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Visit Type: 6 Month SAQ (Infant Feeding)

Target: Mother

OMB Control Number: 0925-0593

OMB Expiration Date: July 13, 2013

Recruitment Strategy Substudy

Event Name(s):

6-Month Mother SAQ (EH, PB, HI)

Instrument Name(s) and Versions:

6-Month Mother SAQ (EH, PB, HI)– 1.0

Recruitment Groups:

Enhanced Household, Provider-Based, High Intensity

TABLE OF CONTENTS

IN INTERVIEW INTRODUCTIOn 3

CFQ Child feeding questionnaire 4

NOTE: THE SAQS MAY BE COMPLETED IN EITHER A PAPI OR CASI MODE

Interview Introduction

INTERVIEWER INSTRUCTION: IF COMPLETED AS A PAPI, ENTER THE PARTICIPANT ID ON THE INSTRUMENT

(TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IN001 Thank you for agreeing to participate in the National Children’s Study. This self-administered questionnaire will take about 10 minutes to complete. There are questions about your child’s diet.

Your answers are important to us. There are no right or wrong answers. You can skip over any question. We will keep everything that you tell us confidential.

Child Feeding Questionnaire

CFQ001 1. First, we will ask about the milk, formula, and food your child has eaten.

CFQ003 2. Did you ever breast feed your baby?

Yes

No GO TO QUESTION 4

CFQ005 3. Are you currently breast feeding your baby?

Yes

No

CFQ007 4. Did you ever fed your baby pumped or expressed breast milk?

Yes

No GO TO QUESTION 6

CFQ009 5. Are you currently feeding your baby pumped or expressed breast milk?

Yes GO TO QUESTION 7

No

CFQ011 6. How old was your baby when you completely stopped feeding your baby breast milk?

Never fed breast milk Go to Question 12

Age in weeks (if younger than 1 month): GO TO QUESTION 12

Age in months (if older than 1 month): GO TO QUESTION 12

CFQ012 In the past 7 days, how often was your baby fed each item listed below?

Include feedings by everyone who feeds the baby and include snacks and night-time feedings. If your baby was fed the item once a day or more, write the number of feedings per day in the first column. If your baby was fed the item less than once a day, write the number of feedings per week in the second column. Fill in only one column for each item. If your baby was not fed the item at all during the past 7 days, write 0 in the second column.

	Number of Feedings per Day	Number of Feedings per Week
Breast milk (include breast fed and expressed or pumped breast milk)? (BREAST_DAY)/(BREAST_WEEK)	_________	_________
Formula? (FORMULA_DAY)/(FORMULA_WEEK)	_________	_________
Cow’s milk? (COW_MILK_DAY)/(COW_MILK_WEEK)	_________	_________
Other milk (soy milk, rice milk, goat milk)? (MILK_OTH_DAY)/(MILK_OTH_WEEK)	_________	_________

CFQ013 7. In the past 7 days, about how often was your baby fed pumped or expressed breast milk? Include feedings by everyone who feeds the baby and include snacks and night-time feedings.

Never GO TO QUESTION 12

1 time per week

2 to 4 times per week

Nearly every day

1 to 3 times per day

More than 4 times per day

CFQ015 8. In the past 7 days, about how long was your breast milk usually stored in the refrigerator before it was fed to your baby? (Include cooler with cold source such as freezer packs).

1 day or less

2-3 days

4-5 days

More than 6 days

DID NOT STORE BREAST MILK IN REFRIGERATOR

CFQ017 9. In the past 7 days, about how long was your breast milk usually kept at room temperature and then fed to your baby?

Less than 2 hours

2-4 hours

5-8 hours

More than 8 hours

DID NOT KEEP BREAST MILK AT ROOM TEMPERATURE

CFQ023 12. How old was your baby when (he/she) was first fed formula on a daily basis?

Never fed formula  Go to Question 23

Less than one week

7 to 13 days

14 to 31 days

More than 31 days

CFQ027 14. Was the formula fed to your baby within the past 7 days with iron or a low iron formula?

With iron

Low iron

CFQ031 15. Was the formula fed to your baby within the past 7 days ready-to-feed, liquid concentrate, powder from a can that makes more than one bottle, or powder from single serving packets? (Mark all that apply.)

Ready-to-feed

Liquid concentrate

Powder from a can that makes more than one bottle

Powder from single serving packets

CFQ032 If your baby was ONLY fed ready-to-feed formula GO TO QUESTION 19.

CFQ034 16. When the formula was mixed, was it made according to the directions on the formula label?

