Form 1 Safety Net Consumer Survey R1

HEALTHY PREGNANCY AND PARENTING SURVEY

ROUND 1: PREGNANT WOMEN

Prepared by Mathematica Policy Research

OMB Number: 0915-0347

Expiration Date: 02/28/2015

Public Burden Statement:  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 project is 0915-0347.  Public reporting burden for this collection of information is estimated to average 20 minutes 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 10-49, Rockville, MD 20857.

Table of Contents

Section Page

A. Programmer Instructions 1

B. CONTACT (B1 - sample member; b2 - parent/guardian) 2

C. Consent 18

D. TEXT4BABY ENROLLMENT AND USE OF SERVICES 22

E. TEXT4BABY DISENROLLMENT AND NEVER ENROLLMENT 31

F. satisfaction with text4baby 35

G. DELETED.

H. HEALTH CARE ACCESS, UTILIZATION, KNOWLEDGE, AND BEHAVIOR 39

I. health status 50

J. participant background 52

K. future contact information 58

L. survey backend 65

A. Programmer Instructions

Data from Sample File

S1. SAMPLE MEMBER’S FULL NAME [FULLNAME]

S2. SAMPLE MEMBER’S FIRSTNAME [FIRSTNAME]

S3. SAMPLE MEMBER’S PHONE NUMBER

S4. SAMPLE MEMBER’S DATE OF BIRTH

S5. STATE HEALTH INSURANCE NAME

1 = CHIP State Name

IF STATE1 (GA) = FILLPeachCare for Kids

IF STATE2 (CA) = FILL Healthy Families Program or County Medical Services Program (CMSP)

IF STATE3 (NY) = FILL Child Health Plus (CHPlus)

IF STATE4 (IL) = FILL All Kids

2 = Medicaid State Name

IF STATE1 (GA) = FILL Medicaid

IF STATE2 (CA)= FILL Medi-Cal or County Medical Services Program (CMSPP)

IF STATE3 (NY) = FILL Medicaid or Family Health Plus program

IF STATE4 (IL) = FILL FamilyCare

S6. HC NAME

S7. Sign up DATE: MM/DD/YYYY

S8. Parental permission obtained = 1

S9. Call to…

Call to	last status	start at
1. first call to sample member	New	docallback = no
2. callback to sample member	800 – 820 (callback)	docallback = yes
3. CALLBACK USING TTY	calltty = 1	GO TO DOCALLBACK = YES

S10. CENTER CONSENT MODEL

Model 1 (consent)

Model 2 (permission)

S11. Date of consent/Date of permission

S12. Due date: MM/DD/YYYY

B. contact

B.1 sample member contact

Docallback = No

AUTOFILL INTVNAME

S1 = FULLNAME

S2 = FIRSTNAME

Hello. Hello, my name is [INTVNAME]. I am calling on behalf of the U.S. Department of Health and Human Services (HHS). May I please speak to [FULLNAME]?

SPEAKING TO [FIRSTNAME] 1 Go to SampMemb

[FIRSTNAME] COMES TO THE PHONE 2 Go to SampMemb

PERSON ASKS WHAT CALL IS ABOUT 3 Go to Whatabout

NEED TO CALLBACK 4 Go to Callback

[FIRSTNAME] HAS A HEALTH PROBLEM 5 Go to HealthProb

[FIRSTNAME] IS IN AN INSTITUTION 6 Go to Institution

[FIRSTNAME] HAS MOVED 7 Go to KnowWhere

[FIRSTNAME] DOES NOT SPEAK ENGLISH 8 Go to Lang

NEVER HEARD OF [FULLNAME]/WRONG # 9 Go to End 1

HUNG UP DURING INTRODUCTION 10 Status 640, Exit

REFUSED r Status 220, Exit

HELLO = 3

S2 = FIRST NAME

If CENTER = Model 1: Recently [FIRST NAME] signed up to take part in a brief health survey.

If CENTER = Model 2: I am calling to ask [FIRST NAME] to take part in a brief health survey.

WhatAbout [Recently [FIRST NAME] signed up to take part in a brief health survey.]/[I am calling to ask [FIRST NAME] to take part in a brief health survey. May I speak with her now?

[FIRSTNAME] COMES TO THE PHONE 1 Go to SampMemb

NEED TO CALLBACK 2 Go to Callback

[FIRSTNAME] HAS HEALTH PROBLEM/IS

DECEASED 3 Go to HealthProb

[FIRSTNAME] IS IN AN INSTITUTION 4 Go to Institution

[FIRSTNAME] MOVED 5 Go to KnowWhere

[FIRSTNAME] DOES NOT SPEAK ENGLISH 6 Go to Lang

[FIRSTNAME] DIDN'T RECEIVE LETTER 7 Go to NoLetter

HUNG UP DURING INTRODUCTION 8 Status 640, Exit

SUPERVISOR REVIEW 9 Status 380, Exit

REFUSED r Status 220, Exit

Hello = 5 OR WhatAbout = 3

HealthProb. ENTER TYPE OF HEALTH PROBLEM.

