PRAMS Livebirth Phase 9 Standard Phone Questionnaire (En

Attachment 10g – PRAMS Livebirth Phase 9 Standard Phone Module – English

Form Approved

OMB No. 0920-1273

Exp. Date xx/xx/xxxx

Pregnancy Risk Assessment Monitoring System (PRAMS)

Phase 9 Standard Phone Module - 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.

SKIP: If the mom was not trying to get pregnant when she got pregnant with her 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.
	(Don't Read)
	No → Go to Question #
	Yes
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

A2.	Did you use any of the following fertility treatments to help you get pregnant with your new baby?
	For each one, answer Yes or No. (PROBE: To help you get pregnant with your new baby, did you use______?)
		Fertility-enhancing drugs prescribed by a doctor to stimulate ovulation
		Intrauterine insemination or artificial insemination which are treatments in which sperm, but NOT eggs, were collected and medically placed into the uterus
		Assisted reproductive technology such as 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)
		Did you use any other medical treatments to help you get pregnant with your new baby?
		IF YES, ASK: What? ______________________________________________________________________ ___________________________________________________________________________________________ INTERVIEWER: Go to Question # if the mother answered YES to any of the treatment options listed above.
		INTERVIEWER: Select the option below if the mom DIDN’T use any fertility treatments Didn’t use fertility treatments

A4.	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.
	Was it _____?
	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
	(Don't Read)
	Refused
	Don't Know/Don't Remember

	A5.	How many cycles of fertility treatments (complete or incomplete) did you have before you got pregnant with your new baby?
		Was it _____?
			1 cycle
			2 to 3 cycles
			4 to 6 cycles
			7 or more cycles
			(Don't Read)
			Refused
			Don't Know/Don't Remember

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?
	For each one, answer Yes or No. Was it because______? (PROBE: Was this a reason you did not breastfeed your new baby?)
		You were sick or on medicine
		You had other children to take care of
		You had too many other things going on
		You didn’t like breastfeeding
		You tried, but it was too hard
		You didn’t want to
		You went back to work
		You went back to school
		Was there any other reason you didn’t breastfeed your new baby?
	IF YES, ASK: What was that?______________________________________________________
	SKIP: If she did not breastfeed her 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?
	For each one, answer Yes or No. Was it because______? (PROBE: Was this a reason you stopped breastfeeding your new baby?)
		Your baby had difficulty latching or nursing
		Breast milk alone didn’t satisfy your baby
		You thought your baby wasn’t gaining enough weight
		Your nipples were sore, cracked, or bleeding, or it was too painful
		You thought you weren’t producing enough milk, or your milk dried up
		You had too many other things going on
		You felt it was the right time to stop breastfeeding
		You got sick or you had to stop for medical reasons
		You went back to work
		You went back to school
		Your spouse or partner didn’t support breastfeeding
		Your baby was jaundiced, which is yellowing of the skin or whites of the eyes
		Was there any other reason you stopped breastfeeding your new baby?
		IF YES, ASK: What was that reason?______________________________________________________

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).

	SKIP: If the baby was not born in a hospital, go to Question #. During your hospital stay after your new baby was born, did any of the following things happen? For each one, answer Yes or No. (PROBE: Did this happen at the hospital where your new baby was born?)
B3.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Hospital staff talked to you about how to breastfeed, such as how often and long to breastfeed
	Your baby stayed in the same room with you at the hospital
	Hospital staff helped you learn how to breastfeed
	You breastfed as soon as possible after your baby was born
	Your baby was placed in skin-to-skin contact as soon as possible after birth
	Your baby was fed only breast milk at the hospital
	Hospital staff helped you recognize when your baby was hungry
	The hospital gave you a gift pack with formula
	The hospital gave you information about who you could contact for breastfeeding support when you left the hospital
	Hospital staff tied or blocked your tubes
	Hospital staff placed an IUD
	Hospital staff placed a contraceptive implant in your arm
	Hospital staff gave you a contraceptive shot or injection

B4.	During your most recent pregnancy, what did you think about breastfeeding your new baby?
	I’m going to read a list of options. Please tell me which one best describes you. (PROBE: Repeat question as necessary.)
	You knew you wanted to breastfeed
	You thought you might breastfeed
	You knew you would not breastfeed
	You didn’t know what to do about breastfeeding
	(Don't Read)
	Refused
	Don't Know/Don't Remember

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 which is the Special Supplemental Nutrition Program for Women, Infants, and Children?
	(Don't Read)
	No → Go to Question #
	Yes
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

B7.	When you went for WIC visits during your most recent pregnancy, did you receive information on breastfeeding?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

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?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

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?
	For each one, answer Yes or No. (PROBE: Before your new baby was born, ______?)
	Did someone answer your questions about breastfeeding?
	Were you offered a class on breastfeeding?
	Did you attend a class on breastfeeding?
	Did you decide or plan to feed only breast milk to your baby?
	Did you discuss feeding only breast milk to your baby with your family/friends?
	Did you discuss feeding only breast milk to your baby with a healthcare provider?
	Did you decide not to breastfeed your baby?

B10.	How old was your new baby the first time they drank liquids other than breast milk, such as formula, water, juice, or cow’s milk?
	(PROBE: About how many weeks or months old?)
	(Don't Read)
	Number of weeks______ (RANGE: 1-40)
	or Number of months______ (RANGE: 1-9)
	The baby was less than 1 week old
	The baby has not had any liquids other than breast milk
	Refused
	Don't Know/Don't Remember

B11.	How old was your new baby the first time they ate food, such as baby cereal, baby food, or any other food?
	(PROBE: About how many weeks or months old?)
	(Don't Read)
	Number of weeks______ (RANGE: 1-40)
	or Number of months______ (RANGE: 1-9)
	The baby was less than 1 week old
	The baby has not eaten any foods
	Refused
	Don't Know/Don't Remember

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? (PROBE: After your new baby was born, _____?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)		Don’t know (9)
	Did you have someone to answer your questions?
	Did you get help getting your baby positioned correctly?
	Did you get help knowing if your baby was getting enough milk?
	Did you get help with managing pain or bleeding nipples?
	Did you get information about where to get a breast pump?
	Did you get help using a breast pump?
	Did you get information about breastfeeding support groups?
	Did you get any other kinds of help with breastfeeding your new baby?
	IF YES, ASK: What was that? __________________________________________________________________________________

B14.	Have you used a breast pump to express milk to feed to your new baby?
	(Don't Read)
	No → Go to Question #
	Yes
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

B16.	Where did you get the breast pump that you used with your new baby?
	For each one, answer Yes or No.
	Did you get it for free from WIC?
	Did you get it for free from the hospital?
	Did you get it as a gift or borrow it from someone else?
	Did your health insurance pay for it?
	Did you rent or buy it yourself?
	Did you have one from a previous child?
	Did you get your breast pump from some other place?
	IF YES, ASK: Where was that?___________________________________________________________

B17.	Before or after your new baby was born, did you receive information about breastfeeding from any of the following sources? For each one, answer Yes or No. (PROBE: Before or after your new baby was born, did you receive information about breastfeeding from __________?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	A doctor
	A nurse or midwife
	A doula
	A breastfeeding or lactation specialist
	Your 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
	Some other source
	IF YES, ASK: Who was that? ___________________________________________________________________________________

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?
	For each one, answer Yes or No.
	No, you don’t go to school or work → Go to Question #
	Yes, you go to school or work outside the home
	Yes, you go to school or work from home
	(Don't Read)
	Refused → Go to Question #
	Don’t Know/Don’t Remember → Go to Question #

C2.	Which one of the following people spends the most time taking care of your new baby when you are at school or work?
	Is it______? (PROBE: Who spends the most time taking care of your baby when you are at school or work?)
	Your spouse or partner
	Your baby’s grandparent
	Another close family member or relative
	A friend or neighbor
	A babysitter, nanny, or other childcare provider
	Staff at day care center
	Another person
	IF YES, ASK: Who is that? ____________________________________________________________________________
	The baby is with you while you are at school or working → Go to Question #
	(Don't Read)
	Refused
	Don’t Know/Don’t remember

