PRAMS Livebirth Phase 9 Standard Mail Questionnaire (Eng

Attachment 10e – PRAMS Livebirth Phase 9 Standard Mail Module - English

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Pregnancy Risk Assessment Monitoring System (PRAMS)

Phase 9 Standard (Module) Mail Questionnaire – English

Assisted Reproduction and Fertility

NOTE: Skip A1–A5 if the mother was not trying to get pregnant (E5).
A1 is required if A2, A4 or A5 are used.

If you were not trying to get pregnant when you got pregnant with your new baby, go to Question #.

A1.	Did you take any fertility drugs or receive any medical procedures from a healthcare provider to help you get pregnant with your new baby? This may include infertility treatments such as fertility-enhancing drugs or assisted reproductive technology.
	No → Go to Question #
	Yes

A2. (MOD)	Did you use any of the following fertility treatments to help you get pregnant with your new baby?
	Check ALL that apply
	Fertility-enhancing drugs prescribed by a doctor to stimulate ovulation
	Intrauterine insemination or artificial insemination (treatments in which sperm, but NOT eggs, were collected and medically placed into the uterus)
	Assisted reproductive technology (treatments in which a woman’s eggs or embryos were handled in the laboratory, such as in vitro fertilization [IVF] with or without, intracytoplasmic sperm injection [ICSI], or other related procedures)
	Other medical treatment ⤷ Please tell us:____________________________________________________________
	I wasn’t using fertility treatments to help me get pregnant with my new baby

A4. (MOD)	How long had you been trying to get pregnant before you took any fertility drugs or used any medical procedures to help you get pregnant with your new baby? Do not count long periods of time when you and your partner were apart or not having sex.
	0 to 6 months
	7 months to less than 1 year
	1 to 2 years
	3 to 4 years
	5 to 6 years
	More than 6 years

A5.	How many cycles of fertility treatments (complete or incomplete) did you have before you got pregnant with your new baby?
	1 cycle
	2 to 3 cycles
	4 to 6 cycles
	7 or more cycles

Breastfeeding

NOTE: Skip B1 if infant is not alive or not living with the mother (Core 33 and/or Core 34).
Skip B1 if the mother ever breastfed (Core 35).

B1.	What were your reasons for not breastfeeding your new baby?
	Check ALL that apply
	I was sick or on medicine
	I had other children to take care of
	I had too many other things going on
	I didn’t like breastfeeding
	I tried, but it was too hard
	I didn’t want to
	I went back to work
	I went back to school
	Other
	⤷ Please tell us: ____________________________________________________
	If you didn’t breastfeed your new baby, go to Question #.

NOTE: Skip B2 if infant is not alive or not living with the mother (Core 33 and/or Core 34).
Skip B2 if the mother did not breastfeed or is still breastfeeding (Core 35).

B2.	What were your reasons for stopping breastfeeding?
	Check ALL that apply
	My baby had difficulty latching or nursing
	Breast milk alone didn’t satisfy my baby
	I thought my baby wasn’t gaining enough weight
	My nipples were sore, cracked, or bleeding, or it was too painful
	I thought I wasn’t producing enough milk, or my milk dried up
	I had too many other things going on
	I felt it was the right time to stop breastfeeding
	I got sick or had to stop for medical reasons
	I went back to work
	I went back to school
	My spouse or partner didn’t support breastfeeding
	My baby was jaundiced (yellowing of the skin or whites of the eyes)
	Other
	⤷ Please tell us: ___________________________________________________

NOTE: Skip B3 if infant is not alive or not living with the mother (Core 33 and/or Core 34).
Skip B3 if infant was not born in a hospital (Core 32).

	If your baby was not born in a hospital, go to Question #.
B3. (MOD)	During your hospital stay after your new baby was born, did any of the following things happen?
	For each one, check No or Yes.
		No Yes
	Hospital staff talked to me about how to breastfeed (how often and long to breastfeed)	 
	My baby stayed in the same room with me at the hospital	 
	Hospital staff helped me learn how to breastfeed	 
	I breastfed as soon as possible after my baby was born	 
	My baby was placed in skin-to-skin contact as soon as possible after birth	 
	My baby was fed only breast milk at the hospital	 
	Hospital staff helped me recognize when my baby was hungry	 
	The hospital gave me a gift pack with formula	 
	The hospital gave me information about who I could contact for breastfeeding support when I left the hospital	 
	Hospital staff tied or blocked my tubes	 
	Hospital staff placed an IUD	 
	Hospital staff placed a contraceptive implant in my arm	 
	Hospital staff gave me a contraceptive shot/injection	 

B4.	During your most recent pregnancy, what did you think about breastfeeding your new baby? Check ONE answer
	I knew I wanted to breastfeed
	I thought I might breastfeed
	I knew I would not breastfeed
	I didn’t know what to do about breastfeeding

NOTE: B12 must be used with B7-B8. Skip B7-B8 if mother was not on WIC during her pregnancy (B12). B8 goes before B7.

B12.	During your most recent pregnancy, were you on WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)?
	No → Go to Question #
	Yes

B7.	When you went for WIC visits during your most recent pregnancy, did you receive information on breastfeeding?
	No
	Yes

B8.	During your most recent pregnancy, when you went for your WIC visits, did you speak with a breastfeeding peer counselor or another WIC staff person about breastfeeding?
	No
	Yes

NOTE: Skip B9, B10, B11 if infant is not alive or not living with the mother (Core 33 and/or Core 34).

Skip B10 if mother said that she did not breastfeed (Core 35).

B9.	Before your new baby was born, did any of the following things happen?
	Check ALL that apply
	Someone answered my questions about breastfeeding
	I was offered a class on breastfeeding
	I attended a class on breastfeeding
	I decided or planned to feed only breast milk to my baby
	I discussed feeding only breast milk to my baby with my family/friends
	I discussed feeding only breast milk to my baby with my healthcare provider
	I decided not to breastfeed my baby

B10.	How old was your new baby the first time they had liquids other than breast milk (such as formula, water, juice, or cow’s milk)?
	Write ONE answer
	My baby was:
	_______ Week(s) OR
	_______ Month(s)
	My baby was less than 1 week old
	My baby has not had any liquids other than breast milk

B11.	How old was your new baby the first time they ate food (such as baby cereal, baby food, or any other food)?
	Check ONE answer
	My baby was:
	______Week(s) OR
	______Month(s)
	My baby was less than 1 week old
	My baby has not eaten any foods

NOTE: Skip B13, B14, B16 if mother did not breastfeed (Core 35).

B16 requires B14, but B14 can be used alone

B13.	After your new baby was born, did you get any of the following kinds of help with breastfeeding?
	For each one, check No or Yes.
				No Yes
	Someone to answer my questions			 
	Help getting my baby positioned correctly			 
	Help knowing if my baby was getting enough milk			 
	Help with managing pain or bleeding nipples			 
	Information about where to get a breast pump			 
	Help using a breast pump			 
	Information about breastfeeding support groups			 
	Other			 
	Please tell us:_____________________________________________

B14.	Have you used a breast pump to express milk to feed to your new baby?
	No → Go to Question #
	Yes

B16. (MOD)	Where did you get the breast pump that you used with your new baby?
	Check ALL that apply
	I got it for free from WIC
	I got it for free from the hospital
	I got it as a gift or borrowed from someone else
	My health insurance paid for it
	I rented or bought it myself
	I had one from a previous child
	Other
	⤷ Please tell us:)______________________________________________

B17.	Before or after your new baby was born, did you receive information about breastfeeding from any of the following sources?
	For each one, check No or Yes.
		No Yes
	A doctor	 
	A nurse or midwife	 
	A doula	 
	A breastfeeding or lactation specialist	 
	My baby’s doctor or healthcare provider	 
	A breastfeeding support group	 
	A breastfeeding hotline or toll-free number	 
	Websites or apps about pregnancy or infant care	 
	Social media (such as Facebook, Instagram, TikTok)	 
	Family or friends	 
	Other	 
	⤷ Please tell us:______________________________________

Occupational Status and Workplace Leave

NOTE: Skip C1–C2 if infant is not alive or not living with the mother or is still in the hospital (Core 33 and/or Core 34, and Core 32).

C2 requires C1. C1 can be used alone. If C1 is used alone, it does not need to be skipped if infant is not alive or not living with the mother, or if the baby is still in the hospital.

C1.		Are you currently in school or working? Check ALL that apply
		No, I don’t go to school or work → Go to Question #
		Yes, I go to school or work outside the home
		Yes, I go to school or work from home
C2.	Which one of the following people spends the most time taking care of your new baby when you are in school or working? Check ONE answer
	My spouse or partner
	Baby’s grandparent
	Other close family member or relative
	Friend or neighbor
	Babysitter, nanny, or other childcare provider
	Staff at day care center
	Other
	⤷ Please tell us:___________________________
	The baby is with me while I am in school or working → Go to Question #

C4.	At any time during your most recent pregnancy, did you work at a job for pay?
	No → Go to Question #
	Yes

NOTE: C7 requires C4 (skip C7 if C4 is no). If C7 is no and not returning, skip C8-C10 and C14 (mom goes to C11 in this series, if used, or to next topic).

C7.	Have you returned to the job you had during your most recent pregnancy?
	Check ONE answer
	No, and I don’t plan to return → Go to Question #
	No, but I will be returning
	Yes

NOTE: C8 requires C7 and C4.

If a site adds a site-specific option to C8, insert “Yes, I took…” for options such as Family Medical Leave and “Yes, I took leave and used…” for options such as Temporary/Short-term Disability Insurance.

C8.	Did you take leave from work after your new baby was born?
	Check ALL that apply
	Yes, I took paid leave from my job
	Yes, I took unpaid leave from my job
	Site-specific options (Leave or disability programs)
	No, I didn’t take any leave

C9.	How did you feel about the amount of time you were able to take off after the birth of your new baby? Check ONE answer
		Too little time
		Just the right amount of time
		Too much time

C10.	Did any of the following things affect your decision about taking leave from work after your new baby was born? For each one, check No or Yes.
		No Yes
	I couldn’t financially afford to take leave	 
	I was afraid I’d lose my job if I took leave or stayed out longer	 
	I had too much work to do to take leave or stay out longer	 
	My job doesn’t have paid leave	 
	My job doesn’t offer a flexible work schedule	 
	I hadn’t built up enough leave time to take any or more time off	 

C11. (MOD)	After your new baby was born, did your spouse or partner take time off from work? Check ONE answer
	No, they didn’t take leave from work
	Yes, they took paid leave from work
	Yes, they took unpaid leave from work
	Yes, they took paid and unpaid leave from work
	My spouse or partner didn’t work at a job for pay
	I didn't have a spouse or partner

NOTE: C14 requires C8. Add a skip arrow to C8 response option “I didn’t take any leave” that goes to C9, (or C10, C11), if used, or to next topic.

