Attachment B - Summary of Survey Additions and Deletions MCHB - MCH Jurisdictional Survey - Revision

^{Maternal and Child Health (MCH) Jurisdictional Survey Instrument for the Title V MCH} Block Grant Program

Attachment B: Summary of Added/Revised and Deleted Survey Questions

1. Added/Revised Items

2. Deleted Items

Added/Revised Questions

Jurisdiction

Question Text

Summary

Federated States of Micronesia and CNMI

What is the primary language spoken in the household?

☐ ENGLISH

☐ SPANISH

[DISPLAY OPTIONS 3-6 FOR FSM ONLY]

☐ CHUUKESE

☐ KOSRAEN

☐ POHNPEIAN

☐ YAPESE

[DISPLAY OPTIONS 7-9 FOR CNMI ONLY]

☐ CHAMORRO

☐ REFALUWASCH

☐ TAGALOG

☐ ANOTHER LANGUAGE, PLEASE SPECIFY:

Revised: Response options 3-6 were added in Section A of the Screener for Federated States of Micronesia only and response option 7-9 were added in Section A of the Screener for CNMI only. These options provide additional detail requested by the MCH Block Grant jurisdiction leadership.

All

What is this child’s race and/or ethnicity? SELECT ALL THAT APPLY

Is this child…

Hispanic or Latino?

☐ Yes

☐ No

[IF YES] Please describe this child’s Hispanic or Latino background. Is this child…?

☐ Mexican

☐ Puerto Rican

☐ Salvadoran

☐ Cuban

☐ Dominican

☐ Guatemalan

☐ Other Hispanic or Latino. Please specify this child’s other Hispanic or Latino background. For example, Colombian, Honduran, Spaniard, etc. ______________________

Native Hawaiian or Pacific Islander?

☐ Yes

☐ No

[IF YES] Please describe this child’s Native Hawaiian or Pacific Islander background. Is this child…?

☐ Native Hawaiian

☐ Tongan

☐ Samoan

☐ Fijian

☐ Guamanian

☐ Chamorro

☐ Marshallese

☐ [DO NOT DISPLAY IN NP] Saipanese

☐ Mortlockese

☐ Kosraen

☐ Carolinian

☐ Palauan

☐ Pohnpeian

☐ Yapese

☐ Chuukese

☐ Other Native Hawaiian or Pacific Islander background. Please describe this child’s other Native Hawaiian or Pacific Islander background. For example, Tahitian, etc. ____________________

American Indian or Alaska Native?

☐ Yes

☐ No

[IF YES] Please describe this child’s American Indian or Alaska Native background. For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow lnupiat Traditional Government, Nome Eskimo

Community, Aztec, Maya, etc. _________________________________

Asian?

☐ Yes

☐ No

[IF YES] Please describe this child’s Asian background. Is this child…?

☐ Chinese

☐ Asian Indian

☐ Filipino

☐ Vietnamese

☐ Korean

☐ Japanese

☐ Other Asian. Please specify this child’s other Asian background. For example, Pakistani, Hmong, Aghan, etc. _________________________

Black or African American?

☐ Yes

☐ No

[IF YES] Please describe this child’s Black or African American background. Is this child…?

☐ African American

☐ Jamaican

☐ Haitian

☐ Nigerian

☐ Ethiopian

☐ Somali

☐ Other Black or African American. Please specify this child’s other Black or African American background. For example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc. _____________________________

Middle Eastern or North African?

☐ Yes

☐ No

[IF YES] Please describe this child’s Middle Eastern or North African background. Is this child…?

☐ Lebanese

☐ Iranian

☐ Egyptian

☐ Syrian

☐ Iraqi

☐ Israeli

☐ Other Middle Eastern or North African. Please specify this child’s Middle Eastern or North African background. For example, Moroccan, Yemeni, Kurdish, etc. ___________________________

White?

☐ Yes

☐ No

[IF YES] Please describe this child’s White background. Is this child…?

☐ English

☐ German

☐ Irish

☐ Italian

☐ Polish

☐ Scottish

☐ Other White. Please describe this child’s other White background. For example, French, Swedish, Norwegian, etc. _________________________

Revised: This question was updated in Section A of the Screener for every jurisdiction. The question was updated to reflect the most up to date standards in race and ethnicity questions. This information is collected for the first four children identified in the screener.

See: Office of Management and Budget, “Revisions to OMB’s Statistical Policy Directive No. 15: Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity,” Federal Register 89, no. 61 (March 29, 2024): 22182-22190, https://www.federalregister.gov/documents/2024/03/29/2024-06469/revisions-to-ombs-statistical-policy-directive-no-15-standards-for-maintaining-collecting-and/.

All

[ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD. ELSE GO TO SECTION D]

How old was this child when they were FIRST fed formula?

__ DAYS (OR)

__ WEEKS (OR)

__ MONTHS (OR)

☐ AT BIRTH

☐ CHILD HAS NEVER BEEN FED FORMULA

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to 'Section C. This Child as an Infant' of the Core Questionnaire for every jurisdiction in order to provide data around when a child was first fed formula.

All

During the past 12 months, did you, another caregiver, or a health care provider need to make any decisions regarding this child’s health care, such as whether to get prescriptions, referrals, or procedures?

☐ Yes

☐ No

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to 'Section E. Experience with This Child's Health Care Providers' of the Core Questionnaire for every jurisdiction to better understand shared decision making.

All

[IF YES] During the past 12 months, how often did this child’s doctors or other health care providers…​

	Always	Usually	Sometimes	Never	DON’T KNOW	PREFER NOT TO ANSWER
E3a. discuss with you the range of options to consider for their health care or treatment?	☐	☐	☐	☐	☐	☐
E3b. make it easy for you to raise concerns or disagree with recommendations for this child’s health care?	☐	☐	☐	☐	☐	☐
E3c. work with you to decide which health care and treatment choices would be best for this child?	☐	☐	☐	☐	☐	☐

Added: This question was added to 'Section E. Experience with This Child's Health Care Providers' of the Core Questionnaire for every jurisdiction to better understand shared decision making.