C4.	At any time during your most recent pregnancy, did you work at a job for pay?
	(Don't Read)
	No → Go to Question #
	Yes
	Refused → Go to Question #
	Don’t Know/Don’t remember → Go to Question #

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?
	I’m going to read three options. Please tell me which one applies to you.
	No, and you don’t plan to return → Go to Question #
	No, but you will be returning
	Yes, you have returned
	(Don't Read)
	Refused → Go to Question #
	Don’t Know/Don’t remember → Go to Question #

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?
	For each one, answer Yes or No.
	You took paid leave from your job
	You took unpaid leave from your job
	Site-specific options (Leave or disability programs)
	Would you say that you didn’t take any leave from work after the birth of your new baby?
	(Don't Read)
	Refused
	Don’t Know/Don’t remember

C9.	How did you feel about the amount of time you were able to take off after the birth of your new baby?
	Would you say that it was ______?
	Too little time
	Just the right amount of time
	Too much time
	(Don't Read)
	Refused
	Don’t Know/Don’t remember

C10.	Did any of the following things affect your decision about taking leave from work after your new baby was born? For each one, answer Yes or No. Would you say _____?
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	You couldn’t financially afford to take leave
	You were afraid you’d lose your job if you took leave or stayed out longer
	You had too much work to do to take leave or stay out longer
	Your job doesn’t have paid leave
	Your job doesn’t offer a flexible work schedule
	You hadn’t built up enough leave time to take any or more time off

C11.	After your new baby was born, did your spouse or partner take time off from work? Would you say ______ ?
	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
	Your spouse or partner didn’t work at a job for pay
	You didn’t have a spouse or partner
	(Don't Read)
	Refused
	Don’t Know/Don’t remember

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?
	(PROBE: About how many weeks or months, in total?)
	(Don't Read)
	____________Number of weeks
	____________Number of months
	Less than 1 week
	Refused
	Don’t Know/Don’t remember

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.
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

E5.	When you got pregnant with your new baby, were you trying to get pregnant?
	(Don't Read)
	No
	Yes → Go to Question #
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

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

E6.	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.
	(Don't Read)
	No
	Yes → Go to Question #
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

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

E7.	What were your reasons for not doing anything to keep from getting pregnant?
	For each one, answer Yes or No. (PROBE: Was one of the reasons that you were not doing anything to keep from getting pregnant because _________?)
	You didn’t mind if you got pregnant
	You thought you couldn’t get pregnant at that time
	You didn’t want to use birth control
	You had side effects from the birth control method you were using
	You had problems getting birth control you wanted
	You thought your spouse or partner or you were sterile or couldn’t get pregnant at all
	Your spouse or partner didn’t want to use condoms
	Your spouse or partner didn’t want you to use birth control
	You forgot to use a birth control method
	Was there some other reason why you or your spouse or partner was not doing anything to keep from getting pregnant?
	IF YES, ASK: What was that? _____________________________________________________________________

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

SKIP: If she 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?
	For each one, answer Yes or No.
	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)
	Were you using any other method to keep from getting pregnant?
	IF YES, ASK: What was that?_______________________________________________________________

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?
	For each one, answer Yes or No. Does your baby sleep with_________________?
	You
	Your spouse or partner
	A grandparent
	Your baby’s twin
	An older sibling
	Someone else
	IF YES, ASK: Who is that?__________________________________________________________________________
	SKIP: If the 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, answer Yes or No.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	On their back to sleep
	In a crib, bassinet, or portable crib
	Without a blanket, soft toys, cushions, or pillows in your baby's crib or bed
	Place your baby's crib, bassinet, or portable crib in your room

F6.	Did you get information about how to place your baby to sleep during any of the following times? For each one, answer Yes or No. (PROBE: Did you get information about how to place your baby to sleep ____________?)
		(Don’t read)
		No (1)		Yes (2)		Refused (8)		Don’t know (9)
	During a prenatal care visit
	In the hospital, when your baby was born
	During your baby’s healthcare visit
	During a postpartum care visit
	Did you get information somewhere else?
	IF YES ASK: Where was that? ________________________________________________________________________________

F7.	Did you get information about how to place your baby to sleep from any of the following sources? For each one, answer Yes or No.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Your family doctor
	Your OB/GYN
	A nurse or midwife
	A doula or a childbirth educator
	Your baby’s doctor or health care provider
	Websites or apps about pregnancy or infant care
	Social media such as Facebook, Instagram, or TikTok
	From someone else?
	IF YES, ASK: Who? _________________________________________________________________________________________

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?
	Please tell me which one applies to you. (PROBE: About how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin?)
	You didn’t take a multivitamin, prenatal vitamin, or folic acid vitamin in the month before you got pregnant
	1 to 3 times a week
	4 to 6 times a week
	Every day of the week
	(Don't Read)
	Refused
	Don't Know/Don't Remember

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? Was it because _________? (PROBE: Was this a reason you did not take multivitamins, prenatal vitamins, or folic acid vitamins during the month before you got pregnant with your new baby?)
	You weren’t planning to get pregnant
	You didn’t think you needed to take vitamins
	You didn’t want to take vitamins
	The vitamins were too expensive
	The vitamins gave you side effects such as nausea or constipation
	Was there any other reason?
	IF YES, ASK: What was the reason? _________________________________________________________________

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?
	Please tell me which one applies to you. (PROBE: About how many times a week did you take a multivitamin, prenatal vitamin, or folic acid vitamin?)
	You did not 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
	(Don't Read)
	Refused
	Don't Know/Don't Remember

G6.	During the past month, how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin?
	Please tell me which one applies to you. (PROBE: About how many times a week did you take a multivitamin, prenatal vitamin, or folic acid vitamin?)
	You 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
	(Don't Read)
	Refused
	Don't Know/Don't Remember

G7a.	During the last 3 months of your most recent pregnancy, about how many servings of fruit did you have in a day?
	Please tell me which one applies to you.
		Zero servings or none
		1 or 2 servings per day
		3 or 4 servings per day
		5 or more servings per day
		(Don't Read)
		Refused
		Don't Know/Don't Remember

G7b.	During the last 3 months of your most recent pregnancy, about how many servings of vegetables did you have in a day?
	Please tell me which one applies to you.
	Zero servings (none)
	1 or 2 servings per day
	3 or 4 servings per day
	5 or more servings per day
	(Don't Read)
	Refused
	Don't Know/Don't Remember

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?
	For each one, answer Yes or No. Does your new baby have ______? (PROBE: What type of insurance does your new baby have?)
	Private health insurance paid for by you, 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)
	Does your baby have some other kind of health insurance?
	INTERVIEWER: Go to Question X if the mother answered YES to any of the insurance options listed above.
	IF YES, ASK: What is that? ________________________________________________________________________
	Would you say that your new baby does not have any health insurance?
	Interviewer: If the mother answered that she did not have any health insurance, check YES.

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 #.”

SKIP: If the mother did not have health insurance during the month before she got pregnant, go to Question DD7. If she 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?
	For each one, answer Yes or No.
	Health insurance was too expensive
	You couldn’t get health insurance from your job or the job of your spouse or partner
	You applied for health insurance but were waiting to get it
	You had problems with the health insurance application or website
	Your income was too high to qualify for Medicaid
	Your income was too high to qualify for a tax credit from the <Site > Health Insurance Marketplace or HealthCare.gov
	You didn’t know how to get health insurance
	Site-specific (You’re not a US citizen, or you didn’t have the right residency documents)
	Was there some other reason that you did not have health insurance during the month before you got pregnant with your new baby?
	IF YES, ASK: What was the reason? ___________________________________________________________________

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 #.”

SKIP: If the mother did not have health insurance during her most recent pregnancy, go to Question DD11. If she did, go to Question #.”