C14.	How many weeks or months of leave, in total, did you take or will you take?
	Write ONE answer
	_______Week(s) OR
	[BOX] Month(s)
	Less than 1 week

Contraception

Also see B3 for contraception during hospital stay after delivery

E4.	Before you got pregnant with your new baby, had you ever heard or read about emergency birth control (the “morning-after pill”)? This combination of pills is used to prevent pregnancy up to 5 days after unprotected sex.
	No
	Yes

E5.	When you got pregnant with your new baby, were you trying to get pregnant?
	No
	Yes → Go to Question #

NOTE: E5 is a required filter for E6 and Q7.

E6. (MOD)	When you got pregnant with your new baby, were you or your spouse or partner doing anything to keep from getting pregnant? This can include having your tubes tied, using birth control pills, condoms, natural family planning, or other methods.
	No
	Yes

NOTE: E6 is a required filter for E3 and E7.

E7.	What were your reasons for not doing anything to keep from getting pregnant?
	Check ALL that apply
	I didn’t mind if I got pregnant
	I thought I couldn’t get pregnant at that time
	I didn’t want to use birth control
	I had side effects from the birth control method I was using
	I had problems getting birth control I wanted
	I thought my spouse or partner or I was sterile (couldn’t get pregnant at all)
	My spouse or partner didn’t want to use condoms
	My spouse or partner didn’t want me to use birth control
	I forgot to use a birth control method
	Other ⤷ Please tell us:___________________________

NOTE: Skip E3 if mother was not using birth control when she got pregnant (E6).

If you or your spouse or partner was not doing anything to keep from getting pregnant, go to Question #.
E3.	What kind of birth control were you using when you got pregnant?
	Check ALL that apply
	Birth control pills
	Condoms
	Shots or injections
	Contraceptive patch or vaginal ring
	IUD
	Contraceptive implant in the arm
	Withdrawal (pulling out)
	Natural family planning or fertility awareness methods (such as rhythm or calendar method or fertility apps)
	Other
	⤷ Please tell us:__________________________________________

Infant Sleep Environment

NOTE: Inserting F4 after Core 37 requires the skip arrow to be changed from “Never” to “Always” so the filter will work properly.

F4.	Who does your new baby usually sleep with when they are not sleeping alone?
	Check ALL that apply
	Me
	My spouse or partner
	A grandparent
	My baby’s twin
	An older sibling
	Someone else
	⤷ Please tell us:______________________
	If your baby never sleeps alone in their own crib or bed, go to Question #.
F5.		Did a healthcare provider tell you to place your baby to sleep in the following ways? For each one, check No or Yes.
				No Yes
		On their back to sleep		 
		In a crib, bassinet, or portable crib		 
		Without a blanket, soft toys, cushions, or pillows in my baby's crib or bed		 
		Place my baby's crib, bassinet, or portable crib in my room		 

F6.	Did you get information about how to place your baby to sleep during any of the following times?
	For each one, check No or Yes.
		No Yes
	During a prenatal care visit	 
	In the hospital, when my baby was born	 
	During my baby’s healthcare visit	 
	During a postpartum care visit	 
	Other	 
	⤷ Please tell us:_________________

F7. (NEW)	Did you get information about how to place your new baby to sleep from any of the following sources?
	For each one, check No or Yes.
		No Yes
	My family doctor	 
	My OB/GYN	 
	A nurse or midwife		 
	Doula or a childbirth educator		 
	My baby’s doctor or healthcare provider		 
	Websites or apps about pregnancy or infant care		 
	Social media (such as Facebook, Instagram, TikTok)		 
	Other sources		 
	⤷ Please tell us:____________________________

Maternal Nutrition and Supplement Use

G9.	During the month before you got pregnant with your new baby, how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin?
	I didn’t take a multivitamin, prenatal vitamin, or folic acid vitamin in the month before I got pregnant
	1 to 3 times a week
	4 to 6 times a week
	Every day of the week
NOTE: G8 requires G9. Skip G8 if mother took a multivitamin 1 or more times a week (G9).

G8.

During the month before you got pregnant with your new baby, what were your reasons for not taking multivitamins, prenatal vitamins, or folic acid vitamins? Check ALL that apply

I wasn’t planning to get pregnant

I didn’t think I needed to take vitamins

I didn’t want to take vitamins

The vitamins were too expensive

The vitamins gave me side effects (such as nausea or constipation)

Other

⤷ Please tell us:_______________________________

G5.

During the last 3 months of your most recent pregnancy, how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin?

I didn’t take a multivitamin, prenatal vitamin, or folic acid vitamin at all

1 to 3 times a week

4 to 6 times a week

Every day of the week

G6.

During the past month, how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin?

I didn’t take a multivitamin, prenatal vitamin, or folic acid vitamin at all

1 to 3 times a week

4 to 6 times a week

Every day of the week

G7a.

During the last 3 months of your most recent pregnancy, about how many servings of fruit did you have in a day? Check ONE answer

Zero servings (none)

1 or 2 servings per day

3 or 4 servings per day

5 or more servings per day

G7b.	During the last 3 months of your most recent pregnancy, about how many servings of vegetables did you have in a day?
	Check ONE answer
	Zero servings (none)
	1 or 2 servings per day
	3 or 4 servings per day
	5 or more servings per day

Health Insurance

Infant Health Insurance Coverage

NOTE: Skip H2 if infant is not alive or not living with the mother (Core 33 and/or Core 34).

H2.	What kind of health insurance is your new baby covered by now? Check ALL that apply
		Private health insurance (paid for by me, someone else, or through a job)
		Medicaid (site Medicaid name)
		Site-specific option (Other government plan or program such as SCHIP/CHIP)
		Site-specific option (Other government plan or program not listed above such as MCH program, indigent program or family planning program)
		Site-specific option (TRICARE or other military healthcare)
		Site-specific option (IHS or tribal)
		Other health insurance ⤷ Please tell us:_______________________________________
	I don’t have any health insurance for my new baby

Maternal Health Insurance Coverage

NOTE: Skip DD7 if mother was insured during the month before she got pregnant (Core 6).

BEFORE DD7, insert instruction box that says, “If you did not have health insurance during the month before you got pregnant, go to Question DD7. If you did, go to Question #.”

	If you did not have health insurance during the month before you got pregnant, go to Question DD7. If you did, go to Question #.
DD7.	What was the reason that you did not have any health insurance during the month before you got pregnant with your new baby?
	Check ALL that apply
	Health insurance was too expensive
	I couldn’t get health insurance from my job or the job of my spouse or partner
	I applied for health insurance but was waiting to get it
	I had problems with the health insurance application or website
	My income was too high to qualify for Medicaid
	My income was too high to qualify for a tax credit from the <Site> Health Insurance Marketplace or HealthCare.gov
	I didn’t know how to get health insurance
	Site-specific option (I’m not a US citizen, or I don’t have the right residency documents)
	Other
	⤷ Please tell us:_______________________________

NOTE: Skip DD11 if mother had health insurance during pregnancy (Core 7).

BEFORE DD11, insert instruction box that says, “If you did not have health insurance during your most recent pregnancy, go to Question DD11. If you did, go to Question #.”

	If you did not have health insurance during your most recent pregnancy, go to Question DD11. If you did, go to Question #.
DD11. (MOD)	What was the reason that you did not have any health insurance during your most recent pregnancy?
	Check ALL that apply
	Health insurance was too expensive
	I couldn’t get health insurance from my job or the job of my spouse or partner
	I applied for health insurance but was waiting to get it
	I had problems with the health insurance application or website
	My income was too high to qualify for Medicaid
	My income was too high to qualify for a tax credit from the <Site> Health Insurance Marketplace or HealthCare.gov
	I didn’t know how to get health insurance
	Site-specific option (I’m not a US citizen, or I don’t have the right residency documents)
	Other
	⤷ Please tell us:­______________________________________________________________

NOTE: Skip DD20 if mother has health insurance now (Core 8).

BEFORE DD20, insert instruction box that says, “If you do not have health insurance now, go to Question DD20. If you do, go to Question #.”

	If you do not have health insurance now, go to Question DD20. If you do, go to Question #.
DD20.	What is the reason that you do not have any health insurance now?
	Check ALL that apply
	Health insurance is too expensive
	I can’t get health insurance from my job or the job of my spouse or partner
	I applied for health insurance, but I’m still waiting to get it
	I had problems with the health insurance application or website
	My income is too high to qualify for Medicaid
	My income is too high to qualify for a tax credit from the <Site > Health Insurance Marketplace or HealthCare.gov
	I don’t know how to get health insurance
	Site-specific (I’m not a US citizen, or I don’t have the right residency documents)
	Other
	⤷ Please tell us:______________________________________________

HIV and Sexually Transmitted Infections

EE3.	During your most recent pregnancy, did a healthcare provider tell you that you had any of the following infections?
	For each one, check No or Yes.
		No Yes
	Genital warts (HPV)	 
	Herpes	 
	Chlamydia	 
	Gonorrhea	 
	Pelvic inflammatory disease (PID)	 
	Syphilis	 
	Group B Strep (Beta Strep)	 
	Bacterial vaginosis	 
	Trichomoniasis (Trich)	 
	Yeast infection	 
	Urinary tract infection (UTI)	 
	Other ⤷ Please tell us:	 

NOTE: I9 needs I8, but I8 can be used alone.

Skip I9 if mom indicated in I8 that she was tested during pregnancy or delivery.

I8.		At any time during your most recent pregnancy or at delivery, did you have a test for HIV (the virus that causes AIDS)?
		No
		Yes → Go to Question #
		I don’t know → Go to Question #
I9.	Why didn’t you have an HIV test during your most recent pregnancy or delivery?
	Check ALL that apply
			I wasn’t offered the test
			I didn’t want to have the test
			I already knew my HIV status
			I didn’t think I was at risk for HIV
			I didn’t want people to think I was at risk for HIV
			I was afraid of getting the result
			I was tested before this pregnancy and didn’t think I needed to be tested again
			Other reason
	⤷ Please tell us:

I10.	What are you doing now to keep from getting sexually transmitted infections (STIs), including HIV?
	Check ALL that apply
	I’m not doing anything
	Using condoms
	I get tested for STIs/HIV
	Mutual monogamy (partners only have sex with each other)
	Other
	⤷Please tell us:____________________________________________

Postpartum Care

NOTE: Skip J3 if mom had a postpartum checkup.

If J3 is added, the skip arrow on Core 44 should be switched from “no” to “yes”.