All

[ONLY ASK THIS QUESTION IF CHILD IS 6 MONTHS-5 YEARS OLD]

How often…​

	Always	Usually	Sometimes	Never	DON’T KNOW	PREFER NOT TO ANSWER
H5a. is this child affectionate with you?	☐	☐	☐	☐	☐	☐
H5b. does this child bounce back quickly when things do not go their own way?	☐	☐	☐	☐	☐	☐
H5c. does this child show interest and curiosity in learning new things?	☐	☐	☐	☐	☐	☐
H5d. does this child smile and laugh?	☐	☐	☐	☐	☐	☐

Added: This question was added to 'Section H. This Child’s Learning’ of the Core Questionnaire for every jurisdiction to provide data around well-being.

All

[ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

How often does this child…​

	Always	Usually	Sometimes	Never	DON’T KNOW	PREFER NOT TO ANSWER
H7a. show interest and curiosity in learning new things?	☐	☐	☐	☐	☐	☐
H7b. work to finish tasks they start?	☐	☐	☐	☐	☐	☐
H7c. stay calm and in control when faced with a challenge?	☐	☐	☐	☐	☐	☐
H7d. care about doing well in school?	☐	☐	☐	☐	☐	☐
H7e. do all required homework?	☐	☐	☐	☐	☐	☐
H7f. argue too much?	☐	☐	☐	☐	☐	☐

Added: This question was added to 'Section H. This Child’s Learning’ of the Core Questionnaire for every jurisdiction to provide data around well-being.

All

[ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

Other than you or other adults in your home, is there at least one other adult in this child’s school, neighborhood, or community who knows this child well and who they can rely on for advice or guidance?

☐ YES

☐ NO

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to 'Section I. About You and This Child’ of the Core Questionnaire for every jurisdiction to collect data on whether the surveyed child has an adult mentor.

All

The next few questions are about housing.

During the past 12 months, was there a time when you were not able to pay the mortgage or rent on time?

☐ YES

☐ NO

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to 'Section J. About Your Family and Household’ of the Core Questionnaire for every jurisdiction to collect data around housing instability.

All

During the past 12 months, how many times has this child moved to a new address?

____NUMBER OF TIMES

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to 'Section J. About Your Family and Household’ of the Core Questionnaire for every jurisdiction to collect data around housing instability.

All

Since this child was born, have they ever been homeless or lived in a shelter? This can include living in a shelter, motel, temporary or transitional living situation, scattered site housing, or having no steady place to sleep at night.

☐ YES

☐ NO

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to 'Section J. About Your Family and Household’ of the Core Questionnaire for every jurisdiction to collect data around housing instability.

All

Many people experience stressful life events. These things can happen in any family, but some people may feel uncomfortable with these questions. The next questions are about events that may have happened during this child’s life. As a reminder, your responses are confidential, and you may skip any questions you do not want to answer.​

To the best of your knowledge, has this child EVER experienced any of the following?​

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
J11a. Parent or guardian divorced or separated?	☐	☐	☐	☐
J11b. Parent or guardian died?	☐	☐	☐	☐
J11c. Parent or guardian served time in jail or prison?	☐	☐	☐	☐
J11d. Saw or heard parents or adults slap, hit, kick, punch one another in the home?	☐	☐	☐	☐
J11e. Was a victim of violence or witnessed violence in their neighborhood?​	☐	☐	☐	☐
J11f. Lived with anyone who was mentally ill, suicidal, or severely depressed?​	☐	☐	☐	☐
J11g. Lived with anyone who had a problem with alcohol or drugs​?	☐	☐	☐	☐
J11h. Treated or judged unfairly because of their race or ethnic group​?	☐	☐	☐	☐
J11i. Treated or judged unfairly because of their sexual orientation or gender identity?	☐	☐	☐	☐
J11j. Treated or judged unfairly because of a health condition or disability?	☐	☐	☐	☐

Added: This question was added to 'Section J. About Your Family and Household’ of the Core Questionnaire for every jurisdiction to collect data on adverse childhood experiences.

American Samoa, Federated States of Micronesia, Guam, RMI, Palau, Puerto Rico, and USVI

[ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Since your new baby was born, have you had a postpartum checkup for yourself? A postpartum checkup is a regular health checkup you have up to 12 weeks after giving birth.

☐ YES

☐ NO [GO TO AS8]

☐ DON’T KNOW [GO TO AS8]

☐ PREFER NOT TO ANSWER [GO TO AS8]

Added: This question was added to 'Section AS. American Samoa Jurisdiction Specific Module’, ‘Section FM. FSM Jurisdiction Specific Module’, ‘ ‘Section MI. Marshall Islands Jurisdiction Specific Module’, ‘Section PA. Palau Jurisdiction Specific Module’, ‘Section PR. Puerto Rico Jurisdiction Specific Module’, and ‘Section VI. USVI Jurisdiction Specific Module’ to provide data the postpartum visit. This question was revised in ‘Section GM. Guam Jurisdiction Specific Module’. This information is collected in the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire. To avoid duplicate data collection, this question is only asked in jurisdictions that do not currently have access to this data from PRAMS.

American Samoa, Federated States of Micronesia, Guam, RMI, Palau, and USVI

[ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

[IF YES] During your postpartum checkup, did a healthcare provider talk to you about…?​ ​

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
AS5a. healthy eating, exercise, and losing weight gained during pregnancy	☐	☐	☐	☐
AS5b. how long to wait before getting pregnant again?	☐	☐	☐	☐
AS5c. birth control methods?	☐	☐	☐	☐
AS5d. warning signs of medical problems you might be at risk for due to your pregnancy?	☐	☐	☐	☐
AS5e. regularly checking your blood pressure?	☐	☐	☐	☐
AS5f. what to do if you feel depressed or anxious?	☐	☐	☐	☐

Added: This question was added to 'Section AS. American Samoa Jurisdiction Specific Module’, ‘Section FM. FSM Jurisdiction Specific Module’, ‘Section GM. Guam Jurisdiction Specific Module’, ‘Section MI. Marshall Islands Jurisdiction Specific Module’, ‘Section PA. Palau Jurisdiction Specific Module’, and ‘Section VI. USVI Jurisdiction Specific Module’ to provide data the postpartum visit. This information is collected in the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire. To avoid duplicate data collection, this question is only asked in jurisdiction that do not currently have access to this data from PRAMS.