DD11. (MOD)	What was the reason that you did not have any health insurance during your most recent pregnancy?
	For each one, answer Yes or No.
	Health insurance was too expensive
	You couldn’t get health insurance from your job or the job of your spouse or partner
	You applied for health insurance but were waiting to get it
	You had problems with the health insurance application or website
	Your income was too high to qualify for Medicaid
	Your income was too high to qualify for a tax credit from the <Site > Health Insurance Marketplace or HealthCare.gov
	You didn’t know how to get health insurance
	Site -specific (You’re not a US citizen or you didn’t have the right residency documents)
	Was there some other reason that you didn’t have health insurance during your most recent pregnancy?
	IF YES, ASK: What was the reason? _____________________________________________________________

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 #.”

SKIP: If the mother does 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?
	For each one, answer Yes or No.
	Health insurance is too expensive
	You can’t get health insurance from your job or the job of your spouse or partner
	You applied for health insurance, but you’re still waiting to get it
	You had problems with the health insurance application or website
	Your income is too high to qualify for Medicaid
	Your income is too high to qualify for a tax credit from the <Site > Health Insurance Marketplace or HealthCare.gov
	You don’t know how to get health insurance
	Site -specific (You’re not a US citizen, or you don’t have the right residency documents)
	Is there some other reason that you don’t have health insurance now?
	IF YES, ASK: What is the reason? ________________________________________________________________________

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, answer Yes or No. (PROBE: During your most recent pregnancy, did a healthcare provider tell you that you had _____?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Genital warts (HPV)
	Herpes
	Chlamydia
	Gonorrhea
	Pelvic inflammatory disease or PID
	Syphilis
	Group B Strep (Beta Strep)
	Bacterial vaginosis
	Trichomoniasis or Trich
	Yeast infection
	Urinary tract infection or UTI
	Were you told that you had any other infection?
	IF YES, ASK: What was it? ______________________________________________________________________________________

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)?
	(Don't Read)
	No
	Yes → Go to Question #
	Don’t know/Don’t Remember → Go to Question #
	Refused → Go to Question #

I9.	Why didn’t you have an HIV test during your most recent pregnancy or delivery?
	Was it because_____________? (PROBE: Why didn’t you have an HIV test during your most recent pregnancy or delivery?)
	You weren’t offered the test?
	You didn’t want to have the test?
	You already knew your HIV status?
	You didn’t think you were at risk for HIV?
	You didn’t want people to think you were at risk for HIV?
	You were afraid of getting the result?
	You were tested before this pregnancy and didn’t think you needed to be tested again?
	Was there some other reason why you didn’t have an HIV test during your most recent pregnancy or delivery?
	IF YES ASK: What was that? _____________________________________________________________________________

I10.	What are you doing now to keep from getting sexually transmitted infections (STIs), including HIV?
	Would you say _____?
	You’re not doing anything?
	You’re using condoms?
	You’re getting tested for sexually transmitted infections or HIV?
	You’re practicing mutual monogamy, which is when two partners agree to only have sex with each other?
	Are you doing something else?
	IF YES, ASK: What are you doing? ______________________________________________________________________

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?
	For each one, answer Yes or No. Was it because_________?
	You didn’t know you needed one
	You didn’t have enough money or insurance to pay for the visit
	You felt fine and didn’t think you needed to have a visit
	You couldn’t get an appointment when you wanted one
	You didn’t have any transportation to get to the clinic or doctor’s office
	You had too many other things going on
	You couldn’t take time off from work or school
	You didn’t have anyone to help you take care of your children
	The doctor’s office was too far away
	Did you have some other reason?
	IF YES, ASK: What kept you from having a postpartum checkup? _________________________________ ____________________________________________________________________________________________
	SKIP: If the mother 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 one, tell me whether or not you got care for it or tell me if you didn’t have the condition. (PROBE: Since your new baby was born, have you received care for ______?
					(Don’t Read)
					No (1)	Yes (2)		DH (3)	Refused (8)		Don’t Know (3)
	Diabetes
	Hypertension or high blood pressure
	Depression
	Anxiety
	Heart conditions like birth defects of the heart, fast or skipped heartbeat, heart failure, enlarged heart, heart attack, chest pain, heart transplant, or pacemaker

J7.	For the next questions, please answer Yes or No. Overall, since your new baby was born…
			(Don’t read)
			No (1)		Yes (2)	Refused (8)	Don’t know (9)
	Have you felt…
	Comfortable asking questions about the postpartum care that you received?
	Comfortable declining care if you didn't want it?
	Comfortable accepting the type of care that your healthcare providers recommended?
	Have you felt…you were able to choose the care options that you received?
	That your providers treated you with respect?
	Have you felt…satisfied with the postpartum care you 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.	Why didn’t you have any healthcare visits in the 12 months before you got pregnant with your new baby?
	For each one, answer Yes or No. Was it because ______?
	You didn’t know you needed one
	You didn’t have enough money or insurance to pay for the visit
	You felt fine and didn’t think you needed to have a visit
	You couldn’t get an appointment when you wanted one
	You didn’t have any transportation to get to the clinic or doctor’s office
	You had too many other things going on
	You couldn’t take time off from work or school
	You didn’t have anyone to help you take care of your children
	The doctor’s office was too far away
	Was there another reason why you didn’t have any healthcare visits in the 12 months before you got pregnant?
	IF YES, ASK: What was that? ________________________________________________________________________
	SKIP: If the mother didn’t have any healthcare visits, go to Question #.

Labor and Delivery

K3.	How was your new baby delivered? Was it _____?
	Vaginally
	Or a cesarean delivery or c-section
	(Don't Read)
	Refused
	Don’t Know / Don’t Remember

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

K4.	How did your prenatal provider suggest you deliver your new baby?
	Please tell me which one applies to you.
	They suggested you deliver your baby vaginally or naturally
	They suggested you have a cesarean delivery or c-section
	They didn’t suggest how you deliver your baby
	(Don't Read)
	Refused
	Don't Know/Don't Remember

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 or c-section?
	Please tell me which one applies to you.
	Your health care provider recommended a cesarean delivery before you went into labor
	Your healthcare provider recommended a cesarean delivery while you were in labor
	You asked for the cesarean delivery
	(Don't Read)
	Refused
	Don't Know/Don't Remember

K7.	What was the reason that your new baby was born by cesarean delivery or c-section?
	For each one, answer Yes or No. Was it because ________? (PROBE: Was your new baby born by cesarean delivery because _____?)
	You had a previous cesarean delivery or c-section
	Your baby was in the wrong position, such as breech
	You were past your due date
	Your health care provider worried that your baby was too big
	You had a medical condition that made labor dangerous for you, such as a heart condition or physical disability
	You had a complication in your pregnancy, such as pre-eclampsia, placental problems, infection, or preterm labor
	Your health care provider tried to induce your labor, but it didn’t work
	Labor was taking too long
	The fetal monitor showed that your baby was having problems before or during labor or fetal distress
	You wanted to schedule your delivery
	You didn’t want to have your baby vaginally
	Was there any other reason?
	IF YES, ASK: What was the reason? ________________________________________________________________________

K8.	Did you plan or schedule a cesarean delivery or c-section at least one week before your new baby was born?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

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?
	(Don't Read)
	No → Go to Question #
	Yes
	Don’t Know/Don’t Remember → Go to Question #
	Refused → Go to Question #

K10.	Why did your healthcare provider try to induce your labor?
	For each one, answer Yes or No. Was it because ________? (PROBE: Was your healthcare provider trying to induce your labor because _____?)
	Your water broke, and there was a fear of infection
	You were past your due date
	Your healthcare provider worried about the size of the baby
	Your baby was not doing well and needed to be born
	You had a complication in your pregnancy such as low amniotic fluid or pre-eclampsia
	You wanted to schedule your delivery
	You wanted to give birth with a specific healthcare provider
	Was there any other reason?
	IF YES, ASK: What was the reason? ______________________________________________________________________

K16.	After delivery, was your baby put in an intensive care unit or NICU?
	[NOTE: Do not read letters, pronounce as “nick-you”]
	(Don't Read)
	No
	Yes
	Don’t know/Don’t remember
	Refused

K17.	For the next questions, please answer Yes or No. Overall, during the delivery of your baby, did you feel...
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Comfortable asking questions about the labor and delivery care that you received?
	Comfortable declining care if you didn't want it?
	Comfortable accepting the options for care that your provider recommended?
	Did you feel… You were able to choose the care options that you received?
	Your providers treated you with respect?
	Did you feel… Satisfied with the labor and delivery care you received?

