





  1. To help me with my feelings or emotions





  1. To help me sleep





  1. To feel good or get high





  1. Because I was “hooked” or I had to have them





  1. Was there some other reason?





  1. If YES, ask: What was it?



  1. 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






















  1. 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)

  1. Over-the-counter pain medication such as aspirin, Tylenol®, Tylenol PM®, Tylenol Extra Strength®, Advil®, Motrin®, or Aleve®





  1. Medication for depression such as Prozac®, Zoloft®, Lexapro®, Paxil®, or Celexa®





  1. Medication for anxiety such as Valium®, Xanax®, Ativan®, Klonopin®, or other benzodiazepines, also known as “benzos”





  1. Methadone, Subutex®, Suboxone®, or buprenorphine





  1. Naloxone





  1. Cannabidiol or CBD products





  1. Adderall®, Ritalin®, or another stimulant





  1. Marijuana or hash





  1. Synthetic marijuana, or K2 or Spice





  1. Heroin, also known as smack, junk, Black Tar, or Chiva





  1. Amphetamines, also known as uppers, speed, crystal meth, crank, ice, or agua





  1. Cocaine, also known as crack, rock, coke, blow, snow, or nieve





  1. Tranquilizers, also known as downers or ludes





  1. Hallucinogens, such as LSD/acid, PCP/angel dust, Ecstasy, Molly, mushrooms, or bath salts





  1. Sniffing gasoline, glue, aerosol spray cans, or paint to get high, also known as huffing






The next questions are about tobacco products.


  1. 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



  1. 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)

  1. E-cigarettes or other electronic vaping products with nicotine






  1. Hookah






  1. Chewing tobacco, snuff, snus, or dip






  1. Cigars, cigarillos, or little filtered cigars








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



  1. 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.


  1. 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


  1. 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



  1. 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



  1. 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




  1. 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.


  1. 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










  1. 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)

  1. Prescription pain relievers





  1. Drugs or medications other than pain relievers





  1. Alcohol





  1. Cigarettes or other tobacco products





  1. Did you need treatment or counseling for your use of any other substance?





  1. 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.



  1. 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)

  1. Prescription pain relievers





  1. Drugs or medications other than pain relievers





  1. Alcohol





  1. Cigarettes or other tobacco products





  1. Did you need treatment or counseling for your use of any other substance?





  1. 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.













  1. 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)

  1. You could not get an appointment or were put on a waiting list





  1. You was able to cut down or stop using without help





  1. You didn’t think I needed help





  1. You didn’t have enough money or insurance to pay for services





  1. You didn’t know where to go for help





  1. You didn’t have transportation





  1. You didn’t want people to think you had a problem





  1. Your partner did not want me to get help





  1. You were afraid to lose custody of your baby or children





  1. You had too many other things going on





  1. Was there another reason?





  1. If YES, ask: What was it?




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



  1. 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)

  1. Individual counseling with a behavioral health professional





  1. Group counseling with a behavioral health professional





  1. Counseling with a clergy member or other religious or community counselor





  1. Self-help or recovery group meetings (such as Alcoholics Anonymous, Self-Management and Recovery Training (SMART), Moderation Management (MM))





  1. Medication-assisted treatment (MAT) using medicines such as methadone, buprenorphine, Suboxone®, Subutex® or naltrexone (Vivitrol®).





  1. Tobacco cessation counseling or treatment





  1. Did you receive another type of treatment or counseling?

  1. If YES, ask: What did you receive?




  1. 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)

  1. Self-help group meetings





  1. A private doctor’s office





  1. An emergency room





  1. A hospital as an inpatient where I stayed at night





  1. A treatment facility as an outpatient where I did not stay at night





  1. A residential treatment facility where I stayed at night





  1. A prison or jail





  1. Did you receive treatment somewhere else?





  1. If YES, ask: Where?



  1. 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


  1. 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)

  1. You had a problem with the program





  1. You could not afford to continue treatment





  1. Your family needed you





  1. You began using medications, drugs, or alcohol again





  1. Was there another reason?





If YES, ask: What was it?






