Form 2 Prenatal Form

Healthy Start Mandatory Prenatal Form | Jan 2023

OMB Control No. 0915-0338, Expiration Date xx/xx/xxxx

INFORMATION IN THIS BOX IS FOR GRANTEE records ONLY—DO NOT UPLOAD

Name of This Primary Participant: ________________________________ Date of Birth:_______________

Name(s) & Date(s) of Birth of Other Linked Primary Participants (up to 2 people, as applicable):

Name of Other Linked PP: ______________________________________ Date of Birth:_______________

Name of Other Linked PP: ______________________________________ Date of Birth:_______________

Name of Interviewer: ______________________________

Names and dates of birth are included above for grantee tracking purposes only and should not be submitted to HRSA. The primary participant for this form is a pregnant woman who is enrolled for prenatal services.

Public Burden Statement: The purpose of this data collection is to obtain consistent information across all grantees about Healthy Start and its outcomes. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0338 and it is valid until 02/28/2023. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 0.5 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

INSTRUCTIONS

• This form must be administered by a trained case worker or other Healthy Start grantee staff member, to ensure consistency in responding across participants and grantees when questions or misunderstandings arise. It should not be self-administered or administered by untrained staff.

• This Prenatal Form is to be completed, along with a new or updated Background Information form, when a pregnant woman enrolls or as soon as it is known that an enrolled woman is pregnant. Only enrolled pregnant women complete this form.

• Every form should include the primary participant’s Unique ID# (UID). Each person’s UID should remain the same across phases and years, and should be in the format described in Question G1.

• If there is more than one primary participant in the family unit, the UIDs must appear together on this form so that all associated UIDs can be linked in the database.

• Items in italics are questions for or statements to the participant. Instructions to staff may be [bracketed].

See the next page for instructions on completing form updates.

INSTRUCTIONS: FORM UPDATES

Post-Pregnancy Follow-Up

This Prenatal Form contains a Post-Pregnancy Follow-Up section at the end.

• When the pregnant woman gives birth or the pregnancy otherwise ends, complete:

  • General Information: Question G5 (select “Pregnancy Ends”)

  • Post-Pregnancy Follow-Up: All Questions (Q1-Q5)

Note: The participant’s Background Information Form must also be updated following the steps outlined in the Background Information Form instructions.

Other Form Updates

• When a woman exits HS before the end of her pregnancy, complete:

• General Information: Question G5 (“Other update”)

And, rescreen the following questions:

• General Information: Question G2

• Pregnancy and Health: Questions 1-3, 5, 5a (as applicable), 6

• Home Life: Question 10 (as applicable)

• Tobacco and Alcohol: Questions 11-13

Note: The participant’s Background Information Form should also be updated following the steps outlined in the Background Information Form instructions

• For other updates: To update a specific question(s) or section(s), such as when a participant experiences a major life event or a significant change in health status, please complete Question G5, “Other update,” and revise the relevant question(s) and/or section(s).

Other Linked Primary Participant Updates

• To add an “other linked primary participant,” complete “Other update” in Question G5, and add the other linked primary participant’s UID in Question G3. The participant’s Background Information form should also be updated to match.

• To change/remove an “other linked primary participant,” email [email protected] using the subject line, “Technical Support Request for HSMED-II” with your requested change/removal.

Participant Re-Enrollment

To re-enroll a pregnant participant who exited the program earlier in the same pregnancy, please:

• Select “other update” in Question G5 of the Prenatal Form and enter the date of the update/re-enrollment. For update reason, indicate “re-enrollment after exit”

• Remove the previous exit information from Question G5

• No additional responses need to be updated or changed. When the participant delivers, follow the Post-Pregnancy Follow-Up instructions above.

• Note: The participant’s PPUID should never change; use the same PPUID as when first enrolled.

[GENERAL INFORMATION to be completed by staff before uploading data for this prenatal form:]

G1. This Primary Participant’s Unique ID#: ______________________________________

[Enter as One Number: Grantee Org Code + PP + Client’s Unique ID (e.g., 123PP45678)]

G2. other participants’ (if applicable) Unique ID numbers that should be linked to this Primary participant (Enter up to 2 & Use format indicated in question g1):

• Other Linked PP ID#: ______________________________________

• Other Linked PP ID#: ______________________________________

• Or, no other participants are linked to the primary participant completing this form

G3. Date of Enrollment in Healthy Start:

• Primary Participant’s Enrollment Date_________________

G4. Initial completion of this form by Primary Participant:

 Date of initial completion of this Prenatal Form: _____________

[Staff: This is the date that the form has been completed in its entirety up to the Post-Pregnancy Follow-Up Section. When the pregnant woman gives birth or the pregnancy otherwise ends, complete a new form in its entirety through the end of the Post-Pregnancy Follow-Up Section and enter the date of the update in Question G5.]