Preconception Health

L10.	Before you got pregnant, would you say that, in general, your health was—
	Excellent
	Very good
	Good
	Fair
	Poor
	(Don't Read)
	Refused
	Don't Know/Don't Remember

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
	Asthma
	Anemia, poor blood, or low iron
	Epilepsy or seizures
	Thyroid problems
	PCOS or 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?
	(Don't Read)
	No → Go to Question #
	Yes
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

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, answer Yes or No.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Getting vaccines before pregnancy
	Getting counseling for any genetic diseases that run in your 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 you 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, answer Yes or No. Did you______? (PROBE: At any time during the 12 months before you got pregnant with your new baby, did you ______?)
				(Don’t read)
				No (1)		Yes (2)	Refused (8)	Don’t know (9)
	Diet or change your eating habits to lose weight
	Exercise 3 or more days of the week for fitness outside of your regular job
	Regularly take prescription medicines other than birth control
	Visit a healthcare provider and get checked for diabetes
	Talk to a healthcare provider about your 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 #.”

SKIP: 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, answer Yes or No. Was it because ________? (PROBE: Did you not get a flu shot because ________?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Your doctor didn’t mention anything about a flu shot
	You were worried about side effects of the flu shot for yourself
	You were worried that the flu shot might harm your baby
	You weren’t worried about getting sick with the flu
	You don’t think the flu shot works
	You don’t normally get a flu shot
	Was there any other reason you didn’t get a flu shot during the 12 months before the birth of your new baby?
	IF YES, ASK: What was that reason? __________________________________________________________________________

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

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

L19.	Where did you get your flu shot?
	I’m going to read a list of options. Please tell me which one applies to you. Did you get your flu shot at _________?
	Your OB/GYN’s office
	Your family doctor or other doctor’s office
	A health department or community clinic
	A hospital
	A pharmacy, drug store, or grocery store
	Your workplace or school
	Did you get your flu shot somewhere else?
	IF YES, ASK: Where? _______________________________________________________________________________

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?
	I’m going to read a list of options, please tell me which one applies to you. Would you say ________?
	Your baby will be vaccinated the way your baby’s doctor recommends
	Your baby will get every vaccine but at different times than your baby’s doctor recommends
	Your baby will get only some of the recommended vaccines
	Your baby will not get any vaccines
	(Don't Read)
	Refused
	Don't Know/Don't Remember

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?
	(Don't Read)
	No → Go to Question #
	Yes
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

 

M23.	Were you able to get the mental health services that you needed?
	(Don't Read)
	No
	Yes → Go to Question #
	Refused→ Go to Question #
	Don't Know/Don't Remember → Go to Question #

 

M24.	Which of these statements explains why you did not get the mental health services you needed?
	For each one, answer Yes or No. Was it because ________? (PROBE: Did you not get the mental health services you needed because __________?)
	You couldn’t afford the cost
	You couldn’t get an appointment as soon as you needed
	Your health insurance doesn’t cover any type of mental health services
	Your health insurance doesn’t pay enough for mental health services
	You didn’t know where to go to get services
	You were concerned that the information you shared might not be kept confidential
	You didn’t want others to find out that you needed treatment
	You were concerned that you might be committed to a psychiatric hospital
	You were concerned that you might have to take medicine
	You had no transportation, treatment was too far away, or the hours were not convenient
	You didn't have time (because of a job, childcare, or other commitments)
	Did you not get mental health services you needed for some other reason?
	IF YES, ASK: What was the reason?_________________________________________________

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 #.”

	SKIP: 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?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

M5.	Since your new baby was born, has a healthcare provider told you that you had depression?
	(Don't Read)
	No → Go to Question #
	Yes
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

M6.	Since your new baby was born, have you asked for help for depression from a healthcare provider?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

M7.	How would you describe the time during your most recent pregnancy?
	I’m going to read a list of options. Please tell me which one best describes how you felt.
	One of the happiest times of your life
	A happy time with few problems
	A moderately hard time
	A very hard time
	One of the worst times of your life
	(Don't Read)
	Refused
	Don't Know/Don't Remember

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 #.”

	SKIP: 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?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

M9.	At any time during your most recent pregnancy, did you get counseling for your depression?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

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?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

M11.	Since your new baby was born, have you gotten counseling for your depression?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

M14.	At any time during your most recent pregnancy, did you ask for help for anxiety from a healthcare provider?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

M15.	Since your new baby was born, has a healthcare provider told you that you had anxiety?
	(Don't Read)
	No → Go to Question #
	Yes
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

M16.	Since your new baby was born, have you asked for help for anxiety from a healthcare provider?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

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 #.”

	SKIP: 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?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

M18.	At any time during your most recent pregnancy, did you get counseling for your anxiety?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

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?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

M20.	Since your new baby was born, have you gotten counseling for your anxiety?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

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?
	(Don't Read)
	No → Go to Question #
	Yes
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

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?
	(PROBE: About how many weeks or months?)
	(Don't Read)
	Number of weeks ______ (Range: 1-40 weeks)
	Number of months ______ (Range: 1-9 months)
	Refused
	Don't Know/Don't Remember

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?
	Was it ________ ?
	Always → Go to Question #
	Often → Go to Question #
	Sometimes
	Rarely
	Never
	(Don't Read)
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

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, answer Yes or No.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Help with childcare
	Help with housework
	Knowing you wouldn’t lose your job
	Money to make up for not working
	Are there any other types of support that would have helped you stay in bed for the recommended time?
	IF YES, ASK: What is that? ___________________________________________________________________________________

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 or 17 alpha-hydroxyprogesterone to try to keep your new baby from being born too early?
	(Don't Read)
	No
	Yes
	Don't Know/Don't Remember
	Refused

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 #.”

SKIP: If you had gestational diabetes during your most recent pregnancy, go to Question N7. If you didn’t, go to Question #.
N7.	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, answer Yes or No. Did a healthcare provider ________?
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Refer you to a nutritionist
	Talk to you about the importance of exercise
	Talk to you about getting to a healthy weight after delivery
	Talk to you about your risk for Type 2 diabetes

N9.	Did you have any of the following problems during your most recent pregnancy?
	For each one, answer Yes or No. Did you have ________? (PROBE: Did you have ________ during your most recent pregnancy?)
		(Don’t read)
	GRID: No/Yes/Ref/DKDR	No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Vaginal bleeding
	Kidney or bladder or urinary tract infection
	Severe nausea, vomiting, or dehydration that sent you to the doctor or hospital
	Did your cervix have to be sewn shut, also known as cerclage for incompetent cervix?
	Problems with the placenta, such as abruptio placentae or placenta previa
	Labor pains more than 3 weeks before your baby was due, or preterm or early labor
	Did your water break more than 3 weeks before your baby was due, also known as preterm premature rupture of membranes or PPROM?
	Did you have a blood transfusion?
	Were you hurt in a car accident?

O4.	Since your new baby was born, have you been tested for diabetes or high blood sugar?
	(Don't Read)
	No → Go to Question #
	Yes
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

O7.	Have you experienced any of the following things during your pregnancy or after your baby was born? For each one, answer Yes or No. (PROBE: During your pregnancy or after your baby was born _____?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Have you felt something wasn’t right with your health?
	Have you felt your concerns for your health weren’t taken seriously?
	Have you felt your doctor ignored your concerns about your health or symptoms?