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


  1. 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



  1. 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)

  1. Your baby’s doctor, nurse, or other health care worker





  1. Your doctor, nurse, or other health care worker





  1. Your husband or partner





  1. Your mother, father, or in-laws





  1. Other family member or relative





  1. Your friends





  1. Did someone else suggest you do not breastfeed your baby?





  1. 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.



  1. 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)

  1. You had a medical condition that made breastfeeding a problem for you





  1. You had a medical condition that made breastfeeding unsafe for your baby





  1. There was concern that drugs or medications you were using would pass to the baby through your milk





  1. Your baby had a medical condition and breastfeeding was not recommended





  1. Was there another reason?





  1. If YES, ask: What was the reason?



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

  1. 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

  1. 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)

  1. Medications such as morphine, methadone, or buprenorphine





  1. Fluids through an IV





  1. Skin-to-skin care or Kangaroo Care





  1. Sleeping in quiet, dimly lit room





  1. High calorie formula





  1. Breastfeeding or pumped breast milk





  1. Donor breast milk





  1. Did your baby receive other treatment?





  1. If YES, ask: What did your baby receive?



  1. 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)

  1. Talk to me about why my baby had drug withdrawal





  1. Talk to me about treatment for babies with drug withdrawal





  1. Talk to me about how long my baby’s withdrawal signs may last





  1. Talk to me about the things my baby could experience





  1. Talk to me about my baby’s behavior





  1. Talk to me about when my baby would be able to go home





  1. Ask me about medications I was taking or took during pregnancy





  1. Suggest I receive counseling or treatment for my use of medications, drugs or alcohol





  1. Suggest I receive services for my baby such as early intervention or home visiting programs





  1. Did a blood test or scoring test to evaluate my baby for neonatal abstinence syndrome






  1. 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



  1. 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)

  1. Your age





  1. Your weight





  1. Your income





  1. Your education level





  1. Your race or ethnicity





  1. Your cultural background or language





  1. Your sexual orientation or gender identity





  1. Your type of health insurance or your lack of health insurance





  1. Your use of substances such as alcohol or drugs during pregnancy





  1. Differing opinions with medical staff about how to care for yourself





  1. Differing opinion with medical staff about how to care for your baby





  1. Did you feel you were treated poorly because of something else?





  1. If YES, ask: For what?



  1. 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)

  1. How to soothe your baby





  1. How to respond to your baby’s needs





  1. Feeling a bond with your baby





  1. Feeding your baby at home





  1. Having a safe place for your baby to sleep





  1. Having someone that can help you take care of your baby





  1. Taking your baby to doctors’ visits





  1. Keeping your baby safe in your home





  1. Recognizing signs or symptoms in my baby that require medical attention







  1. 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




  1. 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



  1. 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












  1. 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)

  1. Breathing problems





  1. Feeding difficulties





  1. Dehydration





  1. Surgery





  1. Injury





  1. Drug withdrawal





  1. Jaundice





  1. Fever





  1. Respiratory or other infections





  1. Audiology screening or rescreening





  1. Did they have to go back to the hospital for another reason?





  1. If YES, ask: What was it?



  1. 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.


  1. 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






  1. 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


  1. 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)

  1. Spend enough time with you and your baby






  1. Listen carefully to you






  1. Show sensitivity to your family’s values and customs






  1. Provide the information you needed concerning your baby






  1. Help you feel like a partner in your baby’s care






  1. Ask you if you had concerns about your baby’s development







  1. 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)

  1. Does your baby have a hard time being with new people?






  1. Does your baby have a hard time in new places?






  1. Does your baby have a hard time with change?






  1. Does your baby mind being held by other people?






  1. Does your baby cry a lot?






  1. Does your baby have a hard time calming down?






  1. Is your baby fussy or irritable?






  1. Is it hard to comfort your baby?






  1. Is it hard to keep your baby on a schedule or routine?






  1. Is it hard to put your baby to sleep?






  1. Is it hard for you to get enough sleep because of your baby?






  1. Does your baby have trouble staying asleep?







  1. 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)

