Postpartum Survey - 12 months

_{ATTACHMENT 3G}

_{Postpartum Survey- 12 months (includes Food Frequency Questionnaires)}

Form Approved:

OMB No. 0923-xxxx

Exp. Date xx/xx/20xx

Participant Number:

Version 1

SURVEY at 12 MONTHS

INTERVIEWERS: PLEASE PRINT CLEARLY]

_{Date of Interview:}

_{Interviewer Name:}

_{Location of Interview:}

Is there any change in your contact information since we last spoke to you?

 Yes  No  Don’t Know

UPDATED CONTACT INFORMATION Mailing Address

_{Telephone Number – Home Cell Message}

Has the person who is providing care for your baby changed since we last spoke to you?

 Yes

 No

 Don’t know

 Refused

If yes, may we contact them to do baby’s growth and development questionnaires if you are unavailable?

If you don’t mind if we contact them please provide their name and contact information below: Name

_{Phone number}

Public reporting burden of this collection of information is estimated to average 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX).

1

_{Participant Number:}

_{Version 1}

CURRENT BREASTFEEDING PRACTICES

1. Are you currently breastfeeding your baby?

 No, [ skip to 3.]  Refused

_{ Yes If yes, 1a. Number of times breastfeed baby per day}

2. Do you currently feed your baby exclusively (ONLY) with breast milk?

No  Refused

 Yes [stop here]

USE AND PREPARATION OF INFANT FORMULA

3. Do you use baby formula to feed your baby?

 No, [ skip to 5.]  Refused

 Yes If yes, specify below:

_{3a. Brand of baby formula}

_{3b. Number of times per day}

4. Do you use water to mix or prepare baby formula?

 No  Refused

 Yes If yes, specify type of water below:

4a. Type of water used to prepare baby formula

 Unfiltered tap water

 Filtered tap water

 Bottled water

_{ Other → 4b. Specify}

CESSATION OF BREASTFEEDING

5. Have you completely stopped breastfeeding?

 No  Refused

 Yes If Yes, 5a. How old was your baby when you completely stopped breastfeeding?

_{months weeks}

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_{Participant Number:}

_{Version 1}

INTRODUCTION OF FOODS

6. Do you feed your baby milk (other than breast milk or formula), like cow’s milk, whole milk, soy milk, or Lactaid milk? This includes drinking milk or putting milk in cereal. This does not include using milk in recipes.

 No  Refused

_{ Yes → 6a. If yes, What type of other milk?}

7. Do you feed your baby cereal, including baby cereal, on a daily basis?

 No  Refused

 Yes → 7a. If yes, on a daily basis since he/she was months weeks old

8. Do you feed your baby pureed food on a daily basis? This includes commercial or homemade baby food.

 No  Refused

 Yes → 8a. If yes, on a daily basis since he/she was months weeks old

9. Do you feed your baby solid foods?

 No  Refused

 Yes → 9a. If yes, on a daily basis since he/she was months weeks old

FOOD SOURCES

10. Do you participate in the WIC program?

 No  Refused

 Yes → 10a. If yes, Which foods do you obtain for your baby using WIC coupons?

HOME QUESTIONS AND OBSERVATIONS

Questions 11 through 20 should be asked of Mom or care giver. 21 through 29 are observations and should be recorded by the interviewer.

11. About how often does your child have a chance to get out of the house (either by himself/herself, or with an older person)?

 Not at all

 About once a month or less

 A few times a month

 About once a week

 4 or more times a week

_{ Every day}

3

_{Participant Number:}

_{Version 1}

12. About how many children’s books does your child have?

 None

 1 or 2 books

 3 to 9 books

 10 or more books

13. How often do you get a chance to read stories to your child?

 Never

 Several times a year

 Several times a month

 Once a week

 About 3 times a week

 Every day

14. About how often do you take your child to the grocery store?

 Twice a week or more

 Once a week

 Once a month

 Hardly ever

15. About how many, if any, cuddly, soft, or role-playing toys (like a doll) does your child have? (May be shared with sister or brother.)

NUMBER OF TOYS

16. About how many, if any, push or pull toys does your child have? (May be shared with sister or brother.)

NUMBER OF TOYS

17. Some parents spend time teaching their children new skills while other parents believe that children learn best on their own. Which of the following best describes your attitude?

 “Parents should always spend time teaching their children.”

 “Parents should usually spend time teaching their children.”

 “Parents should usually allow their children learn on their own.”

 “Parents should always allow their children learn on their own.”