O8.	Have you regularly monitored your blood pressure at home or outside of a healthcare visit during any of the following time periods? For each time period, say Yes or No.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	During the 12 months before your most recent pregnancy
	During your most recent pregnancy
	Since your 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? For each one, answer Yes or No.
			(Don’t read)
			No (1)		Yes (2)		Refused (8)		Don’t know (9)
	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 time period, answer Yes or No. Did a healthcare provider talk about warning signs _______?
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	During the 12 months before you got pregnant
	During your most recent pregnancy
	During your labor and delivery hospitalization
	Since your 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?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

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?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

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 eaten in your household?
	Would you say that you had _____?
	Enough of the kinds of food you wanted to eat → Go to Question #
	Enough, but not always the kinds of food you wanted to eat → Go to Question #
	Sometimes not enough to eat
	Often not enough to eat
	(Don't Read)
	Refused
	Don't Know/Don't Remember

P21.	Why didn’t you have enough to eat?
	For each one, answer Yes or No. Was it because ______?
	You couldn’t afford to buy more food
	You couldn’t get out to buy food for example, didn’t have transportation or had mobility or health problems that kept you from getting out
	You were afraid or didn’t want to go out to buy food
	You couldn’t get groceries or meals delivered
	The stores didn’t have the food you 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.
	Was it ______?
	Always
	Usually
	Sometimes
	Rarely
	Never
	(Don't Read)
	Refused
	Don't Know/Don't Remember
P23.		What is your living situation today?
		I’m going to read a list of options. Please tell me which one best describes your situation. Would you say that _____?
		You have a steady place to live
		You have a place to live today, but you’re worried about losing it in the future
		You don’t have a steady place to live. For example, you’re 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
		(Don’t Read)
		Refused
		Don't Know/Don't Remember

 

BB3.	Since your new baby was born, how often would you say you were worried or stressed about having enough money to pay your bills?
	Would you say ______ ?
	Always
	Often
	Sometimes
	Rarely
	Never
	(Don't Read)
	Refused
	Don't Know/Don't Remember

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?
	Did you feel unsafe ______?
	Always
	Often
	Sometimes
	Rarely
	Never
	(Don't Read)
	Refused
	Don't Know/Don't Remember

Family Planning

Q1.	Which of the following statements best describes you during the 3 months before you got pregnant with your new baby?
	Would you say ______ ?
	You were trying to get pregnant
	You were trying to keep from getting pregnant but weren’t trying very hard not to
	You were trying hard to keep from getting pregnant
	(Don't Read)
	Refused
	Don't Know/Don't Remember

Q2.	Which of the following statements best describes your spouse or partner during the 3 months before you got pregnant with your new baby?
	Your spouse or partner _____?
	Wanted you to get pregnant
	Didn’t care one way or the other whether you got pregnant
	Didn’t especially want you to get pregnant
	(Don't Read)
	Refused
	Don't Know/Don't Remember

Q3.	Thinking back to just before you got pregnant with your new baby, how did your spouse or partner feel about your becoming pregnant?
	Your spouse or partner ________?
	Wanted you to be pregnant sooner
	Wanted you to be pregnant later
	Wanted you to be pregnant then
	Didn’t want you to be pregnant then or at any time in the future
	You don’t know
	You didn’t have a spouse or partner
	(Don't Read)
	Refused
	Don't Know/Don't Remember

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?
	I’m going to read a list of options. Please tell me which one applies to you. You wanted to wait _______?
	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
	(Don't Read)
	Refused
	Don't Know/Don't Remember

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, answer Yes or No. (PROBE: When you found out you were pregnant with your new baby, ________?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Were you worried that you didn’t know enough about how to take care of a baby?
	Did you think a new baby would keep you from doing the things you were used to doing, like working, going to school, or going out?
	Did you look forward to teaching and caring for a new baby?
	Did you look forward to the new experiences that having a baby would bring?
	Did you look forward to telling your friends that you were pregnant?
	Were you worried that you didn’t have enough money to take care of a baby?
	Did you not look forward to telling your friends that you were pregnant?
	Did you look forward to buying things for a new baby?

Q6.	How did you feel when you found out you were pregnant with your new baby?
	Would you say you were ________?
	Very unhappy to be pregnant
	Unhappy to be pregnant
	Not sure
	Happy to be pregnant
	Very happy to be pregnant
	(Don't Read)
	Refused
	Don't Know/Don't Remember

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.
	Were you trying for _______?
	0 to 3 months
	4 to 6 months
	7 to 12 months
	13 to 24 months
	More than 24 months
	(Don't Read)
	Refused
	Don't Know/Don't Remember

SKIP: If mom was trying to get pregnant when she got pregnant with her 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?
	(PROBE: How many weeks or months pregnant were you?)
	(Don't Read)
	Number of weeks______ (Range: 1-40 weeks)
	Number of months______ (Range: 1-9 months)
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

R20.	Did you get prenatal care as early in your pregnancy as you wanted?
	(Don't Read)
	No
	Yes → Go to Question #
	Refused → Go to Question #
	Don't Know/Don't Remember → 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, answer Yes or No. Was it because________________? (PROBE: Was the reason you did not get prenatal care as early as you wanted because ________?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	You couldn’t get an appointment when you wanted one
	You didn’t have enough money or insurance to pay for your visits
	You had no transportation to get to the clinic or doctor’s office
	The doctor or your health plan wouldn’t start care as early as you wanted
	You had too many other things going on
	You couldn’t take time off from work or school
	You didn’t have your Medicaid (or state Medicaid name) card
	You didn’t have anyone to take care of your children
	You didn’t know that you were pregnant
	You didn’t want anyone else to know you were pregnant
	You 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?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

R7.	During any of your prenatal care visits, did a healthcare provider talk with you about the bacteria Group B Strep or Beta Strep?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

R8.	At any time during your most recent pregnancy, did you get tested for the bacteria Group B Strep or Beta Strep?
	(Don't Read)
	No
	Yes
	Don't Know/Don't Remember
	Refused

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?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

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?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

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?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

R15.	Where did you go most of the time for your prenatal care visits? Do not include visits for WIC.
	Would you say that most of the time you went to a...
	Private doctor’s office
	Hospital clinic
	Health department clinic
	State-specific
	State-specific
	Or you went somewhere else?
	IF YES, ASK: Where did you go? __________________________________________________________________________
	(Don't Read)
	Refused
	Don't Know/Don't Remember

R16.	During your most recent pregnancy, did a healthcare provider talk with you about any of the following things? Please count only discussions, not reading materials or videos. For each one, answer Yes or No. Did someone talk with you about ________?
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Foods that are good to eat during pregnancy
	Exercise during pregnancy
	Programs or resources to help you gain the right amount of weight during pregnancy
	Programs or resources to help you 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.
	(PROBE: How many weeks or months pregnant were you?)
	(Don't Read)
	Number of weeks ______ (Range: 1-40)
	Number of months ______ (Range: 1-9)
	Don't Know/Don't Remember
	Refused

R25.	For the next questions, please answer Yes or No. Overall, during your pregnancy, did you feel:
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Comfortable asking questions about the prenatal care that you received?
	Comfortable declining care if you didn't want it?
	Comfortable accepting the options for care that your provider recommended?
	Did you feel… you were able to choose the care options that you received?
	Your providers treated you with respect?
	Did you feel… satisfied with the prenatal care you 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?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

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.	I’m going to read a list of statements about safety.
	For each one, answer Yes or No.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	You always used a seatbelt during your most recent pregnancy
	Your home has a working smoke alarm
	You have received information about infant products that should be taken off the market or product recalls since your new baby was born
	Your 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?
	Is it ______?
	Always
	Often
	Sometimes
	Rarely
	Never → Go to Question #
	(Don't Read)
	Refused → Go to Question #
	Don’t know/Don’t remember → 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?
	(Don't Read)
	No → Go to Question #
	Yes
	Refused → Go to Question #
	Don’t know/Don’t remember → Go to Question #

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

S12.	How did you learn to install and use your infant car seat?
	For each one, answer Yes or No.
	Did you read the instructions?
	Did a friend or family member show you?
	Did a health or safety professional show you?
	Did you figure it out yourself?
	Did you already know how to install it because you have other children?
	Did you learn to install and use your infant car seat another way?
	IF YES, ASK: How did you learn to install and use your infant car seat? ________________________________ __________________________________________________________________________________________________________

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?
	(Don't Read)
	No
	Yes
	Refused
	Don't Know/Don't Remember

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, answer Yes or No.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Arsenic
	Lead
	Other contaminants
	IF YES, ASK: What was it?_____________________________________________________________________

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?
	(Don't Read)
	No → Go to Question #
	Yes
	Don’t know/Don’t remember → Go to Question #
	Refused→ Go to Question #