AFTER J3, add: “If you did not have a postpartum checkup, go to Question #.”

J3.	Did any of these things keep you from having a postpartum checkup?
	Check ALL that apply
	I didn’t know I needed one
	I didn’t have enough money or insurance to pay for the visit
	I felt fine and didn’t think I needed to have a visit
	I couldn’t get an appointment when I wanted one
	I didn’t have any transportation to get to the clinic or doctor’s office
	I had too many other things going on
	I couldn’t take time off from work or school
	I didn’t have anyone to help me take care of my children
	The doctor’s office was too far away
	Other ⤷ Please tell us:________________________________________

	If you did not have a postpartum checkup, go to Question #
J6.		Since your new baby was born, have you received follow-up care for any of the following? For each item, check No if you didn’t get it, check Yes if you did get it, or check DH if you didn’t have the condition.
			No Yes DH
		Diabetes	  
		Hypertension (high blood pressure)	  
		Depression	  
		Anxiety	  
		Heart conditions (e.g., birth defects of the heart, fast or skipped heartbeat, heart failure, enlarged heart, heart attack, chest pain, heart transplant, pacemaker)	  

J7.	Overall, since my new baby was born, I have felt:
	For each one, check No or Yes.
		No Yes
	Comfortable asking questions about the postpartum care that I received	 
	Comfortable declining care if I didn't want it	 
	Comfortable accepting the options for care that my provider recommended	 
	I was able to choose the care options that I received	 
	My providers treated me with respect	 
	Satisfied with the postpartum care I received	 

Preconception Care

NOTE: Skip J5 if mom had a healthcare visit (Core 4).

If J5 is added, the instructional box after Core 4 should be changed to “If you didn’t have any healthcare visits in the 12 months before you got pregnant, go to Question #.”

AFTER J5, add: “If you didn’t have any healthcare visits, go to Question #.”

J5. (NEW)	Why didn’t you have any healthcare visits in the 12 months before you got pregnant with your new baby?
	Check ALL that apply
	I didn’t know I needed one
	I didn’t have enough money or insurance to pay for the visit
	I felt fine and didn’t think I needed to have a visit
	I couldn’t get an appointment when I wanted one
	I didn’t have any transportation to get to the clinic or doctor’s office
	I had too many other things going on
	I couldn’t take time off from work or school
	I didn’t have anyone to help me take care of my children
	The doctor’s office was too far away
	Other ⤷ Please tell us:___________________________________________
	If you didn’t have any healthcare visits, go to Question #.

Labor and Delivery

K3.	How was your new baby delivered?
	Vaginally
	Cesarean delivery (c-section)

NOTE: Skip K4 if mother did not have prenatal care (Core 10).

K4.	How did your prenatal provider suggest you deliver your new baby?
		Check ONE answer
			Suggested I deliver my baby vaginally (naturally)
			Suggested I have a cesarean delivery (c-section)
			Didn’t suggest how I deliver my baby

NOTE: Skip K6 and K7 if the mother did not have a cesarean delivery for her new baby (K3).

K6 and K7 must be used with K3, but K3 may be used alone.

K6.	Which statement best describes whose idea it was for you to have a cesarean delivery (c-section)?
	Check ONE answer
		My healthcare provider recommended a cesarean delivery before I went into labor
		My healthcare provider recommended a cesarean delivery while I was in labor
		I asked for the cesarean delivery

K7.	What was the reason that your new baby was born by cesarean delivery (c-section)? Check ALL that apply
	I had a previous cesarean delivery (c-section)
	My baby was in the wrong position (such as breech)
	I was past my due date
	My healthcare provider worried that my baby was too big
	I had a medical condition that made labor dangerous for me (such as heart condition, physical disability)
	I had a complication in my pregnancy (such as pre-eclampsia, placental problems, infection, preterm labor)
	My healthcare provider tried to induce my labor, but it didn’t work
	Labor was taking too long
	The fetal monitor showed that my baby was having problems before or during labor (fetal distress)
	I wanted to schedule my delivery
	I didn’t want to have my baby vaginally
	Other ⤷ Please tell us:____________________________________

K8.	Did you plan or schedule a cesarean delivery (c-section) at least one week before your new baby was born?
	No
	Yes

NOTE: K10 needs K9, but K9 can be used alone.

K9.	Did your healthcare provider try to induce your labor using different methods to start your contractions (such as medications or thinning of the membrane)?
	No → Go to Question #
	Yes
	I don’t know → Go to Question #

K10.	Why did your healthcare provider try to induce your labor?
	Check ALL that apply
	My water broke, and there was a fear of infection
	I was past my due date
	My healthcare provider worried about the size of the baby
	My baby was not doing well and needed to be born
	I had a complication in my pregnancy (such as low amniotic fluid or pre-eclampsia)
	I wanted to schedule my delivery
	I wanted to give birth with a specific healthcare provider
	Other
	⤷ Please tell us:___________________________________________

K16.	After delivery, was your baby put in an intensive care unit (NICU)?
	No
	Yes
	I don’t know

K17.	Overall, during the delivery of my baby, I felt:
	For each one, check No or Yes.
		No Yes
	Comfortable asking questions about the labor and delivery care that I received	 
	Comfortable declining care if I didn't want it	 
	Comfortable accepting the options for care that my provider recommended	 
	I was able to choose the care options that I received	 
	My providers treated me with respect	 
	Satisfied with the labor and delivery care I received	 

Preconception Health

L10.	Before you got pregnant, would you say that, in general, your health was—
	Excellent
	Very good
	Good
	Fair
	Poor
Response options for L11 are added directly to Core 3 and/or Core 15 if this question is selected.

L11.	Additional options for Core 3 and/or Core 15
		No Yes
	Asthma	 
	Anemia (poor blood, low iron)	 
	Epilepsy (seizures)	 
	Thyroid problems	 
	PCOS (polycystic ovarian syndrome)	 

NOTE: Skip L18 if healthcare provider didn’t talk with mother about preparing for pregnancy (L27). L27 must be used before L18.

L27.	In the 12 months before you got pregnant with your new baby, did a healthcare provider talk to you about preparing for a pregnancy?
	No → Go to Question #
	Yes

L18.	In the 12 months before you got pregnant with your new baby, did a healthcare provider talk with you about the following things?
	For each one, check No or Yes.
		No Yes
	Getting vaccines before pregnancy	 
	Getting counseling for any genetic diseases that run in my family	 
	Getting counseling or treatment for depression or anxiety	 
	The safety of using prescription or over-the-counter medicines during pregnancy	 
	How smoking during pregnancy can affect a baby	 
	How drinking alcohol during pregnancy can affect a baby	 
	How using drugs not prescribed to me during pregnancy can affect a baby	 

L26.	At any time during the 12 months before you got pregnant with your new baby, did you do any of the following things?
	For each one, check No or Yes.
		No Yes
	I was dieting (changing my eating habits) to lose weight	 
	I was exercising 3 or more days of the week for fitness outside of my regular job	 
	I was regularly taking prescription medicines other than birth control	 
	A healthcare provider checked me for diabetes	 
	I talked to a healthcare provider about my family medical history	 

Vaccinations

Also see COVID-19 Vaccine Supplement

Maternal

NOTE: Skip L14 if mother got a flu shot (Core 13).

BEFORE L14, add: “If you got a flu shot before or during your pregnancy, go to Question #.”

If you got a flu shot before or during your pregnancy, go to Question #.

L14.	What were your reasons for not getting a flu shot during the 12 months before the birth of your new baby?
	For each one, check No or Yes.
		No Yes
	My doctor didn’t mention anything about a flu shot	 
	I was worried about side effects of the flu shot for me	 
	I was worried that the flu shot might harm my baby	 
	I wasn’t worried about getting sick with the flu	 
	I don’t think the flu shot works	 
	I don’t normally get a flu shot	 
	Other	 
	⤷ Please tell us:_______________________

BEFORE L19, add: “If you didn’t get a flu shot before or during your pregnancy, go to Question #.”

If you didn’t get a flu shot before or during your pregnancy, go to Question #.

L19.	Where did you get your flu shot?
	Check ONE answer
	My OB/GYN’s office
	My family doctor or other doctor's office
	A health department or community clinic
	A hospital
	A pharmacy, drug store, or grocery store
	My workplace or school
	Other
	⤷ Please tell us:______________________________________________________

Child Vaccinations

NOTE: Skip L33 if infant is not alive or not living with the mother (Core 33 and/or Core 34).

L33.	What are your plans for vaccinating your new baby?
	Check ONE answer
	My baby will be vaccinated the way my baby’s doctor recommends
	My baby will get every vaccine but at different times than my baby’s doctor recommends
	My baby will get only some of the recommended vaccines
	My baby will not get any vaccines

Mental Health

Note: M23 needs M22, but M22 can be used alone

M24 needs M22 and M23

M22.	Since your new baby was born, have you felt that you’ve needed mental health services such as counseling, medications, or support groups to help with feelings of anxiety, depression, grief, or other issues?
	No → Go to Question #
	Yes

 

M23.	Were you able to get the mental health services that you needed?
	No
	Yes → Go to Question #

 

M24.	Which of these statements explains why you did not get the mental health services you needed?  Check ALL that apply
	I couldn’t afford the cost
	I couldn’t get an appointment as soon as I needed
	My health insurance doesn’t cover any type of mental health services
	My health insurance doesn’t pay enough for mental health services
	I didn’t know where to go to get services
	I was concerned that the information I shared might not be kept confidential
	I didn’t want others to find out that I needed treatment
	I was concerned that I might be committed to a psychiatric hospital
	I was concerned that I might have to take medicine
	I had no transportation, treatment was too far away, or the hours were not convenient
	I didn't have time (because of a job, childcare, or other commitments)
	Some other reason
	⤷ Please tell us:_______________________________________

Note: Skip M4 if mom does not indicate she had depression in Core 15 (Q15, item c).

BEFORE M4, add instruction: “If you had depression during your most recent pregnancy, go to Question M4. If you didn’t, go to Question #.”

M4.	At any time during your most recent pregnancy, did you ask for help for depression from a healthcare provider?
	No
	Yes

M5.	Since your new baby was born, has a healthcare provider told you that you had depression?
	No → Go to Question #
	Yes
M6.	Since your new baby was born, have you asked for help for depression from a healthcare provider?
	No
	Yes
M7.	How would you describe the time during your most recent pregnancy?
	Check ONE answer
	One of the happiest times of my life
	A happy time with few problems
	A moderately hard time
	A very hard time
	One of the worst times of my life

Note: Skip M8 and M9 if mom does not indicate she had depression in Core 15 (Q15, item c).