18. How often does your child eat a meal with both mother and father (step-father or father-figure)?

 More than once a day

 Once a day

 Several times a week

 About once a week

 About once a month

 Never

_{ No father, step-father, or father-figure}

4

_{Participant Number:}

_{Version 1}

19. Children seem to demand attention while their parents are busy, doing housework, for example.

How often do you talk to your child while you are working?

 Always talk to child when I’m working

 Often talk to child when I’m working

 Sometimes talk to child when I’m working

 Rarely talk to child when I’m working

 Never talk to child when I’m working

20. Sometimes kids mind pretty well and sometimes they don’t. About how many times, if any, have you had to spank your child in the past week?

NUMBER OF TIMES

 Did not spank last week

OBSERVATIONS

21. Mom / care giver spontaneously vocalized to/conversed with child at least twice.

 Yes  No

22. Mom / care giver responded verbally to child.  Yes  No

23. Mom / care giver showed physical attention to child.  Yes  No

_{24. Mom / care giver did not spank child.  Yes  No}

25. Mom / care giver did not interfere/restrict child more than 3 times.	 Yes	 No
26. Mom / care giver provided appropriate toys/activities to child. 27. Mom / care giver kept child in view.  Yes	 Yes  No	 No
28. Play environment is safe (home or building).  Yes	 No

PERCEIVED STRESS SCALE

The following questions ask about Mom’s feelings and thought during the last month.

29. In the last month, how often have you felt that you were unable to control the important things in your life?

 Never

 Almost never

 Sometimes

 Fairly often

 Very often

_{ No answer}

5

_{Participant Number:}

_{Version 1}

30. In the last month, how often have felt confident about your ability to handle your personal problems?

 Never

 Almost never

 Sometimes

 Fairly often

 Very often

 No answer

31. In the last month, how often have you felt that things were going your way?

 Never

 Almost never

 Sometimes

 Fairly often

 Very often

 No answer

32. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

 Never

 Almost never

 Sometimes

 Fairly often

 Very often

_{ No answer}

6

FOOD FREQUENCY QUESTIONNAIRE

Please tell me how often on average you have eaten a serving of each of the following foods during the past 4 weeks. If you usually eat more than a serving at a time, please tell me about how much you eat at a time.

_Dairy

1. An 8-ounce glass of skim or low-fat milk. Not whole milk. Skim or low fat milk.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

2. An 8-ounce glass of whole milk.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

3.1 cup of yogurt.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

4.½ cup of ice cream.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

5.½ cup of cottage cheese or ricotta cheese.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

6. 1 slice or 1 ounce of some other kind of cheese, like American Cheddar. Please count cheese that you ate either alone or as part of another dish.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

7. 1 pat (teaspoon) of margarine added to food or bread. Don’t count margarine used in cooking.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

8.1 pat (teaspoon) of butter added to food or bread. Don’t count butter used in cooking.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

_Fruits

9. 1 fresh apple or pear.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

10. 1 orange, 1 tangerine or ½ grapefruit.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

11. 1 small glass of orange juice or grapefuit juice..

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

12. 1 fresh or ½ cup canned peaches, apricots, plums or nectarines.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

13. 1 banana.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

14.½ cup of papaya or mango.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

15.½ cup of some other fresh, frozen or canned fruit.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

_Vegetables

16. 1 tomato or 1 small glass of tomato juice.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

17.½ cup of string beans.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

18.½ cup of broccoli.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

19.½ cup of cabbage, cauliflower, or Brussels sprouts.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

20.½ raw carrot or 2-4 raw carrot sticks.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

21.½ cup of cooked carrots.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

22. 1 ear of corn or ½ cup frozen or canned corn.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

23.½ cup of fresh, frozen, or canned peas or lima beans.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

24.½ cup of sweet potatoes or yams.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

25.½ cup of cooked spinach, collard greens, kale or mustard greens.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

26.½ cup of baked or dried beans or lentils.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

27. ½ cup of yellow (winter) squash or pumpkin.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

_{Meat and Fish}

28.1 egg.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

29. 4 to 6 ounces of chicken or turkey, with skin.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

30. 4 to 6 ounces of chicken or turkey, without skin.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

31. 2 slices of bacon.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

32. 1 hot dog.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

33. 1 slice of processed meat, like salami or bologna, or a small piece of sausage.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

34. 3 to 4 ounces of liver.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

35. 1 hamburger patty.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

36. Beef, pork or lamb, as a sandwich or in a mixed dish, like a stew or casserole or in lasagna.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

