Birth Screener

Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx

IFPS-3: Birth Screener

The information you are being asked to provide is authorized to be collected under Section 301 of The Public Health Service Act (42 USC 241). Providing this information is voluntary. CDC will use this information in its study, Feeding My Baby and Me (also known as the Infant Feeding Practices Study III), in order to learn more about the choices mothers make in feeding their babies and toddlers in the first 2 years of life. This information will support efforts to improve the health of our nation’s children. This information will be shared with a contractor, Westat, with which CDC has entered into an agreement to assist with carrying out this study.

Public reporting burden of this collection of information varies from 2 to 24 minutes with an average of 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

Congratulations on your new baby!

What is your baby’s first name?

___________

B6. What is your baby's birthday?

Month [DROP DOWN]

Day [DROP DOWN]

Year [DROP DOWN]

[COMPARE WITH A12 FROM SCREENER, IF B6 MORE THAN 21 DAYS EARLIER THAN A12, INELIGIBLE. IF INELIGIBLE, SHOW INELIGIBILITY SCREEN AND END SURVEY. ELSE GO TO B3.]

[IF INELIGIBLE START INELIGIBILITY SCREEN]

Did you have twins or more than one baby? [ONLY ASK IF RESPONDENT INDICATED DON’T KNOW IN STUDY SCREENER]

• Yes [INELIGIBLE]

• No

[IF INELIGIBLE START INELIGIBILITY SCREEN]

[IF DATE OF BIRTH SCREENER IS ≥ 1 WEEK FROM DATE OF BIRTH, ASK B14 AND B1]

B14. Did {CHILD’S NAME} have to stay in an intensive care unit immediately after birth?

• Yes, one day or less

• Yes, two days

• Yes, three days [END SURVEY, INELIGIBLE]

• Yes, more than three days [END SURVEY, INELIGIBLE]

• No

[IF INELIGIBLE START INELIGIBILITY SCREEN]

B1. Did you have any severe medical problems that prevented you from feeding {CHILD’S NAME} either breast milk or infant formula for 1 week or more following their birth?

• Yes [END SURVEY, INELIGIBLE]

• No

[IF INELIGIBLE START INELIGIBILITY SCREEN]

We’re sorry, as we mentioned when you consented to be in the study, moms whose babies are born prematurely are not eligible to continue with the study. Thank you for your participation, and our warmest wishes for a happy, healthy future for you and your baby.

[END INELIGIBILITY SCREEN, END SURVEY]

B3. Is your baby a boy or a girl?

• Boy

• Girl

B4. What was your baby's length at birth?

________ Inches

B5. How much did your baby weigh at birth?

______ Pounds _______ Ounces

END SCREEN:

THANK YOU, AND CONGRATULATIONS AGAIN! WE’LL BE CONTACTING YOU SOON FOR YOUR 1 MONTH SURVEY!