BEFORE M9/M8, add instruction: “If you had depression during your most recent pregnancy, go to Question M9/M8. If you didn’t, go to Question #.”

If you had depression during your most recent pregnancy, go to Question M9/M8. If you didn’t, go to Question #.

M8.	At any time during your most recent pregnancy, did you take prescription medicine for your depression?
	No
	Yes

M9.	At any time during your most recent pregnancy, did you get counseling for your depression?
	No
	Yes

Note: M10 and M11 need M5, but M5 can be used alone. Skip M10 and M11 if M5 is no.

M10.	Since your new baby was born, have you taken prescription medicine for your depression?
	No
	Yes

M11.	Since your new baby was born, have you gotten counseling for your depression?
	No
	Yes

M14.	At any time during your most recent pregnancy, did you ask for help for anxiety from a healthcare provider?
	No
	Yes

M15.	Since your new baby was born, has a healthcare provider told you that you had anxiety?
	No → Go to Question #
	Yes

M16.	Since your new baby was born, have you asked for help for anxiety from a healthcare provider?
	No
	Yes

Note: Skip M17 and M18 if mom does not indicate she had anxiety in Core 15 (Q15, item d).

BEFORE M17/M18, add instruction: “If you had anxiety during your most recent pregnancy, go to Question M18/M17. If you didn’t, go to Question #.”

If you had anxiety during your most recent pregnancy, go to Question M18/M17. If you didn’t, go to Question #.

M17.	At any time during your most recent pregnancy, did you take prescription medicine for your anxiety?
	No
	Yes

M18.	At any time during your most recent pregnancy, did you get counseling for your anxiety?
	No
	Yes

Note: M19 and M20 need M15, but M15 can be used alone.

M19.	Since your new baby was born, have you taken prescription medicine for your anxiety?
	No
	Yes

M20.	Since your new baby was born, have you gotten counseling for your anxiety?
	No
	Yes

Maternal Morbidity

N1.	At any time during your most recent pregnancy, did a healthcare provider tell you to stay in bed for at least 1 week?
	No → Go to Question #
	Yes

NOTE: N2 needs N1, but N1 can be used alone.

N2.	How many weeks or months pregnant were you when you were told to stay in bed? Write ONE answer
	______Weeks OR
	______Months

NOTE: N3 needs N1, but N1 can be used alone.

N3.	How often were you able to follow your provider’s instruction to stay in bed?
	Always → Go to Question #
	Often → Go to Question #
	Sometimes
	Rarely
	Never

NOTE: N4 needs N3, but N3 can be used alone.

N4.	What types of support would have helped you to stay in bed for the recommended time? For each one, check No or Yes.
		No Yes
	Help with childcare	 
	Help with housework	 
	Knowing I wouldn’t lose my job	 
	Money to make up for not working	 
	Other	 
	⤷ Please tell us:________________________________

N5.	During your most recent pregnancy, did a healthcare provider give you a series of weekly shots of a medicine called progesterone, Makena®, or 17P (17 alpha-hydroxyprogesterone) to try to keep your new baby from being born too early?
	No
	Yes
	I don’t know

NOTE: Skip N7 if the mother did not have gestational diabetes during this pregnancy (Core 15, item a). BEFORE N7, add instruction that says, “If you had gestational diabetes during your most recent pregnancy, go to Question N7. If you didn’t, go to Question #.”

N7. (MOD)	During your most recent pregnancy, when you were told that you had gestational diabetes, did a healthcare provider do any of the things listed below?
	For each one, check No or Yes.
	GRID: No/Yes	No Yes
	Refer me to a nutritionist	 
	Talk to me about the importance of exercise	 
	Talk to me about getting to a healthy weight after delivery	 
	Talk to me about my risk for Type 2 diabetes	 

N9.	Did you have any of the following problems during your most recent pregnancy? For each one, check No or Yes.
		No Yes
	Vaginal bleeding	 
	Kidney or bladder (urinary tract) infection (UTI)	 
	Severe nausea, vomiting, or dehydration that sent me to the doctor or hospital	 
	Cervix had to be sewn shut (cerclage for incompetent cervix)	 
	Problems with the placenta (such as abruptio placentae or placenta previa)	 
	Labor pains more than 3 weeks before my baby was due (preterm or early labor)	 
	Water broke more than 3 weeks before my baby was due (preterm premature rupture of membranes [PPROM])	 
	I had to have a blood transfusion	 
	I was hurt in a car accident	 

O4.	Since your new baby was born, have you been tested for diabetes or high blood sugar?
	No → Go to Question #
	Yes

O7.	Have you experienced any of the following things during your pregnancy or after your baby was born?
	For each one, check No or Yes.
		No Yes
	I felt something wasn’t right with my health	 
	I felt my concerns for my health weren’t taken seriously	 
	I felt my doctor ignored my concerns about my health or symptoms	 

O8.	Have you regularly monitored your blood pressure at home or outside of a healthcare visit during the time periods listed below?
	For each one, check No or Yes.
		No Yes
	During the 12 months before my most recent pregnancy	 
	During my most recent pregnancy	 
	Since my new baby was born	 

Maternal Warning Signs

O9.	Since your new baby was born, have you received information about warning signs of postpartum complications from any of the following sources?
		No Yes
	A healthcare provider (such as a doctor, nurse, or midwife)	 
	Websites or social media (such as Facebook, Instagram, or Twitter)	 
	Any source of information that used the slogan ‘Hear Her’ (such as a website, social media, or paper handout)	 
	Family or friends	 

O10.	Did a healthcare provider talk with you about the warning signs of both pregnancy and postpartum complications during any of the following time periods?
	For each one, check No or Yes.
			No Yes
	During the 12 months before I got pregnant		 
	During my most recent pregnancy		 
	During my labor and delivery hospitalization		 
	Since my new baby was born		 

Food Security and Economic Stability

P14.	During the 12 months before your new baby was born, did you ever eat less than you felt you should because there wasn’t enough money to buy food?
	No
	Yes

P17.	During the 12 months before your new baby was born, did you ever get emergency food from a church, a food pantry, or a food bank, or eat in a food kitchen?
	No
	Yes

NOTE: P21 needs P20 but P20 can be used alone.

P20.	During the 12 months before your new baby was born, which of these statements best describes the food in your household?
	Check ONE answer
	Enough of the kinds of food I wanted to eat → Go to Question #
	Enough, but not always the kinds of food I wanted to eat → Go to Question #
	Sometimes not enough to eat
	Often not enough to eat

P21.	Why didn’t you have enough to eat? Check ALL that apply
	I couldn’t afford to buy more food
	I couldn’t get out to buy food (for example, didn’t have transportation or had mobility or health problems that kept me from getting out)
	I was afraid or didn’t want to go out to buy food
	I couldn’t get groceries or meals delivered
	The stores didn’t have the food I wanted

P22.	During the 12 months before your new baby was born, how often were you unable to afford to eat balanced meals? A balanced meal includes all the types of food that you think should be in a healthy meal. For example, a starch like potatoes or rice, vegetables or fruit, and some protein like meat, fish, cheese, or eggs.
	Always
	Usually
	Sometimes
	Rarely
	Never

P23.	What is your living situation today?
	Check ONE answer
	I have a steady place to live
	I have a place to live today, but I’m worried about losing it in the future
	I don’t have a steady place to live (I’m temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)

 

BB3.	Since your new baby was born, how often would you say you have been worried or stressed about having enough money to pay your bills?
	Always
	Often
	Sometimes
	Rarely
	Never

Neighborhood and Built Environment

P15.	During the 12 months before your new baby was born, how often did you feel unsafe in the neighborhood where you lived?
	Always
	Often
	Sometimes
	Rarely
	Never

Family Planning

Q1.	Which of the following statements best describes you during the 3 months before you got pregnant with your new baby?
	Check ONE answer
	I was trying to get pregnant
	I was trying to keep from getting pregnant but wasn’t trying very hard not to
	I was trying hard to keep from getting pregnant

Q2.	Which of the following statements best describes your spouse or partner during the 3 months before you got pregnant with your new baby? Check ONE answer
	Wanted me to get pregnant
	Didn’t care one way or the other whether I got pregnant
	Didn’t want me to get pregnant

Q3.	Thinking back to just before you got pregnant with your new baby, how did your spouse or partner feel about your becoming pregnant? Check ONE answer
	Wanted me to be pregnant sooner
	Wanted me to be pregnant later
	Wanted me to be pregnant then
	Didn’t want me to be pregnant then or at any time in the future
	I don’t know
	I didn’t have a spouse or partner

NOTE: Skip Q4 if mom wanted to be pregnant sooner, then, not then or any time in future, or if she wasn’t sure (Core 9). Add a skip arrow to Core 9 for the last four responses.

Q4.	How much longer did you want to wait to become pregnant?
	Less than 1 year
	1 year to less than 2 years
	2 years to less than 3 years
	3 years to 5 years
	More than 5 years

Q5.	When you found out you were pregnant with your new baby, did you have any of the following feelings or concerns? For each one, check No or Yes.
		No Yes
	I was worried that I didn’t know enough about how to take care of a baby	 
	I thought a new baby would keep me from doing the things I was used to doing, like working, going to school, or going out	 
	I looked forward to teaching and caring for a new baby	 
	I looked forward to the new experiences that having a baby would bring	 
	I looked forward to telling my friends that I was pregnant	 
	I was worried that I didn’t have enough money to take care of a baby	 
	I didn’t look forward to telling my friends that I was pregnant	 
	I looked forward to buying things for a new baby	 

Q6.	How did you feel when you found out you were pregnant with your new baby?
	Very unhappy to be pregnant
	Unhappy to be pregnant
	Not sure
	Happy to be pregnant
	Very happy to be pregnant

NOTE: Skip Q7 if mother was not trying to get pregnant (E5).

AFTER Q7, insert instruction box that says, “If you were trying to get pregnant when you got pregnant with your new baby, go to Question #.”

Q7.	How many months were you trying to get pregnant? Do not count long periods of time when you and your partner were apart or not having sex.
	0 to 3 months
	4 to 6 months
	7 to 12 months
	13 to 24 months
	More than 24 months
	If you were trying to get pregnant when you got pregnant with your new baby, go to Question #.

Prenatal Care

NOTE: Skip R24 if mother had no prenatal care (Core 10).

R24.	How many weeks or months pregnant were you when you had your first visit for prenatal care?
	Write ONE answer
	____Week(s) OR
	____Month(s)

R20.	Did you get prenatal care as early in your pregnancy as you wanted?
	No
	Yes → Go to Question #

NOTE: R21 needs R20, but R20 can be used alone.

AFTER R21, insert instruction box that says, “If you did not get prenatal care, go to Question #.”