American Samoa, Federated States of Micronesia, Guam, RMI, Palau, and USVI

[ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

[IF YES] During your postpartum checkup, did a healthcare provider ask you…?

​ ​

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
AS6a. if you were smoking cigarettes or using e-cigarettes (“vapes”) or other smokeless tobacco	☐	☐	☐	☐
AS6b. if someone was hurting you emotionally or physically	☐	☐	☐	☐

Added: This question was added to 'Section AS. American Samoa Jurisdiction Specific Module’, ‘Section FM. FSM Jurisdiction Specific Module’, ‘Section GM. Guam Jurisdiction Specific Module’, ‘Section MI. Marshall Islands Jurisdiction Specific Module’, ‘Section PA. Palau Jurisdiction Specific Module’, and ‘Section VI. USVI Jurisdiction Specific Module to provide data the postpartum visit. This information is collected in the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire. To avoid duplicate data collection, this question is only asked in jurisdiction that do not currently have access to this data from PRAMS.

American Samoa, Federated States of Micronesia, Guam, RMI, Palau, and USVI

[ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

[IF YES] During your postpartum checkup, did a healthcare provider…?​ ​

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
AS7a. test you for diabetes?	☐	☐	☐	☐
AS7b. prescribe you medication for depression or anxiety?	☐	☐	☐	☐

Added: This question was added to 'Section AS. American Samoa Jurisdiction Specific Module’, ‘Section FM. FSM Jurisdiction Specific Module’, ‘Section GM. Guam Jurisdiction Specific Module’, ‘Section MI. Marshall Islands Jurisdiction Specific Module’, ‘Section PA. Palau Jurisdiction Specific Module’, and ‘Section VI. USVI Jurisdiction Specific Module to provide data the postpartum visit. This information is collected in the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire. To avoid duplicate data collection, this question is only asked in jurisdiction that do not currently have access to this data from PRAMS.

American Samoa

[ONLY ASK THIS QUESTION IF CHILD IS 3-14 YEARS OLD]

During the past 12 months, did this child have a vision screening?

☐ YES

☐ NO

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to 'Section AS. American Samoa Jurisdiction Specific Module’ to collect data on vision screening.

American Samoa, Federated States of Micronesia, Guam, RMI, Palau, and USVI

[ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD]

When your child was 0-12 months old, how did you most often lay them down to sleep?

☐ On his or her side

☐ On his or her back

☐ On his or her stomach

☐ DON’T KNOW

PREFER NOT TO ANSWER

Added: This question was added to 'Section AS. American Samoa Jurisdiction Specific Module’, ‘Section FM. FSM Jurisdiction Specific Module’, Section GM. Guam Jurisdiction Specific Module’, ‘Section MI. Marshall Islands Jurisdiction Specific Module’, ‘Section PA. Palau Jurisdiction Specific Module’, and ‘Section VI. USVI Jurisdiction Specific Module’ to better understand sleep position. To avoid duplicate data collection, this question is only asked in jurisdiction that do not currently have access to PRAMS data.

Guam

[ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEARS OLD AND IF BIOLOGICAL MOTHER]

For the next set of questions, please select the answer that comes closest to how you have felt since your most recent pregnancy. Since your new baby was born, how often have you…

	Always	Often	Sometimes	Rarely	Never
GM5a. felt down, depressed, or hopeless?	☐	☐	☐	☐	☐
GM5b. had little interest or little pleasure in doing things?	☐	☐	☐	☐	☐
GM5c. felt nervous, anxious, or on edge?	☐	☐	☐	☐	☐
GM5d. not been able to stop or control worrying?	☐	☐	☐	☐	☐

Revised: This question was revised in ‘Section GM. Guam Jurisdiction Specific Module’. There are less response options, and the wording was updated.

Guam

[ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

[IF POSTPARTUM CHECKUP=NO, DK, PNA] Did any of these things keep you from having a checkup after your most recent pregnancy?

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
GM6a. I didn’t have health insurance to cover the cost of the visit	☐	☐	☐	☐
GM6b. I felt fine and did not think I needed to have a visit	☐	☐	☐	☐
GM6c. I couldn’t get an appointment when I wanted one	☐	☐	☐	☐
GM6d. I didn’t have any transportation to get to the clinic or doctor’s office	☐	☐	☐	☐
GM6e. I had too many things going on	☐	☐	☐	☐
GM6f. I couldn’t take time off from work	☐	☐	☐	☐
GM6g. Something else, please specify	☐	☐	☐	☐

Revised: This question was revised in ‘Section GM. Guam Jurisdiction Specific Module’. The logic of the question was revised so only respondents who said NO, DK, or PNA to POSTPARTUM CHECKUP answered this question.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 6-11 or 12-17 YEARS OLD]

Does your child engage in any of the following water activities:

	YES	NO	Don’t Know/ Unsure	Prefer Not to Answer
MP7a. Go to the beach	☐	☐	☐	☐
MP7b. Go to a water park, water slide, or other water attraction	☐	☐	☐	☐
MP7c. Swim in a home pool	☐	☐	☐	☐
MP7d. Go fishing	☐	☐	☐	☐
MP7e. Go boating, sailing, water skiing/jet skiing, or surfing	☐	☐	☐	☐
MP7f. Go snorkeling or scuba diving	☐	☐	☐	☐

Revised: This question was revised in ‘Section MP. CNMI Jurisdiction Specific Module’. The question still asks about swim safety but has updated response options.

CNMI

The next few questions are about your child’s sleeping and eating habits.

[ONLY ASK THIS QUESTION IF CHILD IS 6-11 or 12-17 YEARS OLD]

DURING THE PAST WEEK, how many times did this child drink sugary drinks such as soda, fruit drinks, sports drinks, or sweet tea? Do not include 100% fruit juice.

____Number of times

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section MP. CNMI Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 6-11 or 12-17 YEARS OLD]

DURING THE PAST WEEK, how many times did this child eat vegetables? Include any that were fresh, frozen, or canned. Do not include French fries, fried potatoes, or potato chips.