  1. Holds up arms to be picked up






  1. Gets into a sitting position by him or herself






  1. Picks up food and eats it






  1. Pulls up to standing






  1. Plays games like "peek-a-boo" or "pat-a-cake"






  1. Calls parents "mama" or "dada" or similar name






  1. Looks around when people say things like "Where's your bottle?" or "Where's your blanket?"






  1. Copies sounds that other people make






  1. Walks across a room without help






  1. Follows directions like "Come here" or "Give me the ball"







  1. 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


  1. 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)

  1. Referral to a developmental specialist





  1. Referral to a physical therapist





  1. Services from the Early Head Start program





  1. Services from the Healthy Start program





  1. Services from an early intervention program for babies and children





  1. Services such as parenting programs or support groups





  1. Services such as home visitation





  1. Have you received any other referrals or services for your baby?





If YES, ask: What were they?



  1. 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)

  1. WIC





  1. SNAP





  1. Parenting groups





  1. Housing assistance





  1. Financial assistance





  1. Transportation assistance





  1. 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:


  1. “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



  1. 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



  1. 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



  1. 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



  1. 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)

  1. Your husband or partner





  1. Your mother, father or in-laws





  1. Another family member or relative





  1. A friend





  1. A religious community





  1. Who else would help you?





  1. If YES, ask: Who?


  1. 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.


  1. 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)

  1. Your husband or partner





  1. Children less than 12 months old

IF YES, ASK:     How many? _______ (Range: 0-20)





  1. Children 1 year to 5 years old

IF YES, ASK:     How many? _______ (Range: 0-20)





  1. Children 6 years old and over

IF YES, ASK:     How many? _______ (Range: 0-20)





  1. Your mother





  1. Your father





  1. Your husband’s or partner’s parents





  1. A friend or roommate





  1. Other family member or relative





  1. Does someone else live with you?





  1. If YES, ask: Who?

  1. IF NONE OF ABOVE IS ‘YES’, ASK: Did you live alone?






  1. 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


  1. 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.



  1. 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


  1. 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)

  1. You want to get pregnant





  1. You had your tubes tied or blocked





  1. You don’t want to use birth control





  1. You are worried about side effects from birth control





  1. You are not having sex





  1. Your husband or partner doesn’t want to use anything





  1. You have problems paying for birth control





  1. Is there any other reason you’re not doing anything to keep from getting pregnant now?





  1. 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.








  1. 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)

  1. Tubes tied or blocked, female sterilization, or Essure®





  1. Vasectomy or male sterilization





  1. Birth control pills





  1. Condoms





  1. Shots, injections or Depo-Provera®





  1. Contraceptive patch or OrthoEvra® or vaginal ring or NuvaRing®





  1. IUD, including Mirena®, ParaGard®, Liletta®, or Skyla®





  1. Contraceptive implant in the arm, including Nexplanon® or Implanon®





  1. Natural family planning including rhythm method





  1. Withdrawal or pulling out





  1. Not having sex or abstinence





  1. Are you or your husband or partner using anything else to keep from getting pregnant now?





  1. 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.


  1. 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)

  1. Were your parents ever separated or divorced?





  1. Was your mom less than 18 years old when she had you?





  1. Was your dad less than 18 years old when you were born?





  1. Did you live with anyone who was a problem drinker or alcoholic?





  1. Did you live with anyone who was depressed, mentally ill, or suicidal?





  1. Did you live with anyone who used illegal drugs or who abused prescription medications?





  1. Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?





  1. Did you frequently have to move houses or leave the places where you were living?





  1. Did you like going to school?





  1. Did you drop out of school before you were able to graduate?





  1. 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


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