Yes GO TO QUESTION 17

No

When the formula was mixed, how much formula and how much water were used?

	Amount	Measurement Unit
Formula		Tablespoon Teaspoon Ounce Cup Packet Formula Can
Water		Ounces Cups Formula Can

CFQ036 17. During the past 7 days, what types of water have you and others who care for your baby used for mixing your baby’s formula? (Mark all that apply.)

Tap water from the cold faucet

Warm tap water from the hot faucet

Bottled water

No water used  GO TO QUESTION 19

CFQ038 18. In the past 7 days, was the water used to mix the formula ALWAYS boiled?

Yes

No

CFQ040 19. In the past 7 days, on the average, how many ounces of formula did your baby drink at each feeding?

. Ounces

CFQ044 21. Now think about how you cleaned your hands when you were preparing formula. During the past 7 days, did you never, sometimes, most of the time, or always:

	Never	Sometimes	Most of the Time	Always
a. Rinse hands with water only
b. Wipe hands only
c. Wash hands with soap
d. Use a hand sanitizer (such as gel or wipes)
e. Prepare formula without cleaning your hands

CFQ048 23. In the past 7 days, about how often did your baby drink from each of the following types of bottles and cups?

	Never	Sometimes	Most of the Time	Always
a. Plastic baby bottle with disposable bottle liner
b. Plastic baby bottle without disposable liner
c. Other plastic bottle (for example, a water bottle)
d. Glass baby bottle
e. Plastic “no spill” cup

CFQ050 24. Has your baby used a pacifier in the past 7 days?

Yes

No

CFQ052 25. Has your baby ever been fed cow’s milk that was not sold especially for babies? (This includes whole, lowfat, nonfat, or chocolate milk.)

Yes

No GO TO QUESTION 27

CFQ054 26. How old was your baby when he/she was first fed cow’s milk that was not sold especially for babies?

Age in days (if younger than two weeks):

Age in weeks (if older than two weeks):

CFQ056 27. Have you ever fed your baby fruit juice that was not sold especially for babies?

Yes

No GO TO QUESTION 30

CFQ058 28. How old was your baby when he/she was first fed fruit juice that was not sold especially for babies?

Age in days (if younger than two weeks):

Age in weeks (if older than two weeks):

CFQ060 29. About how often was the fruit juice fortified with calcium?

Always

Sometimes

Rarely

Never

Don’t know

CFQ062 30. Now think about fruits, vegetables, and meats that may have been fed to your baby in the past 7 days. How often was each of the foods your baby ate commercial baby food? (Commercial baby food is food sold for babies. Foods that are NOT commercial baby food are table foods your whole family eats, foods you made especially for your baby, fresh fruit, and fruit juices that are not sold especially for babies.)

Type of Commercial Baby Food	Always	Usually	Sometimes	Never	Not Fed to My Baby
a. Fruit and vegetable juice
b. Fruit
c. Vegetable
d. Meat, chicken and turkey
e. Combination dinner (for example, Spaghetti Dinner, Pasta and Vegetable Dinner, or a Turkey and Rice Dinner)

CFQ064 31. During the past 7 days, were the baby foods your baby ate always, sometimes, rarely, or never organic baby foods?

Always

Sometimes

Rarely

Never

Don’t know

CFQ066 32. Which of the following supplements was your child given at least three days a week during the past 2 weeks? (Mark all that apply.)

Fluoride

Iron

Vitamin D

Other vitamins or supplements—specify: ________________________________

None  GO TO QUESTION 34

CFQ068 33. Were the supplements you gave your baby in the form of drops or pills?
[NOTE: MARK CRUSHED PILLS MIXED WITH LIQUID AS “PILLS”.]

Drops

Pills

CFQ070 34. Was your baby given any herbal or botanical preparations or any kind of tea or home remedy in the past 7 days? Do not count preparations put on the baby’s skin or anything the baby may have gotten from breast milk after you took an herbal or botanical preparation.

Yes

No GO TO LAST PAGE

CFQ071 35. Please write in the name of all of the kinds of herbal or botanical preparations, teas or home remedies your baby was given in the past 7 days.

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CFQ073 (TIME_STAMP_2) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Thank you for participating in the National Children’s Study and for taking the time to complete this survey.

INTERVIEWER INSTRUCTION: IF SAQ IS COMPLETED AS A PAPI, SCs MUST PROVIDE INSTRUCTIONS AND A BUSINESS REPLY ENVELOPE FOR RESPONDENT TO RETURN