____Number of times

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section MP. CNMI Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 6-11 or 12-17 YEARS OLD]

DURING THE PAST WEEK, how many times did this child eat fruit? Include any that were fresh, frozen, canned, or dried. Do not include juice.

____Number of times

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section MP. CNMI Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 6-11 or 12-17 YEARS OLD]

DURING THE PAST WEEK, how many hours of sleep did this child get on most weeknights?

____Number of hours

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section MP. CNMI Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 6-11 or 12-17 YEARS OLD]

ON MOST WEEKDAYS, how much time does this child spend playing outdoors? Include time spent playing in your yard or neighborhood, outside at school or child care, in a park, playground or other outdoor recreation area. Your best estimate is fine.

☐ Less than 1 hour

☐ 1 hour

☐ 2 hours

☐ 3 hours

☐ 4 or more hours

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section MP. CNMI Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 6-11 or 12-17 YEARS OLD]

ON AN AVERAGE WEEKEND DAY, how much time does this child spend playing outdoors? Include time spent playing in your yard or neighborhood, in a park, playground or other outdoor recreation area. Your best estimate is fine.

☐ Less than 1 hour

☐ 1 hour

☐ 2 hours

☐ 3 hours

☐ 4 or more hours

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section MP. CNMI Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 6-11 or 12-17 YEARS OLD]

Does your child have any of the following education plans established?

☐ IFSP – Individualized Family Services Plan

☐ IEP – Individual Education Plan

☐ 504 Plan

☐ None of the above [GO TO MP17]

☐ DON’T KNOW [GO TO MP17]

☐ PREFER NOT TO ANSWER [GO TO MP17]

Added: This question was added to ‘Section MP. CNMI Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 6-11 or 12-17 YEARS OLD]

[IF IFSP, IEP, 504] What was your level of involvement in the development of the IFSP, IEP or 504 Plan?

☐ Very involved

☐ Somewhat involved

☐ Not involved at all

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section MP. CNMI Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 6-11 or 12-17 YEARS OLD]

[IF IFSP, IEP, 504] How satisfied are you with the IEP, IFSP or 504 Plan?

☐ Very satisfied

☐ Satisfied

☐ Unsatisfied

☐ Very dissatisfied

☐ Not sure

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section MP. CNMI Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Other than you or other adults in your home, is there at least one other adult in this child’s school, neighborhood, or community who knows this child well and who they can rely on for advice or guidance?

☐ YES

☐ NO

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section MP. CNMI Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

CNMI

[ASK ALL RESPONDENTS]

The next few questions ask about the neighborhood where you currently live.

MP21. In your neighborhood, is/are there...

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
MP21a. sidewalks or walking paths?	☐	☐	☐	☐
MP21b. a park or playground?	☐	☐	☐	☐
MP21c. a recreation center, community center, or boys’ and girls’ club?	☐	☐	☐	☐
MP21d. a library or bookmobile?	☐	☐	☐	☐
MP21e. litter or garbage on the street or sidewalk?	☐	☐	☐	☐
MP21f. poorly kept or rundown housing?	☐	☐	☐	☐
MP21g. vandalism such as broken windows or graffiti?	☐	☐	☐	☐

Added: This question was added to ‘Section MP. CNMI Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

CNMI

To what extent do you agree with these statements about your neighborhood or community?

		Definitely Agree	Somewhat Agree	Somewhat Disagree	Definitely Disagree	DON’T KNOW	PREFER NOT TO ANSWER
MP22a. People in this neighborhood help each other out		☐	☐	☐	☐	☐	☐
MP22b. We watch out for each other’s children in this neighborhood		☐	☐	☐	☐	☐	☐
MP22c. This child is safe in our neighborhood		☐	☐	☐	☐	☐	☐
MP22d. When we encounter difficulties, we know where to go for help in our community		☐	☐	☐	☐	☐	☐
MP22e. This child is safe at school		☐	☐	☐	☐	☐	☐

Added: This question was added to ‘Section MP. CNMI Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Puerto Rico

[ONLY ASK ITEMS A-D IF CHILD IS 0-17 YEARS OLD; ASK ITEM E IF CHILD IS 0-1 YEARS OLD]

During your child's last well-child visit, did the doctor, nurse, or other health care professional talk to you about the following topics:

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
PR2a. Your child’s healthy eating habits	☐	☐	☐	☐
PR2b. Your child’s physical activity	☐	☐	☐	☐
PR2c. Your child’s oral health care	☐	☐	☐	☐
PR2d. Whether your child’s vaccinations are up to date	☐	☐	☐	☐
PR2e. Safe practices for placing your baby to sleep in a safe environment	☐	☐	☐	☐

Added: This question was added to ‘Section PR. Puerto Rico Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Puerto Rico

[ONLY ASK IF CHILD IS 0-1 YEARS OLD]

During your child’s last well-child visit, did the doctor, nurse, or other health care professional talk to you about the following topics?

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
PR3a. Your emotions after your baby was born	1 ☐	2 ☐	77 ☐	99 ☐
PR3b. What to do if you feel depressed or anxious	1 ☐	2 ☐	77 ☐	☐

Added: This question was added to ‘Section PR. Puerto Rico Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Puerto Rico

[ONLY ASK IF CHILD HAS SEEN A PROVIDER IN PAST 12 MONTHS]

Please indicate whether you believe your child’s healthcare has improved due to any of the following.

[INTERVIEWER NOTE: IF NEEDED, SAY “THERE ARE NO RIGHT OR WRONG ANSWERS HERE. WE ARE INTERESTED IN YOUR OPINION. PLEASE ANSWER TO THE BEST OF YOUR ABILITY.]