R21.	Did any of these things keep you from getting prenatal care when you wanted it? For each one, check No or Yes.
		No Yes
	I couldn’t get an appointment when I wanted one	 
	I didn’t have enough money or insurance to pay for my visits	 
	I didn’t have any transportation to get to the clinic or doctor’s office	 
	The doctor or my health plan wouldn’t start care as early as I wanted	 
	I had too many other things going on	 
	I couldn’t take time off from work or school	 
	I didn’t have my Medicaid <or state Medicaid name> card	 
	I didn’t have anyone to take care of my children	 
	I didn’t know that I was pregnant	 
	I didn’t want anyone else to know I was pregnant	 
	I didn’t want prenatal care	 
	The doctor’s office was too far away	 

NOTE: Skip R6-R16, R25 if mother had no prenatal care (Core 10).

R6.	Have you ever heard of the bacteria Group B Strep or Beta Strep that mothers can pass to their newborns during birth?
	No
	Yes

R7.	During any of your prenatal care visits, did a healthcare provider talk with you about the bacteria Group B Strep or Beta Strep?
	No
	Yes

R8.	At any time during your most recent pregnancy, did you get tested for the bacteria Group B Strep or Beta Strep?
	No
	Yes
	I don’t know

R12.	During any of your prenatal care visits, did a healthcare provider talk with you about taking multivitamins, prenatal vitamins, or folic acid vitamins during your pregnancy?
	No
	Yes

R13.	At any time during your most recent pregnancy, did your regular prenatal care provider ask you to see a specialist doctor for help with any health problems?
	No
	Yes

R14.	During any of your prenatal care visits, did a healthcare provider talk with you about how eating fish containing high levels of mercury could affect your baby?
	No
	Yes

R15.	Where did you go most of the time for your prenatal care visits? Do not include visits for WIC.
	Check ONE answer
	Private doctor’s office
	Hospital clinic
	Health department clinic
	Site-specific option
	Site-specific option
	Other
	⤷ Please tell us:____________________________

R16.	During your most recent pregnancy, did a healthcare provider talk with you about any of the things listed below? Please count only discussions, not reading materials or videos.
	For each one, check No or Yes.
		No Yes
	Foods that are good to eat during pregnancy	 
	Exercise during pregnancy	 
	Programs or resources to help me gain the right amount of weight during pregnancy	 
	Programs or resources to help me lose weight after pregnancy	 

R19.	How many weeks or months pregnant were you when you were sure you were pregnant? For example, you had a pregnancy test, or a healthcare provider said you were pregnant.
	Write ONE answer
	______ Weeks OR
	______ Months
	I don’t remember

R25.	Overall, during my pregnancy, I felt:
	For each one, check No or Yes.
		No Yes
	Comfortable asking questions about the prenatal care that I received	 
	Comfortable declining care if I didn't want it	 
	Comfortable accepting the options for care that my provider recommended	 
	I was able to choose the care options that I received	 
	My providers treated me with respect	 
	Satisfied with the prenatal care I received	 

R23.	During your most recent pregnancy, did you take a class or classes to prepare for childbirth and learn what to expect during labor and delivery?
	No
	Yes

Injury Prevention and Safety

Also see Environmental Exposures Supplement

NOTE: Skip S1 if infant is not alive or not living with the mother (Core 33 and/or Core 34).

S1.	Listed below are some statements about safety. For each one, check No if it does not apply to you or Yes if it does.
		No Yes
	I always used a seatbelt during my most recent pregnancy	 
	My home has a working smoke alarm	 
	I have received information about infant products that should be taken off the market (product recalls) since my new baby was born	 
	My home has a working carbon monoxide detector	 

NOTE: Skip S6 if infant is not alive, is not living with the mother, or is still in the hospital (Core 33, Core 34, or Core 32).

S6.	When riding in a car, truck, or van, how often does your baby ride in an infant car seat?
	Always
	Often
	Sometimes
	Rarely
	Never → Go to Question #

NOTE: Skip S10 and S12 if infant is not alive, is not living with the mother, or is still in the hospital (Core 33, Core 34, or Core 32).

S10.	Do you have an infant car seat that you can use for your new baby?
	No → Go to Question #
	Yes

Note: S12 needs S10, but S10 can be used alone.

S12.	How did you learn to install and use your infant car seat?
	Check ALL that apply
	I read the instructions
	A friend or family member showed me
	A health or safety professional showed me
	I figured it out myself
	I already knew how to install it because I have other children
	Some other way
	⤷ Please tell us:______________________________________

NOTE: Skip S13 if infant is not alive or is not living with the mother (Core 33 or Core 34)

S13.	Have you ever heard or read about what can happen if a baby is shaken?
	No
	Yes

S20.	During the 12 months before your new baby was born, did a healthcare provider talk to you about getting your household water tested for any of the following things?
	For each one, check No or Yes.
		No Yes
	Arsenic	 
	Lead	 
	Other contaminants	 
	⤷ Please tell us:____________________________________________

NOTE: S22 needs S21, S23 needs S22 and S21, but S21 can be used alone.

S21.	Are any firearms kept in or around your home now?
	No → Go to Question #
	Yes
	I don’t know → Go to Question #
S22.		Are any of these firearms now loaded?
		No → Go to Question #
		Yes
		I don't know→ Go to Question #

S23.	Are any of these loaded firearms also unlocked? Unlocked meaning you do not need a key, combination, or hand/fingerprint to get the gun or to fire it. Do not count a safety as a lock.
	No
	Yes
	I don't know

Infant Healthcare

Sick Child Care

NOTE: Skip T1 and T3 if infant is not alive, is not living with the mother, or is still in the hospital (Core 33, Core 34, or Core 32).

T1.	Have you taken your new baby for care when he or she was sick? Check ONE answer
	No
	Yes
	My baby has not been sick → Go to Question #

Note: T3 needs T1, but T1 can be used alone.

T3.	Has your new baby gone for care as many times as you wanted when he or she was sick?
	No
	Yes → Go to Question #

NOTE: T8 requires T3.

T8.	Did any of these things keep you from taking your baby for care when he or she was sick?
	Check ALL that apply
	I didn’t have health insurance to pay for the visit
	I couldn’t get an appointment
	I didn’t have a regular doctor for my baby
	I had no way to get my baby to the clinic or doctor’s office
	I didn’t have anyone to take care of my other children
	Other
	⤷ Please tell us:_____________________________

Well Child Care

NOTE: Skip X2, X9, and X10 if infant is not alive, is not living with the mother, or is still in the hospital (Core 33, Core 34, or Core 32).

X2 needs X9, but X9 can be used alone

X9.	Has your new baby had a well-baby checkup? A well-baby checkup is a regular health visit for your baby usually at 1, 2, 4, and 6 months of age.
	No
	Yes → Go to Question #

X2.	Did any of these things keep your baby from having a well-baby checkup? Check ALL that apply
	I didn’t have enough money or insurance to pay for it
	I had no way to get my baby to the clinic or doctor’s office
	I didn’t have anyone to take care of my other children
	I couldn’t get an appointment
	My baby was too sick to go for a well-baby checkup
	Other
	⤷ Please tell us:____________________________________________________________

X10.	Was your new baby seen by a healthcare provider for a one-week checkup after he or she was born?
	No
	Yes
	My baby was still in the hospital at that time

Substance Use

Also see Marijuana Supplement and Opioid Supplement

NOTE: If using DRUG2/DRUG3, add transition statement: “The next questions are about using different drugs around the time of pregnancy. Your answers are strictly confidential.”

DRUG2.	During the month before you got pregnant, did you take or use any of the following medications or drugs for any reason?
	For each one, check No or Yes.
		No Yes
	Medication for depression	 
	Medication for anxiety	 
	Prescription pain relievers such as hydrocodone (Vicodin®), oxycodone (Percocet®), or codeine	 
	Adderall®, Ritalin®, or another stimulant	 
	Methadone, Subutex®, Suboxone®, or buprenorphine	 
	Naloxone	 
	Marijuana or cannabis products (not including hemp or CBD-only products)	 
	CBD products	 
	Synthetic marijuana (K2 or Spice)	 
	Kratom	 
	Fentanyl or Heroin (smack, junk, Black Tar or Chiva)	 
	Amphetamines (uppers, speed, crystal meth, crank, ice or agua)	 
	Cocaine (crack, rock, coke, blow, snow or nieve)	 
	Benzodiazepines (Valium®, Ativan®, Xanax®) or Tranquilizers (downers or ludes)	 
	Hallucinogens (LSD/acid, PCP/angel dust, Ecstasy, Molly, mushrooms, or bath salts)	 
	Sniffing gasoline, glue, aerosol spray cans, or paint to get high (huffing)	 

DRUG3.	During your most recent pregnancy, did you take or use any of the following medications or drugs for any reason? For each one, check No or Yes.
		No Yes
	Medication for depression	 
	Medication for anxiety	 
	Prescription pain relievers such as hydrocodone (Vicodin®), oxycodone (Percocet®), or codeine	 
	Adderall®, Ritalin®, or another stimulant	 
	Methadone, Subutex®, Suboxone®, or buprenorphine	 
	Naloxone	 
	Marijuana or cannabis products (not including hemp or CBD-only products)	 
	CBD products	 
	Synthetic marijuana (K2 or Spice)	 
	Kratom	 
	Fentanyl or Heroin (smack, junk, Black Tar or Chiva)	 
	Amphetamines (uppers, speed, crystal meth, crank, ice or agua)	 
	Cocaine (crack, rock, coke, blow, snow or nieve)	 
	Benzodiazepines (Valium®, Ativan®, Xanax®) or Tranquilizers (downers or ludes)	 
	Hallucinogens (LSD/acid, PCP/angel dust, Ecstasy, Molly, mushrooms, or bath salts)	 
	Sniffing gasoline, glue, aerosol spray cans, or paint to get high (huffing)	 

BEFORE U10, add:” If you did not use prescription pain relievers during your most recent pregnancy, go to Question #.”

U10.	After your baby was born, did a healthcare provider tell you that your baby had drug withdrawal or neonatal abstinence syndrome?
	No
	Yes

Social Services including Home Visitation

V1.	During your most recent pregnancy, did you use any of these services? For each one, check No or Yes.
		No Yes
	Parenting classes	 
	Counseling for depression or anxiety	 

NOTE: Skip V2 and V3 if infant is not alive or not living with the mother (Core 33 and/or Core 34).

BEFORE V2/V3 insert an instruction that says, “If your baby is not alive or is not living with you, go to Question #.”