S22.	Are any of these firearms now loaded?
	(Don't Read)
	No → Go to Question #
	Yes
	Don't know/Don’t remember → Go to Question #
	Refused→ 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.
	(Don't Read)
	No
	Yes
	Don't know/Don’t remember
	Refused

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?
	(Don't Read)
	No
	Yes
	Your baby has not been sick → Go to Question #
	Refused → Go to Question #
	Don't Know/Don't Remember → 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?
	(Don't Read)
	No
	Yes → Go to Question #
	Refused → Go to Question #
	Don't Know/Don't Remember → 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?
	For each one, answer Yes or No. Was it because _______?
	You didn’t have health insurance to pay for the visit
	You couldn’t get an appointment
	You didn’t have a regular doctor for your baby
	You had no way to get your baby to the clinic or doctor’s office
	You didn’t have anyone to take care of your other children
	Did you have some other reason?
	IF YES ASK: What was that?___________________________________________________________________________________

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.
	(Don’t Read)
	No
	Yes → Go to Question #
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

X2.	Did any of these things keep your baby from having a well-baby checkup?
	For each one, answer Yes or No. Was it because _______?
	You didn’t have enough money or insurance to pay for it
	You had no way to get your baby to the clinic or doctor’s office
	You didn’t have anyone to take care of your other children
	You couldn’t get an appointment
	Your baby was too sick to go for a well-baby checkup
	Did anything else keep your baby from having a well-baby checkup?
	IF YES, ASK: What else kept your baby from having a well-baby checkup? ________________________________ ________________________________________________________________________________________________________________

X10.	Was your new baby seen by a healthcare provider for a one-week checkup after he or she was born?
	(Don't Read)
	No
	Yes
	Your baby was still in the hospital at that time
	Refused
	Don't Know/Don't Remember

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.”

	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, answer Yes or No. Did you take ­_______? (PROBE: During the month before you got pregnant, did you take _______?)
			(Don’t read)
			No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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, answer Yes or No. Did you take ­_______? (PROBE: During your most recent pregnancy, did you take _______?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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?
	(Don't Read)
	No
	Yes
	Refused
	Don’t know/don’t remember

Social Services including Home Visitation

V1.	During your most recent pregnancy, did you use any of these services? For each one, answer Yes or No.
			(Don’t read)
			No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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, answer Yes or No.
			(Don’t read)
			No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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?
	Please tell me which one of the following statements best describes your situation.
	No, you have not used WIC services for yourself or your new baby
	Yes, only you are using WIC services
	Yes. both you and your new baby use WIC services
	Yes, only your new baby uses WIC services
	(Don't Read)
	Refused
	Don’t know/don’t remember

V11.	During your most recent pregnancy, did you feel you needed any of the following services? For each one, answer Yes or No. (PROBE: During your most recent pregnancy, did you need ________?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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 your home
	Help to quit using drugs
	Assistance with housing or rent
	Was there any other service you felt you needed?
	IF YES, ASK: What other service did you need during your most recent pregnancy? _____________________ _____________________________________________________________________________________________________________

V12.	During your most recent pregnancy, did you receive any of the following services? For each one, answer Yes or No. (PROBE: During your most recent pregnancy, did you receive ________?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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 your home
	Help to quit using drugs
	Assistance with housing or rent
	Was there any other service you received?
	IF YES, ASK: What other service did you receive during your most recent pregnancy? ________________ __________________________________________________________________________________________________________

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.
	(Don't Read)
	No → Go to Question #
	Yes
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

V13.	Who was the home visitor that came to your home during your most recent pregnancy?
	Was that person _________?
	A nurse, nurse’s aide, or midwife
	A teacher or health educator
	A doula or childbirth educator
	State option (Someone from the <Healthy Start or other Program Name>)
	Someone else
	IF YES, ASK: What was their specialty or profession? _____________________________________________________
	(Don't Read)
	Refused
	Don't Know/Don't Remember

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?
	Was it _____?
	1 time
	2 to 4 times
	5 or more times
	(Don't Read)
	Refused
	Don't Know/Don't Remember

V15.	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, answer Yes or No. (PROBE: During your most recent pregnancy, did the home visitor talk with you about_______?)
				(Don’t read)
				No (1)	Yes (2)	Refused (8)	Don’t know (9)
	How smoking during pregnancy could affect your baby
	How drinking alcohol during pregnancy could affect your baby
	Doing tests to screen for birth defects or disease that run in your family
	The importance of getting tested for HIV
	The importance of getting tested for sexually transmitted infections
	If someone was hurting you emotionally or physically
	Breastfeeding your baby
	Your 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, answer Yes or No.
				(Don’t read)
				No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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.
	(Don't Read)
	No → Go to Question #
	Yes
	Refused → Go to Question #
	Don't Know/Don't Remember → Go to Question #

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?
	Was that person _________?
	A nurse, nurse’s aide, or midwife
	A teacher or health educator
	A doula or childbirth educator
	State option (Someone from the <Healthy Start or other Program Name>)
	Someone else
	IF YES, ASK: What was their specialty or profession? _____________________________________________________
	(Don't Read)
	Refused
	Don't Know/Don't Remember

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? For each one, answer Yes or No. (PROBE: Since your new baby was born, did the home visitor talk with you about_______?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Breastfeeding your baby
	How long to wait before getting pregnant again
	Family planning services or using contraception
	Postpartum depression
	Resources in your community to support new parents
	Getting to a healthy weight
	How to quit or keep from smoking
	How to get the health care that your baby or you need

V19.	The following questions are about the care you got from the home visitor since your new baby was born.
	For each one, answer Yes or No.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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 time period, answer Yes or No.
			(Don’t read)
			No (1)	Yes (2)	Refused (8)	Don’t know (9)
	During your most recent pregnancy
	During the birth of your new baby
	Since your 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?
	Would ________ have helped you? (PROBE: During your most recent pregnancy, would __________ have helped you if a problem had come up?)
	Your spouse or partner
	Your mother, father, or in-laws
	Other family member or relative
	A friend
	Religious community
	Neighbors
	Would someone else have helped you?
	IF YES, ASK: Who else would have helped you? ____________________________________________________________
	IF NONE OF ABOVE IS YES, ASK:  Would you say that no one would have helped you if a problem had come up?
	INTERVIEWER: If the mother answered that she did not have anyone to help her, check YES.

W3.	Since you delivered your new baby, who would help you if a problem came up? For example, who would help you if you needed to borrow $50 or if you got sick and had to be in bed for several weeks?
	Would ________ help you? (PROBE: Since you delivered your new baby, would ________ help you if a problem came up?)
	Your spouse or partner
	Your mother, father, or in-laws
	Other family member or relative
	A friend
	Religious community
	Neighbors
	Would someone else have helped you?
	IF YES, ASK: Who else would have helped you? __________________________________________________________
	IF NONE OF ABOVE IS YES, ASK: Would you say that no one would help you if a problem came up?
	INTERVIEWER: If the mother answered that she did not have anyone to help her, check YES.