	Strongly Agree		Somewhat Agree	Neither Agree nor Disagree	Somewhat Disagree	Strongly Disagree	Not Applicable	DON’T KNOW	PREFER NOT TO ANSWER
PR4a. The doctor or nurse who treats your child		☐	☐	☐	☐	☐	☐	☐	☐
PR4b. The place where your child is usually cared for when he or she is sick, or when you or another caregiver needs to consult about his or her health		☐	☐	☐	☐	☐	☐	☐	☐
PR4c. The doctor or other health provider spending enough time with your child		☐	☐	☐	☐	☐	☐	☐	☐
PR4d. The doctor or other health care provider paying attention to what you have to say		☐	☐	☐	☐	☐	☐	☐	☐
PR4e. The doctor or other health care provider being sensitive to your family's values and customs		☐	☐	☐	☐	☐	☐	☐	☐
PR4f. The doctor or other health provider answering questions you have about your child		☐	☐	☐	☐	☐	☐	☐	☐
PR4g. The doctor or other health provider making you feel involved in the care of your child		☐	☐	☐	☐	☐	☐	☐	☐
PR4h. It was not difficult to get the necessary referrals		☐	☐	☐	☐	☐	☐	☐	☐
PR4i. You received all the help necessary to coordinate the care of your child.		☐	☐	☐	☐	☐	☐	☐	☐

Added: This question was added to ‘Section PR. Puerto Rico Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Puerto Rico

Where does your child perform physical activity most frequently?

☐ House

☐ School

☐ Park

☐ Sports Complex

☐ Gym

☐ Other, please specify: ____

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section PR. Puerto Rico Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Puerto Rico

What type of physical activity has your child done in the past 7 days? Check all that apply.

☐ Practice any sport

☐ Bicycle

☐ Skateboard

☐ Roller skates

☐ Walking

☐ Jogging

☐ Jump Rope

☐ Other, please specify: ____

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section PR. Puerto Rico Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Puerto Rico

[ONLY ASK IF RESPONDENT NOT CURRENTLY PREGNANT]

Have you given birth in the last 12 months?

☐ YES

☐ NO [GO TO PR23]

☐ DON’T KNOW [GO TO PR23]

☐ PREFER NOT TO ANSWER [GO TO PR23]

Added: This question was added to ‘Section PR. Puerto Rico Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Puerto Rico

[IF YES to PR19] Has a healthcare provider asked you a series of questions, either in person or on a form, to find out if you felt down, depressed, anxious, or irritable during the following periods?

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
PR20a. During your most recent pregnancy	☐	☐	☐	☐
PR20b. Since your new baby was born	☐	☐	☐	☐

Added: This question was added to ‘Section PR. Puerto Rico Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Puerto Rico

[IF YES to PR20a or PR20b]

As a result of these questions, did your health care provider refer you to a mental health provider?

☐ YES

☐ NO [GO TO PR23]

☐ DON’T KNOW [GO TO PR23]

☐ PREFER NOT TO ANSWER [GO TO PR23]

Added: This question was added to ‘Section PR. Puerto Rico Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Puerto Rico

[ONLY ASK IF REFERRED TO MENTAL HEALTH PROVIDER]

After being referred to a mental health provider, did you visit this provider?

☐ YES

☐ NO

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section PR. Puerto Rico Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Palau

When traveling in a vehicle, do you and your child/children always use a seatbelt?

☐ Yes, both my child and I always use a seatbelt.

☐ Yes, I always use a seatbelt, but my child does not.

☐ Yes, my child always uses a seatbelt, but I do not.

☐ No, neither my child nor I always use a seatbelt

☐ Other, please specify: ___________

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section PA. Palau Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Palau

When you make an appointment to see a primary care provider, how many days, on average, do you have to wait until the appointment takes place?

_____ days

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section PA. Palau Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Palau

When you make an appointment to see a dentist, how many days, on average, do you have to wait until the appointment takes place?

_____ days

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section PA. Palau Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Palau

In the past 12 months, have you had an annual check-up that included sexual and reproductive health services?

☐ Yes, I have had an annual check-up that included sexual and reproductive health services.

☐ Yes, I have had an annual check-up, but it did not include sexual and reproductive health services.

☐ No, I have not had an annual check-up in the past year.

☐ Other (please specify): ___________

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section PA. Palau Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Palau

Now, we have some final questions about you.

What is your race and/or ethnicity? Select all that apply.

Are you…

Hispanic or Latino?

☐ Yes

☐ No

[IF YES] Please describe your Hispanic or Latino background. Are you…?

☐ Mexican

☐ Puerto Rican

☐ Salvadoran

☐ Cuban

☐ Dominican

☐ Guatemalan

☐ Other Hispanic or Latino. Please describe your other Hispanic or Latino background. For example, Colombian, Honduran, Spaniard, etc.

Native Hawaiian or Pacific Islander?

☐ Yes

☐ No

[IF YES] Please describe your Native Hawaiian or Pacific Islander background. Are you…?

☐ Native Hawaiian

☐ Tongan

☐ Samoan

☐ Fijian

☐ Guamanian

☐ Chamorro

☐ Marshallese

☐ Saipanese

☐ Mortlockese

☐ Kosraen

☐ Carolinian

☐ Palauan

☐ Pohnpeian

☐ Yapese

☐ Chuukese

☐ Other Native Hawaiian or Pacific Islander background. Please describe your other Native Hawaiian or Pacific Islander background. For example, Tahitian, etc.

American Indian or Alaska Native?

☐ Yes

☐ No

[IF YES] Please describe your American Indian or Alaska Native background. For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of

Montana, Native Village of Barrow lnupiat Traditional Government, Nome Eskimo

Community, Aztec, Maya, etc.

Asian?

☐ Yes

☐ No

[IF YES] Please describe your Asian background. Are you…?

☐ Chinese

☐ Asian Indian

☐ Filipino

☐ Vietnamese

☐ Korean

☐ Japanese

☐ Other Asian. Please describe your other Asian background. For example, Pakistani, Hmong, Aghan, etc.

Black or African American?

☐ Yes

☐ No

[IF YES] Please describe your Black or African American background. Are you…?

☐ African American

☐ Jamaican

☐ Haitian

☐ Nigerian

☐ Ethiopian

☐ Somali

☐ Other Black or African American. Please describe your other Black or African American background. For example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.

Middle Eastern or North African?

☐ Yes

☐ No

[IF YES] Please describe your Middle Eastern or North African background. Are you…?

☐ Lebanese

☐ Iranian

☐ Egyptian

☐ Syrian

☐ Iraqi

☐ Israeli

☐ Other Middle Eastern or North African. Please describe your Middle Eastern or North African background. For example, Moroccan, Yemeni, Kurdish, etc.