V2.	Since your new baby was born, have you used any of these services? For each one, check No or Yes.
		No Yes
	Parenting classes	 
	Counseling for depression or anxiety	 

V3.	Since your new baby was born, have you used WIC services for yourself or your new baby? Check ONE answer
	No
	Yes, only I am using WIC services
	Yes, both my new baby and I use WIC services
	Yes, only my new baby uses WIC services

V11.	During your most recent pregnancy, did you feel you needed any of the following services? For each one, check No or Yes.
		No Yes
	SNAP (the Supplemental Nutrition Assistance Program)	 
	WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)	 
	Counseling for family and personal problems	 
	Help to quit smoking	 
	Help to reduce violence in my home	 
	Help to quit using drugs	 
	Assistance with housing or rent	 
	Other	 
	⤷ Please tell us:_____________________________________________

V12.	During your most recent pregnancy, did you receive any of the following services?
	For each one, check No or Yes.
		No Yes
	SNAP (the Supplemental Nutrition Assistance Program)	 
	WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)	 
	Counseling for family and personal problems	 
	Help to quit smoking	 
	Help to reduce violence in my home	 
	Help to quit using drugs	 
	Assistance with housing or rent	 
	Other	 
	⤷Please tell us:_________________________________

NOTE: Skip V13-V15 and V20, if the mother did not have a home visitor (V21).

V21.	During your most recent pregnancy, did a home visitor come to your home to help you prepare for your new baby? A home visitor is a nurse, healthcare provider, doula, childbirth educator, social worker, or another person who works for a program that helps you during your pregnancy.
	No → Go to Question #
	Yes

V13. (MOD)	Who was the home visitor that came to your home during your most recent pregnancy?
	Check ALL that apply
	A nurse, nurse’s aide, or midwife
	A teacher or health educator
	A doula or childbirth educator
	Site option (Someone from the <Healthy Start or other Program Name>)
	Someone else
	⤷ Please tell us:_____________________________
	I don’t know

V14.	During your most recent pregnancy, how many times did the home visitor come to your home to help you learn how to prepare for your new baby?
	1 time
	2 to 4 times
	5 or more times

V15. (MOD)	During your most recent pregnancy, did the home visitor who came to your home talk with you about any of the things listed below?
	For each one, check No or Yes.
		No Yes
	How smoking during pregnancy could affect my baby	 
	How drinking alcohol during pregnancy could affect my baby	 
	Doing tests to screen for birth defects or diseases that run in my family	 
	The importance of getting tested for HIV	 
	The importance of getting tested for sexually transmitted infections	 
	If someone was hurting me emotionally or physically	 
	Breastfeeding my baby	 
	My emotional well-being	 

V20.	The following questions are about the care you got from the home visitor during your most recent pregnancy. For each one, check No or Yes.
		No Yes
	Were you satisfied with the amount of time the home visitor spent with you?	 
	Were you satisfied with the advice you got on how to take care of yourself and your baby?	 
	Did you feel understood and respected by the home visitor?	 

NOTE: Skip V22 if the baby is not alive (Core 33). DO NOT skip if the baby is not living with the mom or is still in the hospital (Core 34 and Core 32).

Skip arrow for Core 34 should go to V22 and the instruction box before Core Q36 should go to V22 if V22 is inserted.

V22.	Since your new baby was born, has a home visitor come to your home to help you learn how to take care of yourself or your new baby? A home visitor is a nurse, healthcare provider, doula, social worker, or another person who works for a program that helps families with newborns.
	No → Go to Question #
	Yes

NOTE: Skip V16, V18, and V19 if the mother did not have a postpartum home visitor (V22).

V16.	Who was the home visitor that came to your home since your new baby was born?
	Check ALL that apply
	A nurse, nurse’s aide, or midwife
	A teacher or health educator
	A doula or childbirth educator
	Site option (Someone from the <Healthy Start or other Program Name>)
	Someone else
	⤷ Please tell us: ________________________________
	I don’t know

V18.	Since your new baby was born, did the home visitor who came to your home talk with you about any of the things listed below?
		No Yes
	Breastfeeding my baby	 
	How long to wait before getting pregnant again	 
	Family planning services or using contraception	 
	Postpartum depression	 
	Resources in my community to support new parents	 
	Getting to a healthy weight	 
	How to quit or keep from smoking	 
	How to get the healthcare that my baby or I need	 

V19.	The following questions are about the care you got from the home visitor since your new baby was born.
		No Yes
	Were you satisfied with the amount of time the home visitor spent with you?	 
	Were you satisfied with the advice you got on how to take care of yourself and your baby?	 
	Did you feel understood and respected by the home visitor?	 

V23.	Did you use doula support during any of the following time periods? A doula is a trained pregnancy and labor companion who gives comfort, emotional support, and information during birth. A doula does not provide medical care.
	For each one, check No or Yes.
		No Yes
	During my most recent pregnancy	 
	During the birth of my most recent baby	 
	Since my new baby was born	 

Social Support including Partner Experiences

W1.	During your most recent pregnancy, who would have helped you if a problem had come up? For example, who would have helped you if you needed to borrow $50 or if you got sick and had to be in bed for several weeks?
	Check ALL that apply
	My spouse or partner
	My mother, father, or in-laws
	Other family member or relative
	A friend
	Religious community
	Neighbors
	Someone else
	⤷ Please tell us: _________________________________
	No one would have helped me
W3.	Since your new baby was born, 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?
	Check ALL that apply
	My spouse or partner
	My mother, father, or in-laws
	Other family member or relative
	A friend
	Religious community
	Neighbors
	Someone else
	⤷ Please tell us: ___________________________________
	No one would help me

W5.	The following questions are about the people in your life and the support they provided you while you were pregnant.
	For each one, check No or Yes.
		No Yes
	Did you have someone you could go to if you felt lonely?	 
	Did you have someone you could talk with about things that were important to you or how you were feeling?	 
	Did you have someone you could count on to listen to your problems, worries, and fears?	 
	Did you have someone who showed you love and affection?	 
	Did you have someone who did things with you to relax or have fun?	 
	Did you have someone you could count on to loan you money for things like food or bills?	 
	Did you have someone who could take care of your children if you needed help?	 
	Did you have someone who could help with daily chores if you were sick?	 
	Did you have someone who could take you to the clinic or doctor’s office if you needed a ride?	 

W6.	The following questions are about the people in your life and the support they provide you now.
	For each one, check No or Yes.
		No Yes
	Do you have someone you can go to if you’re feeling lonely?	 
	Do you have someone you can talk with about things that are important to you or how you’re feeling?	 
	Do you have someone you can count on to listen to your problems, worries, and fears?	 
	Do you have someone who shows you love and affection?	 
	Do you have someone who does things with you to relax or have fun?	 
	Do you have someone you can count on to loan you money for things like food or bills?	 
	Do you have someone who can take care of your children if you need help?	 
	Do you have someone who can help with daily chores if you’re sick?	 
	Do you have someone who can take you to the clinic or doctor’s office if you need a ride?	 

W7.	Do your neighbors do any of the following things?
	For each one, check No if it does not apply to your neighbors or Yes if it does.
		No Yes
	Do favors for each other or help each other out	 
	Ask each other advice about personal things such as child rearing or job openings	 
	Have parties or other get-togethers where other people in the neighborhood are invited	 
	Visit in each other’s homes or on the street	 
	Watch over each other’s property	 

W8.	Please choose the statement that best describes your current living arrangement with your spouse or partner.
	Lives with me all of the time
	Lives with me some of the time
	Doesn’t live with me
	I don’t have a spouse or partner

W9.	Since your new baby was born, how often does your spouse or partner provide you with encouragement and emotional support?
	Always
	Often
	Sometimes
	Rarely
	Never
	I don’t have a spouse or partner

W10.	Since your new baby was born, how often does your baby’s father or other parent contribute things such as money, food, clothing, shelter, or healthcare to provide for your new baby’s basic needs?
	Always
	Often
	Sometimes
	Rarely
	Never

W11.	When your new baby’s father, or other parent, is with the baby, how often do they hug, kiss, hold, or play with the baby?
	Always
	Often
	Sometimes
	Rarely
	Never
	My new baby’s father, or other parent, doesn’t regularly spend time with my baby

Oral Health

Y3.	Since your new baby was born, have you had your teeth cleaned by a dentist or dental hygienist?
		No
		Yes

NOTE: Skip Y5 and Y8 if mom did not have teeth or gum problems.

BEFORE Y5 and Y8 add an instruction box that says: “If you did not have any problems with your teeth or gums during your pregnancy, go to Question #.”

Y5 and Y8 require Y7 but Y7 can be used alone

Y5.	During your most recent pregnancy, what kind of problem did you have with your teeth or gums?
	For each one, check No or Yes.
		No Yes
	I had cavities that needed to be filled	 
	I had painful, red, or swollen gums	 
	I had a toothache	 
	I needed to have a tooth pulled	 
	I had an injury to my mouth, teeth, or gums	 
	I had some other problem with my teeth or gums	 
	⤷ Please tell us: ____________________________________

Y6.	Did any of the following things make it hard for you to go to a dentist or dental clinic during your most recent pregnancy?
	For each one, check No or Yes.
		No Yes
	I couldn’t find a dentist or dental clinic that would take pregnant patients	 
	I couldn’t find a dentist or dental clinic that would take Medicaid patients	 
	I didn’t think it was safe to go to the dentist during pregnancy	 
	I couldn’t afford to go to the dentist or dental clinic	 
	I couldn’t find a dentist or dental clinic close by that I could get to	 

Y7.	The following statements are about the care of your teeth during your most recent pregnancy.
	For each one, check No or Yes.
		No Yes
	I knew it was important to care for my teeth and gums during my pregnancy	 
	A dental or other healthcare provider talked with me about how to care for my teeth and gums	 
	I knew it was safe to go to the dentist during pregnancy	 
	I had insurance to cover dental care during my pregnancy	 
	I needed to see a dentist for a problem	 
	I went to a dentist or dental clinic about a problem	 

Y8.	Did you get treatment from a dentist or another healthcare provider for the dental problem that you were having during your pregnancy?
	Check ONE answer
	No
	Yes, I got treatment during my pregnancy
	Yes, I got treatment after my pregnancy
	Yes, I got treatment both during and after my pregnancy

Intimate Partner Violence

Z1.	Did your current, or ex, spouse or partner do any of the following things during your most recent pregnancy?
		No Yes
	Threatened me or made me feel unsafe in some way	 
	Made me afraid for my safety or my family’s safety because of their anger or threats	 
	Tried to control my daily activities, for example, controlling who I could talk to or where I could go	 
	Forced me to take part in touching or any sexual activity when I didn’t want to	 

Z2.	Has your current, or ex, spouse or partner done any of the following things since your new baby was born?
		No Yes
	Threatened me or made me feel unsafe in some way	 
	Made me afraid for my safety or my family’s safety because of their anger or threats	 
	Tried to control my daily activities, for example, controlling who I could talk to or where I could go	 
	Forced me to take part in touching or any sexual activity when I didn’t want to	 

Z8.	Before you got pregnant with your new baby, did your spouse or partner ever try to keep you from using your birth control so that you would get pregnant when you did not want to? For example, did they hide your birth control, throw it away, or do anything else to keep you from using it?
		No
		Yes

Z9.	During any of the following time periods, did your spouse or partner threaten you, limit your activities against your will, or make you feel unsafe in any other way?
		No Yes
	During the 12 months before I got pregnant	 
	During my most recent pregnancy	 
	Since my new baby was born	 

Z13.	Since your new baby was born, have any of the following people pushed, hit, slapped, kicked, choked, or physically hurt you in any other way?
	For each one, check No or Yes.
		No Yes
	My spouse or partner	 
	My ex-spouse or ex-partner	 
	Site-added option (Another family member)	 
	Site-added option (Someone else)	 

Z15.	Before you got pregnant with your new baby, did your spouse or partner ever refuse to use a condom when you wanted them to use one?
	No
	Yes
	I didn’t have a partner at that time, or I was in a same sex relationship

Tobacco and Nicotine Product Use and Cessation

NOTE: Skip AA1, AA2, and AA3 if mother did not smoke during the 3 months before she got pregnant (Core 20).