37.4 to 6 ounces of beef, pork or lamb, as a main dish, like steak, roast or ham.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

38. 3 to 5 ounces of fish. Remember to count canned fish, like tuna fish.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

_{Sweets, Cereal and Baked Goods}

39.1 ounce of chocolate.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

40.1 ounce of candy without chocolate.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

41.1 slice of homemade pie.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

42.1 slice of store-bought pie.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

43. 1 slice of cake.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

44.1 cookie.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

45.1 cup of cold breakfast cereal.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

46.1 cup of hot breakfast cereal.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

47.1 slice of white bread. Count pita bread.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

48.1 slice of dark bread. Count wheat pita bread.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

_{Other Foods}

49. 4 ounces of French fried potatoes.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

50.1 baked or boiled potato or 1 cup mashed potatoes.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

51.1 cup of plantain, green banana, yucca or ñame.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

52.1 cup of rice or pasta, like spaghetti or noodles.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

53.1 small bag or 1 ounce of potato chips or corn chips.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

54. 1 small packet or 1 ounce of nuts.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

55.1 tablespoon of peanut butter.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

56.1 tablespoon of oil and vinegar dressing, like Italian.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

_Beverages

57.1 cup of coffee. Don’t count decaffeinated coffee.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

58.1 cup of tea. Don’t count herbal or decaffeinated tea.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

59. 1 glass, bottle, or can of beer (or malt liquor).

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

60.1 glass or can of low-calorie carbonated beverage, like Diet Coke.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

61.1 glass or can of carbonated beverage with sugar, like Coke or Pepsi.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

62. 1 glass of Hawaiian Punch, fruit punch, lemonade or other fruit drink.

 Never

 1-3 times in the past 4 weeks

 1 per week

 2-4 per week

 5- 6 per week

 1 per day

 2-3 per day

 4-5 per day

 6 or more per day

_{Other Eating Habits}

63. Are there any other foods that you usually eat at least once per week that I did not mention?

 No

 Yes

If yes, ask and record in the table below. What foods are these?

For each food, ask:

What is the usual serving size that you eat each time you have that?

If the respondent has difficulty, ask her to point out the size using the food model. About how many servings per week do you eat of that?

Other foods eaten at least once a week Usual serving size # Servings per week

_63a.

_{63 b.}

_{63 c.}

_{63 d.}

_63e.

_{63 f.}

_{63 g.}

64. In all, about how many teaspoons of sugar do you add to your drinks or food each day?

teaspoons

65. How much of the visible fat on your beef, pork or lamb do you remove before eating?

 Remove all visible fat

 Remove most of fat

 Remove small part of fat

 Remove none of fat

 Not applicable, do not eat meat

66. What kind of fat do you usually use for frying and sautéing at home? Don’t count “Pam”- type sprays.

 Real butter

 Regular margarine

 Reduced-fat margarine

 Vegetable oil (including olive oil)

 Vegetable shortening

 Lard

 Not applicable, do not use fat

 Don’t know/Does not cook

67. What kind of fat do you usually use for baking at home?

 Real butter

 Regular margarine

 Reduced-fat margarine

 Vegetable oil (including olive oil)

 Vegetable shortening

 Lard

 Not applicable, do not use fat

 Don’t know/Does not cook

68. How often do you eat food that is fried at home? Don’t count food fried using “Pam”-type sprays.

 Never or less than once per week

 1-3 times per week

 4-6 times per week

 once per day

 2 or more times per day

69. How often do you eat fried food away from home, such as from a restaurant or fast-food place? Think about foods like French fries, fried chicken, or fried fish.

 Never or less than once per week

 1-3 times per week

 4-6 times per week

 once per day

 2 or more times per day

As you answer the following questions, please think carefully about how you usually ate over the last 4 weeks.

70. When you ate bread, how often did you eat whole-grain breads, such as whole wheat, whole-grain rye and multi-grain?

 Never or does not eat bread

 Seldom

 Sometimes

 Often

 Almost always

 Does not know

71. When you ate breakfast cereal, how often did you eat brands that were high in fiber? These are cereals such as Cheerios, All Bran, Bran Flakes, Shredded Wheat, Oatmeal and Grapenuts.

 Never or does not eat cereal

 Seldom

 Sometimes

 Often

 Almost always

 Does not know

72. When you drank milk as a beverage, was it usually:

 Does not drink milk

 Whole milk

 2% milk

 1% milk

 Nonfat/skim milk

 Does not know