 

W5.	The following questions are about the people in your life and the support they provided you while you were pregnant. For each one, answer Yes or No.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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, answer Yes or No.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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, answer Yes or No. (PROBE: Do your neighbors _____?)
				(Don’t read)
				No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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.
	Would you say that your spouse or partner ___?
	Lives with you all of the time
	Lives with you some of the time
	Doesn’t live with you
	You don’t have a spouse or partner
	(Don’t Read)
	Refused
	Don't Know/Don't Remember

W9.	Since your new baby was born, how often does your spouse or partner provide you with encouragement and emotional support?
	Would you say that it’s ______ ?
	Always
	Often
	Sometimes
	Rarely
	Never
	You don’t have a spouse or partner
	(Don’t Read)
	Refused
	Don’t Know / Don’t Remember

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?
	Would you say it’s ______?
	Always
	Often
	Sometimes
	Rarely
	Never
	(Don’t Read)
	Refused
	Don’t Know / Don’t Remember

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?
	Would you say it’s ______?
	Always
	Often
	Sometimes
	Rarely
	Never
	Your new baby’s father, or other parent, doesn’t regularly spend time with your baby
	(Don’t Read)
	Refused
	Don’t Know / Don’t Remember

Oral Health

Y3.	Since your new baby was born, have you had your teeth cleaned by a dentist or dental hygienist?
	(Don’t Read)
	No
	Yes
	Refused
	Don’t know/don’t remember

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, answer Yes or No. (PROBE: During your most recent pregnancy, _____.)
				(Don’t read)
				No (1)	Yes (2)	Refused (8)	Don’t know (9)
	You had cavities that needed to be filled
	You had painful, red, or swollen gums
	You had a toothache
	You needed to have a tooth pulled
	You had an injury to your mouth, teeth, or gums
	Did you have any other problems with your teeth or gums during your most recent pregnancy?
	IF YES, ASK: What was the problem? ________________________________________________________________________

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, answer Yes or No. (PROBE: Was it difficult to go to a dentist or dental clinic during your most recent pregnancy because _____?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	You couldn’t find a dentist or dental clinic that would take pregnant patients
	You couldn’t find a dentist or dental clinic that would take Medicaid patients
	You didn’t think it was safe to go to the dentist during pregnancy
	You couldn’t afford to go to the dentist or dental clinic
	You couldn’t find a dentist or dental clinic close by that you could get to

Y7.	The following statements are about the care of your teeth during your most recent pregnancy. For each one, answer Yes or No. (PROBE: During your most recent pregnancy, _____.)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	You knew it was important to care for your teeth and gums during your pregnancy
	A dental or other healthcare provider talked with you about how to care for your teeth and gums
	You knew it was safe to go to the dentist during pregnancy
	You had insurance to cover dental care during your pregnancy
	You needed to see a dentist for a problem
	You 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?
	I will read a list of options, please tell me which one applies to you.
	No, you didn’t get treatment
	Yes, you got treatment during your pregnancy
	Yes, you got treatment after your pregnancy
	Yes, you got treatment both during and after your pregnancy
	(Don’t Read)
	Refused
	Don't Know/Don't Remember

Intimate Partner Violence

Z1.	Did your current, or ex, spouse or partner do any of the following things during your most recent pregnancy? For each one, answer Yes or No. Did they____? (PROBE: During your most recent pregnancy, did they _____?
				(Don’t read)
				No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Threaten you or make you feel unsafe in some way
	Make you afraid for your safety or your family’s safety because of their anger or threats
	Try to control your daily activities, for example, controlling who you could talk to or where you could go
	Force you to take part in touching or any sexual activity when you 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? For each one, answer Yes or No. Have they____? (PROBE: Since your new baby was born, have they ____?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Threatened you or made you feel unsafe in some way
	Made you afraid for your safety or your family’s safety because of their anger or threats
	Tried to control your daily activities, for example, controlling who you could talk to or where you could go
	Forced you to take part in touching or any sexual activity when you 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 didn’t want to? For example, did they hide your birth control, throw it away, or do anything else to keep you from using it?
	(Don’t Read)
	No
	Yes
	Refused
	Don’t know/don’t remember

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? For each time period, answer Yes or No. (PROBE: Did your spouse or partner threaten you, limit your activities against your will, or make feel unsafe in any way?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	During the 12 months before you got pregnant
	During your most recent pregnancy
	Since your 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, answer Yes or No.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Your spouse or partner
	Your 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?
	(Don’t Read)
	No
	Yes
	You didn’t have a partner at that time, or you were in a same sex relationship
	Refused
	Don’t know/don’t remember

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?
	(Don’t Read)
	No
	Yes
	You didn’t go for prenatal care
	Refused
	Don’t know/don’t remember

AA2.	During your most recent pregnancy, did you try any of the following things to quit smoking? For each one, answer Yes or No. (PROBE: During your most recent pregnancy, did you ________?)
				(Don’t read)
				No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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, or 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 your own or cold turkey
	Did you do anything else to quit smoking?
	IF YES, ASK: What did you do? ____________________________________________________________________________

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, answer Yes or No. (PROBE: During any of your prenatal care visits, did a healthcare provider ________?
				(Don’t read)
				No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Spend time with you discussing how to quit smoking
	Suggest that you set a specific date to stop smoking
	Suggest you attend a class or program to stop smoking
	Provide you with booklets, videos, or other materials to help you quit smoking on your own
	Refer you to counseling for help with quitting
	Ask if a family member or friend would support your decision to quit
	Refer you 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 you quit
	Prescribe a pill like Chantix® (also known as varenicline) to help you 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?
	Would you say _____?
	No one was allowed to smoke anywhere inside your home
	Smoking was allowed in some rooms or at some times
	Smoking was permitted anywhere inside your home
	(Don’t Read)
	Refused
	Don’t know/don’t remember

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?
	Please tell me which one applies to you.
	No, you did not quit smoking
	No, but you cut back
	Yes, you quit before you found out you were pregnant
	Yes, you quit when you found out you were pregnant
	Yes, you quit later in your pregnancy
	(Don’t Read)
	Refused
	Don’t know/don’t remember

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?
	Would you say _____?
	No one is allowed to smoke anywhere inside your home
	Smoking is allowed in some rooms or at some times
	Smoking is permitted anywhere inside your home
	(Don’t Read)
	Refused
	Don’t know/don’t remember

AA8.	How many cigarette smokers, not including yourself, lived in your home during your most recent pregnancy?
	(Don’t Read)
	_____ Number of smokers (Range: 0 - 20)
	Refused
	Don’t know/don’t remember

AA9.	How many cigarette smokers, not including yourself, live in your home now?
	(Don’t Read)
	__________Number of smokers (Range: 0 - 20)
	Refused
	Don’t know/don’t remember

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, answer Yes or No. (PROBE: ________makes it hard to quit smoking?)
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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 you
	Cravings for a cigarette
	Lack of support from others to quit
	Worsening depression
	Worsening anxiety
	Is there anything else that makes it hard for you to quit smoking?
	IF YES: ASK: What is that? __________________________________________________________________________________

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?
	Would you say it was ______?
	Very often
	Somewhat often
	Not very often
	Never
	(Don’t Read)
	Refused
	Don’t know/don’t remember

BB3.	See Food Security and Economic Stability Section

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?
	Would you say it was ______?
	Very often
	Somewhat often
	Not very often
	Never
	(Don't Read)
	Refused
	Don’t know/don’t remember

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?
	Would you say it was ______?
	Very often
	Somewhat often
	Not very often
	Never
	(Don't Read)
	Refused
	Don’t know/don’t remember

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 one, answer Yes or No. Did you experience discrimination because of _____?
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	Your race, ethnicity, or skin color
	Your disability status
	Your immigration status
	Your age
	Your weight
	Your income
	Your sex or gender
	Your sexual orientation
	Your religion
	Your language or accent
	Your type or lack of health insurance
	Your use of substances like alcohol, tobacco, or other drugs
	Your involvement with the justice system (such as jail or prison)
	For something else
	IF YES, ASK: What was it? _______________________________________________________________________________

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.
	Was it___?
	Less than 1 day per week
	1 to 2 days per week
	3 to 4 days per week
	5 or more days per week
	You were told by a healthcare provider not to exercise
	(Don't Read)
	Refused
	Don’t know/don’t remember

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?
	Was it___?
	Less than 1 day per week
	1 to 2 days per week
	3 to 4 days per week
	5 or more days per week
	You were told by a healthcare provider not to exercise
	(Don't Read)
	Refused
	Don’t know/don’t remember

Reproductive History

FF1.	During the 12 months before you got pregnant with your new baby, did you have a miscarriage, fetal death, where the baby died before being born, or stillbirth?
	(Don't Read)
	No
	Yes
	Refused
	Don’t know/don’t remember

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?
	Is it _______?
	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
	(Don't Read)
	Refused
	Don’t know/don’t remember

FF5.	Before you got pregnant with your new baby, did you ever have any other babies who were born alive?
	(Don't Read)
	No → Go to Question #
	Yes
	Refused → Go to Question #
	Don’t know/Don’t remember → Go to Question #

NOTE: FF5 must be used with FF6 and FF7.