White?

☐ Yes

☐ No

[IF YES] Please describe your White background. Are you…?

☐ English

☐ German

☐ Irish

☐ Italian

☐ Polish

☐ Scottish

☐ Other White. Please describe your other White background. For example, French, Swedish, Norwegian, etc.

Added: This question was added to ‘Section PA. Palau Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Palau

In what language do you feel MOST comfortable…

PA11a. speaking with your healthcare provider?

☐ English

☐ Palauan

☐ Filipino

☐ Other, please specify: ___________

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

PA11b. reading healthcare forms or instructions?

☐ English

☐ Palauan

☐ Filipino

☐ Other, please specify: ___________

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Added: This question was added to ‘Section PA. Palau Jurisdiction Specific Module’ to better capture data on the jurisdiction’s MCH Block Grant priorities.

Deleted Questions

Jurisdiction

Question Text

Summary

All

Is this child of Hispanic, Latino, or Spanish origin?

☐ No, not of Hispanic, Latino, or Spanish origin

☐ Yes, Mexican, Mexican American, Chicano

☐ Yes, Puerto Rican

☐ Yes, Cuban

☐ Yes, another Hispanic, Latino, or Spanish origin, please specify:

This question was deleted from ‘Section A. Screener’ for every jurisdiction.

All

[ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Are your child's immunizations up to date?

☐ YES

☐ NO

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section B. This Child’s Health’ from the Core Questionnaire for every jurisdiction.

All

[ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD]

In which position do you most often lay this baby down to sleep now?

☐ On his or her side

☐ On his or her back

☐ On his or her stomach

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section C. This Child as an Infant’ from the Core Questionnaire for every jurisdiction.

All

[ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Have this child’s doctors or other health care providers worked with you and this child to create a written plan to meet his or her health goals and needs?

☐ YES

☐ NO [GO TO E10]

☐ DON’T KNOW [GO TO E10]

☐ PREFER NOT TO ANSWER [GO TO E10]

[IF YES] does this plan identify specific health goals for this child and any health needs or problems this child may have and how to get these needs met?

☐ YES

☐ NO

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Did you and this child receive a written copy of this plan of care?

☐ YES

☐ NO

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

Is this plan currently up-to-date for this child?

☐ YES

☐ NO

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section E. Experience with This Child’s Health Care Providers’ from the Core Questionnaire for every jurisdiction.

American Samoa, RMI, and FSM

During the past 12 months, was this child ever covered by any kind of health insurance or health coverage plan? This includes medical savings accounts, supplemental health, and government funded or subsidized insurance programs.

☐ Yes, this child was covered all 12 months or, if under 1 year old, since birth [GO TO F4]

☐ Yes, but this child had a gap in coverage

☐ No

This question was deleted from ‘Section F. This Child’s Health Insurance Coverage’ from the Core Questionnaire for select jurisdictions.

All

Please indicate whether each of the following is a reason this child was not covered by health insurance during the past 12 months:

	YES	NO
F2a. Change in employer or employment status	☐	☐
F2b. Cancellation from inability to pay insurance fee	☐	☐
F2c. Dropped coverage because it was unaffordable	☐	☐
F2d. Dropped coverage because benefits were inadequate	☐	☐
F2e. Dropped coverage because choice of health care providers was inadequate	☐	☐
F2f. Problems with application or renewal process	☐	☐
F2g. Another reason, please specify	☐	☐

This question was deleted from ‘Section F. This Child’s Health Insurance Coverage’ from the Core Questionnaire for every jurisdiction.

American Samoa, RMI, and FSM

Is this child currently covered by any kind of health insurance or health coverage plan?

☐ YES

☐ NO [GO TO SECTION G]

☐ DON’T KNOW [GO TO SECTION G]

☐ PREFER NOT TO ANSWER [GO TO SECTION G]

This question was deleted from ‘Section F. This Child’s Health Insurance Coverage’ from the Core Questionnaire for select jurisdictions.

American Samoa, RMI, and FSM

Is this child covered by any of the following types of health insurance or health coverage plans? [Interviewer Note: Only read jurisdiction-specific insurance types for your jurisdiction].

	YES	NO
F3a. Private health insurance	☐	☐
F3b. Insurance through your (or your spouse’s) current or former employer or union	☐	☐
F3c. Medicaid, Medical Assistance, or any kind of government assistance plan (includes Guam Medical Indigent Program, Palau National Health Insurance Program, and Puerto Rico Government Health Plan)	☐	☐
F3d. Other government funded or subsidized insurance (includes Micronesia MiCare or Chuuk State, Marshall Islands Public Insurance, and Marshall Islands Supplemental Health Fund)	☐	☐
F3e. Medical savings account	☐	☐
F3f. CHIP (Children’s Health Insurance Program)	☐	☐
F3g. TRICARE or other military health care	☐	☐
F3h. Indian Health Service	☐	☐
F3i. Another type, please specify	☐	☐

This question was deleted from ‘Section F. This Child’s Health Insurance Coverage’ from the Core Questionnaire for select jurisdictions.

American Samoa, RMI, and FSM

How often does this child’s health insurance offer benefits or cover services that meet this child’s needs? Examples include dental or vision services, prescription medications, emergency room visits, maternity services, mental health services, and yearly check-ups or screenings.

☐ Always

☐ Usually

☐ Sometimes

☐ Never

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section F. This Child’s Health Insurance Coverage’ from the Core Questionnaire for select jurisdictions.

American Samoa, RMI, and FSM

How often does this child’s health insurance allow him or her to see the health care providers he or she needs?

☐ Always

☐ Usually

☐ Sometimes

☐ Never

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section F. This Child’s Health Insurance Coverage’ from the Core Questionnaire for select jurisdictions.

All

In an average week, how many hours do you or other family members spend providing health care at home for this child? Care might include changing bandages, or giving medication and therapies when needed.

☐ This child does not need health care provided on a weekly basis

☐ No at home care was provided by me or other family members

☐ Less than 1 hour per week

☐ 1-4 hours per week

☐ 5-10 hours per week

☐ 11 or more hours per week

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section G. Providing for This Child’s Health’ from the Core Questionnaire for every jurisdiction.