BEFORE AA1, AA2, and AA3, insert instruction box that says, “If you did not smoke at any time in the 3 months before you got pregnant OR during your pregnancy, go to Question #.”

AA1.	During any of your prenatal care visits, did a healthcare provider advise you to quit smoking?
	No
	Yes
	I didn’t go for prenatal care
AA2.	During your most recent pregnancy, did you try any of the following things to quit smoking?
	For each one, check No or Yes.
		No Yes
	Set a specific date to stop smoking	 
	Use a text-messaging program for help with quitting	 
	Use websites or apps for help with quitting	 
	Use social media for help with quitting (such as Facebook, Instagram, TikTok)	 
	Call a national or state quit line	 
	Attend a class or program to stop smoking	 
	Go to counseling for help with quitting	 
	Use a nicotine patch, gum, lozenge, nasal spray, or oral inhaler	 
	Take a pill like Zyban® or Wellbutrin® (also known as bupropion) to stop smoking	 
	Take a pill like Chantix® (also known as varenicline) to stop smoking	 
	Try to quit on my own (e.g., cold turkey)	 
	Other:	 
	⤷Please tell us: _________________________________

NOTE: Skip AA3 if mother did not have any prenatal care (AA1). AA3 requires AA1.

Add skip arrow to AA1 off the “I didn’t go for prenatal care” option.

AA3.	During any of your prenatal visits, did a healthcare provider do any of the following things to help you quit smoking?
	For each one, check No or Yes.
		No Yes
	Spend time with me discussing how to quit smoking	 
	Suggest that I set a specific date to stop smoking	 
	Suggest I attend a class or program to stop smoking	 
	Provide me with booklets, videos, or other materials to help me quit smoking on my own	 
	Refer me to counseling for help with quitting	 
	Ask if a family member or friend would support my decision to quit	 
	Refer me to a national or state quit line	 
	Recommend using or prescribe a nicotine gum	 
	Recommend using or prescribe a nicotine patch	 
	Recommend using or prescribe a nicotine lozenge	 
	Prescribe a nicotine nasal spray or nicotine oral inhaler	 
	Prescribe a pill like Zyban® or Wellbutrin® (also known as bupropion) to help me quit	 
	Prescribe a pill like Chantix® (also known as varenicline) to help me quit	 

AA5.	Which of the following statements best describes the rules about smoking inside your home during your most recent pregnancy, even if no one who lived in your home was a smoker?
	Check ONE answer
	No one was allowed to smoke anywhere inside my home
	Smoking was allowed in some rooms or at some times
	Smoking was permitted anywhere inside my home

NOTE: Skip AA6 if mother did not smoke during the 3 months before pregnancy (Core 20).

BEFORE AA6, insert instruction box that says, “If you did not smoke at any time in the 3 months before you got pregnant, go to Question #.”

AA6.	Did you quit smoking around the time of your most recent pregnancy?
	Check ONE answer
	No
	No, but I cut back
	Yes, I quit before I found out I was pregnant
	Yes, I quit when I found out I was pregnant
	Yes, I quit later in my pregnancy

AA7.	Which of the following statements best describes the rules about smoking inside your home now, even if no one who lives in your home is a smoker?
	Check ONE answer
	No one is allowed to smoke anywhere inside my home
	Smoking is allowed in some rooms or at some times
	Smoking is permitted anywhere inside my home

AA8.	How many cigarette smokers, not including yourself, lived in your home during your most recent pregnancy?
	_____ Number of smokers
AA9.	How many cigarette smokers, not including yourself, live in your home now?
	_____ Number of smokers

NOTE: AA10 must be used with AA6.

Skip AA10 if the mother did not smoke 3 months before she got pregnant (Core 20).

AA10.	Would any of the following things make it hard for you to quit smoking?
	For each one, check No or Yes.
		No Yes
	Cost of medicines or products to help with quitting	 
	Cost of classes to help with quitting	 
	Fear of gaining weight	 
	Loss of a way to handle stress	 
	Other people smoking around me	 
	Cravings for a cigarette	 
	Lack of support from others to quit	 
	Worsening depression	 
	Worsening anxiety	 
	Some other reason	 
	⤷ Please tell us: _____________________________

Experiences of Discrimination and Racism

BB1.	During the 12 months before your new baby was born, how often did you feel emotionally upset (for example, angry, sad, or frustrated) because of how you were treated based on your race, ethnicity, or skin color?
	Very often
	Somewhat often
	Not very often
	Never

BB4.	During your life until now, how often have you worried that you might be treated or judged unfairly because of your race, ethnicity, or skin color?
	Very often
	Somewhat often
	Not very often
	Never

BB5.	During your life until now, how often have you worried that a loved one like your partner, child, or parent might be treated or judged unfairly because of their race, ethnicity, or skin color?
	Very often
	Somewhat often
	Not very often
	Never

BB6.	Have you ever experienced discrimination or were prevented from doing something, hassled, or made to feel inferior because of the things listed below?
	For each item, check No if you did not experience discrimination because of it or Yes if you did.
		No Yes
	My race, ethnicity, or skin color	 
	My disability status	 
	My immigration status	 
	My age	 
	My weight	 
	My income	 
	My sex or gender	 
	My sexual orientation	 
	My religion	 
	My language or accent	 
	My type or lack of health insurance	 
	My use of substances (alcohol, tobacco, or other drugs)	 
	My involvement with the justice system (jail or prison)	 
	Another reason	 
	⤷ Please tell us: __________________________________

Physical Activity

CC1.	During the 3 months before you got pregnant with your new baby, how often did you participate in any physical activities or exercise for 30 minutes or more? For example, walking for exercise, swimming, cycling, dancing, or gardening.
	Check ONE answer
	Less than 1 day per week
	1 to 2 days per week
	3 to 4 days per week
	5 or more days per week
	I was told by a healthcare provider not to exercise

NOTE: If state doesn’t choose CC1 with CC2, the list of examples will need to be added for CC2.

CC2.	During the last 3 months of your most recent pregnancy, how often did you participate in any physical activities or exercise for 30 minutes or more?
	Check ONE answer
	Less than 1 day per week
	1 to 2 days per week
	3 to 4 days per week
	5 or more days per week
	I was told by a healthcare provider not to exercise

Reproductive History

FF1.	During the 12 months before you got pregnant with your new baby, did you have a miscarriage, fetal death (baby died before being born), or stillbirth?
	No
	Yes

NOTE: FF5 must be used with FF4. Skip FF4 if mother has not had a previous infant born alive (FF5).

FF4.	What is the age difference between your new baby and the child you delivered just before your new one?
	0 to 12 months
	13 to 18 months
	19 to 24 months
	More than 2 years but less than 3 years
	3 to 5 years
	More than 5 years

FF5.	Before you got pregnant with your new baby, did you ever have any other babies who were born alive?
	No → Go to Question #
	Yes

NOTE: FF5 must be used with FF6 and FF7.

FF6.	Did the baby born just before your new one weigh 5 pounds, 8 ounces (2.5 kilos) or less at birth?
	No
	Yes

FF7.	Was the baby just before your new one born earlier than 3 weeks before their due date?
	No
	Yes

Demographic Information Including Maternal Weight

II1.	How much weight did you gain during your most recent pregnancy?
	Write ONE answer
	I gained _______ pounds
	OR _______kilos
	I didn’t gain any weight during my pregnancy
	I don’t know

II2.	How tall are you without shoes?
	Write ONE answer
	_______ Feet &
	_______ Inches
	OR _______Centimeters

II3.	Just before you got pregnant with your new baby, how much did you weigh?
	Write ONE answer
	_______ Pounds OR
	_______ Kilos

II4.	When was your new baby born?
	Month/Day/Year
	Month: _________
	Day: _________
	Year: _________

Alcohol Consumption

NOTE: If JJ1 and JJ5 are both used, a skip arrow should be added to JJ5 “I didn’t drink then” to skip JJ1.

JJ5.	During the 3 months before you got pregnant, how many alcoholic drinks did you have in an average week?
	Check ONE answer
	14 or more drinks a week
	8 to 13 drinks a week
	4 to 7 drinks a week
	1 to 3 drinks a week
	Less than 1 drink a week
	I didn’t drink then

JJ1.	During the 3 months before you got pregnant, how many times did you drink 4 or more alcoholic drinks in a 2-hour time span?
	Check ONE answer
	6 or more times
	4 to 5 times
	2 to 3 times
	1 time
	I didn’t have 4 or more drinks in a 2-hour time span

NOTE: Skip JJ2 and JJ3 if mother did not drink during the last 3 months of her pregnancy (Core 27).

BEFORE JJ3, insert instruction box that says: “If you didn’t have any alcoholic drinks during the last 3 months of your pregnancy, go to Question #.”

If JJ2 and JJ3 are both used, a skip arrow should be added to JJ3 “I didn’t drink then” to skip JJ2.