G5. this form has been Updated following its initial completion based on [select below as applicable]:

• Pregnancy ends [Staff: Complete the Post-Pregnancy Follow-Up at the end of this form]

 Date Post-Pregnancy Follow-Up completed: _____________ [Staff: This date should match the date entered in the Post-Pregnancy Follow-Up Section on page 7.]

• Other update (e.g., woman chooses to exit HS before end of pregnancy, added/removed other linked primary participant)

 Date updated: _____________

 Specify reason for update: __________________________________________

[Staff: Please read the following statement to the participant:]

Thank you for participating in the Healthy Start program. The purpose of these forms is to examine how well the Healthy Start program is meeting its goals of helping families improve their health and the health of their babies. This Form should take about 10 minutes to complete. Any information you provide will be kept confidential. You do not have to answer any questions you do not want to, and you can end the interview at any time without any penalty or loss of benefits.

Pregnancy and Health

[Staff: Only enrolled women who are pregnant complete this form.]

For this questionnaire, I’d like to start off by asking you a couple questions about your pregnancy.

1. First, what is your baby's due date? [Staff: If woman does not yet know her due date, then this question must be completed when she does.]

• Due Date: [month/day/year]______/_____/_______

• Don’t know

• Declined to answer

2. How many weeks pregnant are you? [Staff: If woman is not sure how many weeks pregnant she is, help her determine this based on her due date and today’s date. If she does not yet know her due date, complete this question after she does.]

• ______ weeks

• Unable to determine. Specify reason:__________________________________________

3. [Staff: Based on how many weeks pregnant the woman is, what trimester is she currently in?]

• First trimester (weeks 0-13)

• Second trimester (weeks 14-27)

• Third trimester (weeks 28-40)

• Unable to determine (based on response to Question 2)

4. [Staff: When did the participant enroll in Healthy Start?]

• Prior to this pregnancy

• During 1^st trimester of this pregnancy (weeks 0-13)

• During 2^nd trimester of this pregnancy (weeks 14-27)

• During 3^rd trimester of this pregnancy (weeks 28-40)

  • Unable to determine

5. How many months pregnant were you when you had your first visit for prenatal care? [Staff: Please indicate number of months].

• _______months

• I haven’t gone for prenatal care yet

• Don’t know

• Declined to answer

5a. [Staff: If participant has not yet had her first visit for prenatal care, ask:] Do you have an appointment scheduled?

• Yes, indicate date scheduled: ______________

• No

• Don’t know

• Declined to answer

6. [Staff: Please select corresponding trimester for when woman had her first prenatal care visit]:

• First trimester (0-13 weeks)

• Second trimester (14-27 weeks)

• Third trimester (28-40 weeks)

• No prenatal care visits yet

• Unable to determine (based on response to Question 5)

6a. Do you know if you are carrying multiple fetuses (e.g., twins, triplets) or not?

• Not pregnant with multiples

• Pregnant with multiples

  • Number of fetuses: _____________

• Don’t know

• Declined to answer

[Staff, If mother has not yet had a prenatal visit and/or does not yet know whether she is pregnant with multiples, then information regarding when she began prenatal care and whether she is carrying multiples needs to be completed for Questions 5, 5a, 6, and 6A when she has had a prenatal visit.]

7. During the 3 months before you got pregnant with this child, did you have any of the following health conditions? [For each one, check No if participant did not have the condition or Yes if she did.]

	Health Condition	Yes	No	Not Sure	Declined to Answer
a.	Type 1 or Type 2 diabetes (not gestational diabetes or diabetes that starts during pregnancy)
b.	High blood pressure or hypertension
c.	Depression
d.	Other chronic condition(s) or illness(es). Specify all that apply:

8. [Staff: If mother currently has another child besides the one she is pregnant with, ask:] Thinking about your child who was born just before the one you’re now pregnant with, how old was he/she when you learned about this pregnancy?

• 0 to 12 months

• 13 to 18 months

• 19 to 24 months

• More than 2 years

• This is my first pregnancy

• Don’t know

• Declined to answer

Home Life

Next, we have a couple questions about your home life and plans for the baby.

9. What method do you plan to use to feed your new baby in the first few weeks?

[Select one.]

• Breastfeed only (baby will not be given formula)

• Formula feed only

• Both breast and formula feed

• Don't know yet

• Declined to answer

9. Would you describe your partner or the father of this baby as:

[Select one.]

• Involved in my pregnancy and supportive of me and the child I’m carrying

• Involved with the child I’m carrying but not supportive of me

• Involved and supportive of me but not the child I’m carrying

• Not involved in my pregnancy but supportive of me and the child I’m carrying

• Not involved/supportive of either me or the child I’m carrying

• Not aware I am pregnant

• Declined to answer

Tobacco and Alcohol

Finally, I'd like to ask you some additional questions about your current use of tobacco and alcohol.