All

In an average week, how many hours do you or other family members spend arranging or coordinating health or medical care for this child, such as making appointments or locating services?

☐ This child does not need health care provided on a weekly basis

☐ No at home care was provided by me or other family members

☐ Less than 1 hour per week

☐ 1-4 hours per week

☐ 5-10 hours per week

☐ 11 or more hours per week

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section G. Providing for This Child’s Health’ from the Core Questionnaire for every jurisdiction.

All

[ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

During the past 12 months, how many times has this child’s school contacted you or another adult in your household about any problems he or she is having with school?

☐ NO TIMES

☐ 1 TIME

☐ 2 OR MORE TIMES

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section H. This Child’s Learning’ from the Core Questionnaire for every jurisdiction.

All

How many times has this child moved to a new address or location since he or she was born?

NUMBER OF TIMES

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section I. About You and This Child’ from the Core Questionnaire for every jurisdiction.

All

[If yes] Were any of this child’s health care visits by video or phone because of the coronavirus pandemic?

☐ YES

☐ NO

This question was deleted from ‘Section I. About You and This Child’ from the Core Questionnaire for every jurisdiction.

All

DURING THE PAST 12 MONTHS, did this child miss, delay or skip any PREVENTIVE check-ups because of the coronavirus pandemic?

☐ YES

☐ NO

This question was deleted from ‘Section I. About You and This Child’ from the Core Questionnaire for every jurisdiction.

All

DURING THE PAST 12 MONTHS, has this child’s regular daycare or other childcare arrangement been closed or unavailable at any time as a result of the coronavirus pandemic?

☐ YES

☐ NO

This question was deleted from ‘Section I. About You and This Child’ from the Core Questionnaire for every jurisdiction.

All

During your most recent pregnancy, did you have your teeth cleaned by a dentist or dental hygienist?

☐ YES

☐ NO

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section L. Health of Child’s Mother’ from the Core Questionnaire for every jurisdiction.

Guam

Since your new baby was born, did a doctor, nurse, or other health care worker talk with you about any of the things listed below?

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
GM1a. Breastfeeding my baby	☐	☐	☐	☐
GM1b. How long to wait before getting pregnant again	☐	☐	☐	☐
GM1c. Family planning services or using contraception	☐	☐	☐	☐
GM1d. Postpartum depression	☐	☐	☐	☐
GM1e. Resources in my community to support new parents	☐	☐	☐	☐
GM1f. Getting to and staying at a healthy weight after delivery	☐	☐	☐	☐
GM1g. How to quit or keep from smoking	☐	☐	☐	☐
GM1h. How to get the health care that my baby or I need	☐	☐	☐	☐

This question was deleted from ‘Section GM. Guam Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

Guam

[ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

Did you have a regular checkup about 4-6 weeks after giving birth?

☐ YES

☐ NO [GO TO GM3]

☐ DON’T KNOW [GO TO GM3]

☐ PREFER NOT TO ANSWER [GO TO GM3]

[IF YES] where did you go for your checkup?

☐ MY FAMILY DOCTOR’S OFFICE

☐ MY OB/GYN’S OFFICE

☐ HOSPITAL CLINIC

☐ HEALTH DEPARTMENT CLINIC

☐ OTHER, PLEASE SPECIFY

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section GM. Guam Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

Guam

For the next set of questions, please select the answer that comes closest to how you have felt since your most recent pregnancy.

GM3a. I have been able to laugh and see the funny side of things.

☐ As much as I always could

☐ Not quite so much now

☐ Definitely not so much now

☐ Not at all

GM3b. I have looked forward with enjoyment to things.

☐ As much as I ever did

☐ Rather less than I used to

☐ Definitely less than I used to

☐ Hardly at all

GM3c. I have blamed myself unnecessarily when things went wrong.

☐ Yes, most of the time

☐ Yes, some of the time

☐ Not very often

☐ No, never

GM3d. I have been anxious or worried for no good reason.

☐ No not at all

☐ Hardly ever

☐ Yes, sometimes

☐ Yes, very often

GM3e. I have felt scared or panicky for no very good reason.

☐ Yes, quite a lot

☐ Yes, sometimes

☐ No, not much

☐ No, not at all

GM3f. I have been so unhappy that I have had difficulty sleeping.

☐ Yes, most of the time

☐ Yes, sometimes

☐ Not very often

☐ No, not at all

GM3g. I have felt sad or miserable.

☐ Yes, most of the time

☐ Yes, sometimes

☐ Not very often

☐ No, not at all

GM3h. I have been so unhappy that I have been crying.

☐ Yes, most of the time

☐ Yes, quite often

☐ Only occasionally

☐ No, never

GM3i. The thought of harming myself has occurred to me.

☐ Yes, quite often

☐ Sometimes

☐ Hardly ever

☐ Never

This question was deleted from ‘Section GM. Guam Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

CNMI

Did you get prenatal care in the first trimester of your pregnancy? The first trimester is defined as weeks 1 through 12 of your pregnancy.

☐ YES

☐ NO

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section NM. CNMI Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD AND BIOLOGICAL MOTHER]

During your most recent pregnancy, were you on WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)?

☐ YES

☐ NO [GO TO NM6]

☐ DON’T KNOW [GO TO NM6]

☐ PREFER NOT TO ANSWER [GO TO NM6]

This question was deleted from ‘Section NM. CNMI Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD AND BIOLOGICAL MOTHER]

Since your youngest child was born, have you used WIC services for yourself or your child?

☐ Yes, only I am using WIC services

☐ Yes, both my child and I use WIC services

☐ Yes, only my child uses WIC services

☐ No

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section NM. CNMI Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

At any time during your most recent pregnancy or after delivery, did a doctor, nurse, or other health care worker talk with you about any of the things listed below? For each one, answer No if they did not talk with you about it or Yes if they did.