FF6.	Did the baby born just before your new one weigh 5 pounds, 8 ounces or 2.5 kilos or less at birth?
	(Don't Read)
	No
	Yes
	Refused
	Don’t know/don’t remember

FF7.	Was the baby just before your new one born earlier than 3 weeks before their due date?
	(Don't Read)
	No
	Yes
	Refused
	Don’t know/don’t remember

Demographic Information Including Maternal Weight

II1.	How much weight did you gain during your most recent pregnancy?
	(PROBE: About how much weight did you gain overall during your pregnancy?)
	(Don't Read)
	Gained _______ Pounds [Range: 0-150 pounds] OR
	________Kilos [Range: 0-68 kilograms]
	Weight didn’t change during pregnancy
	Don’t know/don’t remember
	Refused

II2.	How tall are you without shoes?
	(PROBE: About how tall?)
	(Don't Read)
	_______ Feet &
	_______ Inches
	OR _______Centimeters
	Refused
	Don’t know/don’t remember

II3.	Just before you got pregnant with your new baby, how much did you weigh?
	(PROBE: About how much?)
	(Don't Read)
	_______ Pounds OR
	_______ Kilos
	Refused
	Don’t know/don’t remember

II4.	When was your new baby born?
	(Don't Read)
	Month/Day/Year
	Month: _________
	Day: _________
	Year: _________
	Refused
	Don’t know/don’t remember

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?
	Was it________?
	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
	You didn’t drink then
	(Don't Read)
	Refused
	Don’t know/don’t remember

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?
	Was it________?
	6 or more times
	4 to 5 times
	2 to 3 times
	1 time
	You didn’t have 4 or more drinks in a 2-hour time span
	(Don't Read)
	Refused
	Don’t know/don’t remember

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?
	Was it________?
	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
	You didn’t drink then
	(Don't Read)
	Refused
	Don’t know/don’t remember

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?
	Was it ________?
	6 or more times
	4 to 5 times
	2 to 3 times
	1 time
	You didn’t have 4 or more drinks in a 2-hour time span
	(Don't Read)
	Refused
	Don’t know/don’t remember

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?
	(Don't Read)
	No
	Yes
	Refused
	Don’t know/don’t remember

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.
	(Don't Read)
	No
	Yes
	Refused
	Don’t know/don’t remember

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.
	(Don't Read)
	No
	Yes
	Refused
	Don’t know/don’t remember

KK4.	I am going to read you a list of things that some people do to prepare for a disaster.
	For each one, answer Yes or No. Would you say that ______?
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	You have an emergency meeting place for family members other than your home
	Your family and you have practiced what to do in case of a disaster
	You have a plan for how your family and you would keep in touch if you were separated
	You have an evacuation plan if you need to leave your home and community
	You have an evacuation plan for your children in case of a disaster, for example, permission for day care or school to release your child to another adult
	You have copies of important documents like birth certificates and insurance policies in a safe place outside your home
	You have emergency supplies in your home for your family such as enough extra water, food, and medicine to last for at least three days
	You have emergency supplies that you keep in your car, at work, or at home to take with you if you 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, answer Yes or No.
				(Don’t read)
				No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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, answer Yes or No.
			(Don’t read)
			No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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?
	(Don't Read)
	No
	Yes
	Refused
	Don’t know/don’t remember

Sexual Orientation and Gender Identity

PP1.	How would you describe your gender?
	Would you describe yourself as _______?
	Female
	Male
	Transgender
	Genderqueer or gender nonconforming
	Or would you prefer to self-describe?
	IF YES, ASK: How would you describe your gender? ______________________________________________
	(Don't Read)
	Refused
	Don’t know/don’t remember

PP2.	How would you describe your sexual orientation?
	Would you describe yourself as _______?
	Heterosexual or “straight”
	Lesbian or Gay
	Bisexual
	Or would you prefer to self-describe?
	IF YES, ASK: How would you describe your sexual orientation? _________________________________
	(Don't Read)
	Refused
	Don’t know/don’t remember

P HASE 8 SUPPLEMENTS

GUIDANCE FOR THE USE OF INDIVIDUAL SUPPLEMENT QUESTIONS AND FULL SUPPLEMENTS

All PRAMS supplements deployed in Phase 8 will be available as supplements in Phase 9. Funding is not anticipated to support existing supplements. CDC will weight all supplement data and provide grantees the data along with the annual weighted dataset.  

USING FULL SUPPLEMENT(S) 

• If a site chooses to use an existing supplement during Phase 9, the supplement must be used unaltered. Meaning that sites will not be able to drop or revise questions in the existing supplements. 

• Supplements will be placed at the end of the site’s survey.

• Sites may start and turn off supplements during Phase 9 with approval from their PRAMS program manager. The duration of implementation of the supplement is at the discretion of the PRAMS site. 

• Local IRB approval must be documented before implementing the supplement. Prior local IRB approval (approvals for Phase 8) are acceptable. 

• Due to OMB survey length restrictions, sites can only implement up to 3 supplements concurrently.  

USING INDIVIDUAL SUPPLEMENT QUESTIONS AS STANDARD QUESTIONS 

• Questions from existing or previous PRAMS supplements can be used as standard questions for the Phase 9 survey.  

• When using select supplement questions as standard questions, please note the following: 

  • These questions will be included in the 14-page base questionnaire print file.

  • They cannot be removed until the following survey revision (Phase 10). This is the same policy for all standard questions. 

  • The survey location of the supplement questions selected will depend on the question topic. Some questions will be added to the end of the survey, and others will be inserted throughout. Refer to the flow document for more information on the location for questions. 

  • Supplement questions used as standard questions are not considered site-developed questions. Therefore, they will not require justification, testing, or CDC PRAMS approval.

  • Sites must consider minimum groupings and skip patterns when selecting the supplement questions. For example, some questions may require a screener question or need to be asked together because they are related. 

Disaster Supplement

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.
	(Don’t Read)
	No → Go to the end
	Yes
	Refused
	Don’t know/don’t remember

KK6.	How would you describe any damage to your home from the disaster? I will read a list of options, please tell me which one applies to you
	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? For each one, answer Yes or No.
			(Don’t read)
			No (1)	Yes (2)	Refused (8)		Don’t know (9)
	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? I will read a list of options, please tell me which one applies to you
		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? I will read a list of options, please tell me which one applies to you
	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? For each one, answer Yes or No.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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?
	(Don’t Read)
	No → Go to Question KK14
	Yes
	Refused
	Don’t know/don’t remember

KK12.	Were you able to get the mental health services that you needed?
	No
	Yes → Go to Question KK14
	Refused
	Don’t know/don’t remember

KK13.	Did any of these things keep you from getting the mental health services that you needed after the disaster? For each one, answer Yes or No.
	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? For each one, answer Yes or No. Would you say you have _______?
			(Don’t read)
			No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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.
	(Don’t Read)
	No
	Yes
	Refused
	Don’t know/don’t remember

KK16.	Before the disaster, had you done any of the things listed below to prepare for a disaster?  For each one, answer Yes or No. Would you say________?
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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 Supplement

NN1.	During your most recent pregnancy, how often did you eat largemouth bass, tuna, shark, king mackerel or swordfish? Would you say it was_______?
	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 #
	(Don’t read)
	Refused
	Don’t know/don’t remember

NN2.	Where did you get largemouth bass, tuna, shark, king mackerel or swordfish that you ate during your pregnancy? For each one, answer Yes or No.
	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 you or someone else from a local river, stream, lake, or pond
	Caught by you 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? For each one, answer Yes or No.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	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? Would you say it was__________?
	More than once a day
	Once a day
	2 to 6 times a week
	Once a week
	Less than once a week
	Never
	(Don’t read)
	Refused
	Don’t know/don’t remember

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. For each one, answer Yes or No.
		(Don’t read)
		No (1)	Yes (2)	Refused (8)	Don’t know (9)
	How 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) I will read a list of options, please tell me which one applies to you
	No
	Yes
	You didn’t ask a healthcare provider any questions about environmental exposures
	You didn’t have any concerns about environmental exposures
	(Don’t read)
	Refused
	Don’t know/don’t remember