9. How many cigarettes are you smoking now on an average day? A pack has 20 cigarettes.

• 41 cigarettes or more

• 21 to 40 cigarettes

• 11 to 20 cigarettes

• 6 to 10 cigarettes

• 1 to 5 cigarettes

• Less than 1 cigarette

• I don’t smoke

• Don’t know

• Declined to answer

9. 

   E-cigarettes (electronic cigarettes) and other electronic nicotine vaping products (such as vape pens, e-hookahs, hookah pens, e-cigars, e-pipes) are battery-powered devices that use nicotine liquid rather than tobacco leaves, and produce vapor instead of smoke.

   A hookah is a water pipe used to smoke tobacco. It is not the same as an e-hookah or hookah pen.

   
   
   

   A hookah is a water pipe used to smoke tobacco. It is not the same as an e-hookah or hookah pen.

   
   
   

   How often, on average, are you using other tobacco or nicotine products now?

	Tobacco or Nicotine Product	More than once a day	Once a day	2-6 days a week	1 day a week or less	Not at all	Don’t Know	Declined to Answer
a.	E-cigarettes or other electronic nicotine products
b.	Hookah
c.	Chewing tobacco, snuff, snus, or dip
d.	Cigars, cigarillos, or little filtered cigars

9. Since you found out you were pregnant, how often have you been drinking alcoholic beverages?

• Nearly every day

• Several times a week

• Several times a month

• Less than once a month

• Never

• Don’t know

• Declined to answer

- The Mandatory Prenatal Form is Complete -

(Post-Pregnancy Follow-Up Begins on Next Page)

POST-PREGNANCY FOLLOW-UP

[Staff: Complete this section when the pregnant woman gives birth or the pregnancy otherwise ends.]

Date:__________________ [Staff: This date should match the date entered in Question G5 on page 2.]

This Primary Participant’s Unique ID#______________________

[Enter as One Number: Grantee Org Code + PP + Client’s Unique ID (e.g., 123PP45678)]

[Staff: Please complete the questions below regarding the outcome of this pregnancy once you have been able to confirm the details.

• It is important to record the pregnancy outcome for every woman who was in Healthy Start during her prenatal phase, even if she leaves the program.

• Do not read these questions to the woman. Instead, determine the outcome in a way that is sensitive to the woman’s feelings, and record below:]

1. [Staff: Record initial outcomes of this pregnancy:]

[Select all that apply.]

• Live birth

  • Indicate how many live births from this pregnancy:__________

• Ectopic or tubal pregnancy

• Miscarriage (pregnancy ended spontaneously before 20 weeks)

• Stillbirth or fetal death (pregnancy ended at 20 weeks or more)

  • Indicate how many fetal deaths occurred with this pregnancy:__________

• Termination of pregnancy

• Outcome unknown

  • Describe methods used to track pregnancy outcome: __________________________________________________________________________________________________________________________________________

2. [Staff: If this pregnancy resulted in a live baby(ies) who is now enrolled in HS, indicate the Unique ID#(s) of the enrolled child (EC)/children:]

[Enter as One Number: Grantee Org Code + EC + Client’s Unique ID (e.g., 123EC45678)]

1. UID for 1^st EC: _______________________________________

2. UID for 2^nd EC: _______________________________________

3. UID for 3^rd EC: _______________________________________

4. UID for 4^th EC: _______________________________________

3. [Staff: Among the babies who were born alive from this pregnancy, did any end with a neonatal death (that is, baby is born alive but dies within 0-27 days of life)?]

• Yes

  • Indicate how many neonatal deaths from this pregnancy:

    • Number __________

  • Describe methods used to track neonatal death: __________________________________________________________________________________________________________________________________________

  • No

  • Unable to determine

4. [Staff: Please indicate if this delivery resulted in a maternal death.]

• Yes

  • Describe methods used to track maternal mortality: __________________________________________________________________________________________________________________________________________

• No

• Outcome unknown

5. [Source(s) of information for pregnancy outcomes reported in this section:]

[Select all that apply]:

• Hospital records

• Vital records

• Primary Participant

• Other family member

• Other source, Specify: ________________________________________________________

[Follow-up Instructions - If the outcome of the pregnancy:

• Was a healthy mother and baby, then complete the Parent/Child Form as soon as possible with a primary participant connected to the child, and update the mother’s Background Information form.

• Was mixed and included both a live baby and a fetal or neonatal death, or a very ill baby or mother, then please be sensitive of the participant’s experience, and potentially delay completing (e.g., at the next visit) the Parent/Child Form for the live baby or updating the mother’s Background Information Form.

• Did not include a live birth (e.g., miscarriage, ectopic or tubal pregnancy, fetal death or stillbirth, other pregnancy termination, neonatal death), staff need to be sensitive of the participant’s experience, and potentially delay updating (e.g., at the next visit) the mother’s Background Information Form.]

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