	YES	NO	Don’t Know	Prefer Not to Answer
NM6a. Breastfeeding my baby	☐	☐	☐	☐
NM6b. How long to wait before getting pregnant again	☐	☐	☐	☐
NM6c. Family planning services or using contraception	☐	☐	☐	☐
NM6d. Postpartum depression	☐	☐	☐	☐
NM6e. Resources in my community to support new parents	☐	☐	☐	☐
NM6f. Getting to and staying at a healthy weight after delivery	☐	☐	☐	☐
NM6g. How to quit or keep from smoking	☐	☐	☐	☐
NM6h. How to get the health care that my baby or I need	☐	☐	☐	☐

This question was deleted from ‘Section NM. CNMI Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEARS OLD AND IF BIOLOGICAL MOTHER]

For the next set of questions, please select the answer that comes closest to how you have felt after your most recent pregnancy?

NM7a. I have been able to laugh and see the funny side of things.

☐ As much as I always

☐ Not quite so much now

☐ Definitely not so much now

☐ Not at all

NM7b. I have looked forward with enjoyment to things.

☐ As much as I ever did

☐ Rather less than I used to

☐ Definitely less than I used to

☐ Hardly at all

NM7c. I have blamed myself unnecessarily when things went wrong.

☐ Yes, most of the time

☐ Yes, some of the time

☐ Not very often

☐ No, never

NM7d. I have been anxious or worried for no good reason.

☐ No not at all

☐ Hardly ever

☐ Yes, sometimes

☐ Yes, very often

NM7e. I have felt scared or panicky for no very good reason.

☐ Yes, quite a lot

☐ Yes, sometimes

☐ No, not much

☐ No, not at all

NM7f. I have been so unhappy that I have had difficulty sleeping.

☐ Yes, most of the time

☐ Yes, sometimes

☐ Not very often

☐ No, not at all

NM7g. I have felt sad or miserable.

☐ Yes, most of the time

☐ Yes, sometimes

☐ Not very often

☐ No, not at all

NM7h. I have been so unhappy that I have been crying.

☐ Yes, most of the time

☐ Yes, quite often

☐ Only occasionally

☐ No, never

NM7i. The thought of harming myself has occurred to me.

☐ Yes, quite often

☐ Sometimes

☐ Hardly ever

☐ Never

This question was deleted from ‘Section NM. CNMI Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

CNMI

[ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

Did you have a regular checkup about 4-6 weeks after giving birth?

☐ YES

☐ NO

☐ DON’T KNOW [GO TO NM9]

☐ PREFER NOT TO ANSWER [GO TO NM9]

[IF YES] where did you go for your checkup?

☐ My family doctor’s office

☐ My OB/GYN’s office

☐ Hospital clinic

☐ Health department clinic

☐ Another type, please specify

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

[IF YES] How did you feel about the care you got during your postpartum checkup?

	Satisfied	Not Satisfied	Don’t Know	Prefer Not to Answer
NM8a. The amount of time you had to wait	☐	☐	☐	☐
NM8b. The amount of time the doctor, nurse, or health care worker spent with you	☐	☐	☐	☐
NM8c. The advice you got on how to take care of yourself	☐	☐	☐	☐
NM8d. The understanding and respect shown toward you as a person	☐	☐	☐	☐

[IF NO] Did any of these things keep you from having a checkup after your most recent pregnancy?

	YES	NO	Don’t Know	Prefer Not to Answer
NM8_no_a. I didn’t have health insurance to cover the cost of the visit	☐	☐	☐	☐
NM8_no_b. I felt fine and did not think I needed to have a visit	☐	☐	☐	☐
NM8_no_c. I couldn’t get an appointment when I wanted one	☐	☐	☐	☐
NM8_no_d. I didn’t have any transportation to get to the clinic or doctor’s office	☐	☐	☐	☐
NM8_no_e. I had too many things going on	☐	☐	☐	☐
NM8_no_f. I couldn’t take time off from work	☐	☐	☐	☐
NM8_no_g. Something else, please specify	☐	☐	☐	☐

This question was deleted from ‘Section NM. CNMI Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

CNMI

Thinking about the last time you took your child for sick-child care, well-child check-ups, physical exams, hospitalizations or any other kind of medical care, was your child's doctor a man or a woman?

☐ Man

☐ Woman

☐ Have not taken child for medical care

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section NM. CNMI Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

CNMI

When your child rides in an infant car seat, is he or she usually in the front or back seat of the car, truck, or van?

☐ FRONT SEAT

☐ BACK SEAT

☐ NEVER RIDES IN A CAR [GO TO END]

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section NM. CNMI Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

CNMI

When your child rides in an infant car seat, is he or she usually facing forward or facing the rear of the car, truck, or van?

☐ FACING FORWARD

☐ FACING THE REAR

☐ NEVER RIDES IN A CAR [GO TO END]

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section NM. CNMI Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

CNMI

Does the car, truck, or van that your child usually rides in have an airbag on the passenger side?

☐ YES

☐ NO

☐ NEVER DRIVE OR RIDE IN A CAR [GO TO END]

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section NM. CNMI Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

CNMI

During the last 3 months of your most recent pregnancy, how often did you wear a seat belt when you drove or rode in a car?

☐ Always

☐ Often

☐ Sometimes

☐ Rarely

☐ Never

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section NM. CNMI Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

Palau

[ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Has your child ever completed the Ages and Stages Questionnaire (ASQ) from their doctor or another professional?

☐ YES

☐ NO

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section PA. Palau Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

Palau

[ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

The next few questions are about your health during and post pregnancy.

During your most recent pregnancy, did a doctor, nurse, or other health care worker talk with you about any of the things listed below? Please count only discussions, not reading materials or videos. For each one, check No if no one talked with you about it or Yes if someone did.

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
Foods that are good to eat during pregnancy	☐	☐	☐	☐
Exercise during pregnancy	☐	☐	☐	☐
Programs or resources to help me gain the right amount of weight during pregnancy	☐	☐	☐	☐
Programs or resources to help me lose weight after pregnancy	☐	☐	☐	☐

This question was deleted from ‘Section PA. Palau Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.

Palau

[ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

How much weight did you gain during your most recent pregnancy?

LBS OR KILOS

☐ I DIDN’T GAIN ANY WEIGHT DURING MY PREGNANCY

☐ DON’T KNOW

☐ PREFER NOT TO ANSWER

This question was deleted from ‘Section PA. Palau Jurisdiction Specific Module’ in alignment with updates to the jurisdiction’s MCH Block Grant priorities.