JJ3.	During the last 3 months of your pregnancy, how many alcoholic drinks did you have in an average week?
	Check ONE answer
	14 or more drinks a week
	8 to 13 drinks a week
	4 to 7 drinks a week
	1 to 3 drinks a week
	Less than 1 drink a week
	I didn’t drink then

JJ2.	During the last 3 months of your pregnancy, how many times did you drink 4 or more alcoholic drinks in a 2-hour time span?
	Check ONE answer
	6 or more times
	4 to 5 times
	2 to 3 times
	1 time
	I didn’t have 4 or more drinks in a 2-hour time span

JJ6.	During your most recent pregnancy, did a healthcare provider or home health visitor tell you that it was okay to drink a little alcohol during pregnancy?
	No
	Yes

Disaster and Emergency Preparedness

Also see Disaster Supplement

KK1.	Do you currently have an emergency plan for your family in case of disaster? For example, you and your family have talked about how to be safe if a disaster happened.
	No
	Yes

KK2.	During your most recent pregnancy, did you have an emergency plan for your family in case of disaster? For example, you and your family talked about how to be safe if a disaster happened.
	No
	Yes

KK4.	Below is a list of things that some people do to prepare for a disaster.
	For each one, check No or Yes.
		No Yes
	I have an emergency meeting place for family members (other than my home)	 
	My family and I have practiced what to do in case of a disaster	 
	I have a plan for how my family and I would keep in touch if we were separated	 
	I have an evacuation plan if I need to leave my home and community	 
	I have an evacuation plan for my children in case of a disaster (permission for day care or school to release my child to another adult)	 
	I have copies of important documents like birth certificates and insurance policies in a safe place outside my home	 
	I have emergency supplies in my home for my family such as enough extra water, food, and medicine to last for at least three days	 
	I have emergency supplies that I keep in my car, at work, or at home to take with me if I have to leave quickly	 

Maternal Childhood Experiences

NOTE: LL1: Response items a-h are required for minimum assessment of adverse childhood events (ACEs). Response items i-m are optional (enhanced assessment of ACEs). Sites can select any or all of the optional response items.

LL1.	The next questions are about things that may have happened to you during your childhood, before your 18th birthday.
	For each one, check No or Yes.
		No Yes
	Before your 18th birthday…
	Did you live with someone who was depressed, mentally ill, or suicidal?	 
	Did you live with someone who had a problem with alcohol or drug use?	 
	Were you separated from a parent or guardian because they went to jail, prison, or a detention center?	 
	Did your parents or other adults in your home slap, hit, kick, punch, or beat each other up?	 
	Did a parent or other adult in your home hit, beat, kick, or physically hurt you in any way?	 
	Did a parent or other adult in your home swear at you, insult you, or put you down?	 
	Before your 18th birthday…
	Did an adult or person at least 5 years older than you ever make you do sexual things that you didn’t want to do (such as kissing, touching, or having sexual intercourse)?	 
	Was there an adult in your household who tried hard to make sure your basic needs were met, such as looking after your safety and making sure you had clean clothes and enough to eat?	 
	Was there an adult in your household who tried hard to make sure you felt loved, supported, valued, and like you were special to them?	 
	Before your 18th birthday…
	Did you feel that you were treated badly or unfairly because of your race, ethnicity, or skin color?	 
	Did you feel that you were treated badly or unfairly because you are or people think you are LGBTQIA+? This could include being treated badly because of who you’re sexually attracted to or because you express your gender in a way that is different than what people expect.	 
	Did you see someone get physically attacked, beaten, stabbed, or shot in your neighborhood?	 
	Were your parents or guardians divorced or separated?	 

LL2.	These questions are about things that may have happened to you during your childhood, before your 18th birthday.
	For each one, check No or Yes.
	GRID: No/Yes	No Yes
	Before your 18th birthday…
	Did you feel that you were able to talk to an adult in your family or other caring adult about your feelings?	 
	Did you feel that you were able to talk to a friend about your feelings?	 
	Did you feel a sense of belonging in high school?	 

Disability

Also see Disability Supplement

OO2.	Because of a physical, mental, or emotional condition, do you have difficulty caring for yourself or your newborn?
	No
	Yes

Sexual Orientation and Gender Identity

PP1.	How would you describe your gender?
	Female
	Male
	Transgender
	Genderqueer or gender nonconforming
	Prefer to self-describe
	⤷ Please tell us: _____________________________________________________

PP2.	How would you describe your sexual orientation?
	Heterosexual or “straight”
	Lesbian or Gay
	Bisexual
	Prefer to self-describe
	⤷ Please tell us: __________________________________

Natural Disaster Module

KK5.	Were you living in or staying in an area that was affected by a disaster in the past year? This could be a natural disaster such as a hurricane, tornado, earthquake, etc., or a manmade disaster such as an explosion, chemical spill, etc.
	No → Go to the end
	Yes

KK6.	How would you describe any damage to your home from the disaster? Check ONE answer
	My home was not damaged
	My home had minor damage, but the living areas were still livable
	My home had major damage
	My home was destroyed

KK7.	Did you experience any of the following because of the disaster?
		No Yes
	You felt like your life was in danger when the disaster struck	 
	You were injured or became ill	 
	A member of your household was injured or became ill	 
	You walked through debris or floodwater	 
	You were without electricity for one week or longer	 
	Someone close to you died in the disaster	 
	You saw someone die in the disaster	 
	You were living in temporary housing or in conditions that you were not accustomed to	 
	You lost personal belongings	 
	You were separated from loved ones who you feel close to	 
	You had trouble getting services or aid from the government	 
	You had trouble dealing with insurance or disaster relief agencies	 
	You had trouble getting clean drinking water	 
	You had trouble getting enough food to eat	 
	You felt unsafe because of the lack of order and security after the disaster	 

KK8.	After the disaster, where did you look FIRST for reliable information regarding the disaster and cleaning up or recovery efforts? Check ONE answer
	TV
	Radio
	Text messages
	Neighbor or word of mouth
	Flyers or posters
	Local Newspaper
	Social media sites like Facebook
	Internet
	⤷ Please tell us: ________________________
	Other
	⤷Please tell us: ________________________

KK9.	After the disaster, how would you describe the amount of hard physical work you had to do to take care of your home and yard compared to the time before the disaster? Check ONE answer
	Much more physical work after the disaster
	A little more physical work after the disaster
	The same amount of physical work
	Less physical work since the disaster
	I didn’t do any physical work around the home and yard

KK10.	Did you or any member of your household receive any of the following types of aid as part of disaster relief efforts?
		No Yes
	Food	 
	Water	 
	Shelter	 
	Clothing	 
	Medicine	 
	Financial assistance	 
	Transportation services	 

KK11.		Since the disaster, have you felt that you have needed mental health services such as counseling, medications, or support groups to help with feelings of anxiety, depression, grief, or other problems?
	No → Go to Question KK14
	Yes

KK12.	Were you able to get the mental health services that you needed?
	No
	Yes → Go to Question KK14

KK13.	Did any of these things keep you from getting the mental health services that you needed after the disaster? Check ALL that apply
	Road conditions made it unsafe to travel
	I was sick or injured and couldn’t travel
	I was afraid to leave where I was staying
	I didn’t know where to go to get the services
	Services were not available due to damage to clinic offices from the disaster
	I couldn’t get an appointment when I wanted one
	I was worried about what others would think if I went
	I didn’t have enough money or insurance to pay for the services
	I couldn’t take time off from work or school
	I had no one to take care of children or other family members
	I had too many other things going on
	Other
	⤷Please tell us: ____________________________________________________

KK14.	Since the disaster, would you have the kinds of help listed below if you needed them?
		No Yes
	Someone to loan me $50	 
	Someone to help me if I were sick and needed to be in bed	 
	Someone to talk with about my problems	 

KK15.	Before the disaster, did you have an emergency plan for your family in case of disaster? For example, you and your family had talked about how to be safe if a disaster happened.
	No
	Yes

KK16.	Before the disaster, had you done any of the things listed below to prepare for a disaster?
		No Yes
	You had an emergency meeting place for family members (other than your home)	 
	You and your family had practiced what to do in case of a disaster	 
	You had a plan for how you and your family would keep in touch if you were separated	 
	You had an evacuation plan if you needed to leave your home and community	 
	You had an evacuation plan for your child or children in case of a disaster (permission for day care or school to release your child to another adult)	 
	You had copies of important documents like birth certificates and insurance policies in a safe place outside your home	 
	You had emergency supplies in your home for your family such as enough extra water, food, and medicine to last for at least three days	 
	You had emergency supplies that you kept in your car, at work, or at home to take with you if you needed to leave quickly	 

Environmental Exposures Module

NN1.	During your most recent pregnancy, how often did you eat largemouth bass, tuna, shark, king mackerel or swordfish?
	3 or more times a week
	1 to 2 times a week
	1 to 3 times a month
	Less than once a month
	I didn’t eat those fish during my pregnancy → Go to Question #

NN2.	Where did you get largemouth bass, tuna, shark, king mackerel or swordfish that you ate during your pregnancy? Check ALL that apply
	From the grocery store
	From a fish market or farmer’s market
	From a restaurant
	Caught by you or someone else from the ocean
	Caught by me or someone else from a local river, stream, lake, or pond
	Caught by me or someone else from one of the Great Lakes
	Other
	⤷ Please tell us: __________________________________________

NN3.	During your most recent pregnancy, did you use any of the following things every day or most days around your house or as part of your job?
		No Yes
	Strong degreasers such as oven cleaner or heavy-duty degreaser	 
	Furniture or shoe polish	 
	Bleach or bleach products (such as bathroom tile cleaner, drain cleaner, disinfectants)	 
	Air fresheners or plug-ins	 
	Incense or scented candles	 
	Perfume or nail polish	 
	Permanent pressed (wrinkle-free) clothes or curtains	 

NN4.	During your most recent pregnancy, on average, how often did you eat food that was microwaved in a plastic container? Check ONE answer
	More than once a day
	Once a day
	2 to 6 times a week
	Once a week
	Less than once a week
	Never

NOTE: Skip NN5 If the mother did not have prenatal care (Core 10).

NN5 can be combined with R14 (if used) by adding the response option, “How eating fish with high levels of mercury during pregnancy could affect my baby.”

NN5.	During any of your prenatal care visits, did a healthcare provider talk with you about any of the things listed below? Please count only discussions, not reading materials or videos.
		No Yes
	How me being exposed to lead could affect my baby	 
	How using pesticides, which are chemicals to kill insects, rodents or weeds during pregnancy, could affect my baby	 
	How using water bottles or other bottles made of polycarbonate plastic (BPA, recycle #7) during pregnancy could affect my baby	 

NN6.	During your most recent pregnancy, was a healthcare provider able to answer any questions about environmental exposures? (Environmental exposures include contact with chemicals, substances, or products inside or outside of your household such as bleach, household cleaning products, pesticides, or air pollution) Check ONE answer
	No
	Yes
	I didn’t ask a healthcare provider any questions about environmental exposures
	I didn’t have any concerns about environmental exposures