HEARING PROBLEM 1 Go to AmpTTY

SPEECH PROBLEM 2 Go to AmpTTY

PHYSICAL PROBLEM 3 Go to CallLater

COGNITIVE PROBLEM 4 Go to End 2

IN A COMA 5 Go to End 3

DECEASED 6 Go to Deceased

REFUSED r Status 210, Exit

HealthProb = 1 OR 2

S2 = FIRSTNAME

AmpTTY. I can get on a phone that will amplify my voice or [FIRSTNAME]’s voice, or we could use a TTY service. Would either of these help her to complete the interview?

YES - USE AMPLIFIER PHONE 1 Go to RespAvail

YES - USE TTY CAPABILITY 2 Go to RespAvail

NO 0 Go to End 4

DON’T KNOW d Go to Callback

REFUSED r Go to End 4

amptty = 1 or 2

S2 = FIRSTNAME

RespAvail. Is [FIRSTNAME] available now?

YES 1

NO 0 Go to Callback

PROGRAMMER: If AmpTTY = 1, GoTo AmpPhone, else Go to CallTTY

amptty = 1 AND RESPAVAIL = 1

AmpPhone. Please hold while I get the amplifier phone.

INTERVIEWER: SET UP AMPLIFIER/WEAK SPEECH EQUIPMENT AND ASK GATEKEEPER TO CALL [FIRSTNAME] TO THE PHONE.

[FIRSTNAME] COMES TO THE PHONE 1 Go to SampMemb

NEED TO CALLBACK 2 Go to Callback

AMPTTY = 2 AND respavail = 1

CallTTY. I will call back in a few minutes after I have the help of the TTY operator.

ARRANGE CALL WITH OPERATOR 1 Go to SampMemb

UNSUCCESSFUL -- NEED TO CALLBACK 2 Go to Callback

healthprob = 3

S2 = FIRSTNAME

CallLater. Will [FIRSTNAME] be able to talk on the telephone if I call back in a week or two?

YES/MAYBE – CALLBACK 1 Go to Callback

NO 0 Go to End 4

DON’T KNOW d Go to Callback

REFUSED r Go to End 4

Hello = 5 and healthprob = 6

If CENTER = Model 1: [FIRSTNAME] recently signed up to take part in a health survey we are conducting.

If CENTER = Model 2: [FIRSTNAME] recently gave permission for Mathematica to contact her about a health survey we are conducting.

Deceased. I am very sorry to hear that she passed away. [[FIRSTNAME] recently signed up to take part in a health survey we are conducting.]/[ [FIRSTNAME] recently gave permission for Mathematica to contact her about a health survey we are conducting.] I was calling to follow up. When did [she] pass away?

Thank you. Please accept my condolences. Goodbye.

| | | / | | | / | | | | | Status 440

MONTH DAY YEAR

1-12 1-31 2009- 2011

DON’T KNOW……………………………………………d Go To End 5

REFUSED……………………………………………......r Go To End 5

hello = 6 or whatabout = 4

Institution. INTERVIEWER: ENTER TYPE OF INSTITUTION.

HOSPITAL 1

NURSING HOME 2 Go to End 6

ASSISTED LIVING FACILITY 3 Go to End 6

GROUP HOME 4 Go to End 6

JAIL OR PRISON 5 Go to End 6

institution = 1

S2 = FIRSTNAME

HomeSoon. Do you expect [FIRSTNAME] to come home from the hospital within a week or two?

YES ARRANGE CALLBACK 1 Go to Callback

NO 2 Go to End 7

[FIRSTNAME] UNABLE TO RESPOND OVER THE TELEPHONE 3 Status 410

Hello = 7 OR whatabout = 5

IF S2 = FIRSTNAME

KnowWhere. Do you or anyone there know how we can reach [FIRSTNAME]?

YES 1

NO 0 Go to End 8

DON’T KNOW d Go to End 8

REFUSED r Go to End 8

Hello = 7 or whatabout = 5

NewPhone.

| | | | - | | | | - | | | | | Go To NewAddr

RANGE RANGE RANGE

OUT OF COUNTRY 2 Go to End 9

DON’T KNOW d Go To NewAddr

REFUSED r Go To NewAddr

Hello = 7 whatabout = 5 and knowwhere = 1

NewAddr. May I please have her address?

(STRING 25)

STREET

(STRING 25)

CITY

(STRING 25)

STATE

| | | | | | - | | | | |

ZIP CODE

00501-99950 0001-9999

DON’T KNOW d Go to End 8

REFUSED r Go to End 8

Hello = 8 or whatabout = 6: programmer: 02 - 06 should be reviewed by a supervisor

Lang.

CODE LANGUAGE NEEDED TO COMPLETE INTERVIEW IF KNOWN

SPANISH 1 Go to End 10

FRENCH 2 Go To End 11

CHINESE 3 Go To End 11

RUSSIAN 4 Go To End 11

GERMAN 5 Go To End 11

OTHER LANGUAGE SPECIFY 6 Go To End 11 ________________________________ (STRING 20)

DON’T KNOW d Go To End 11 REFUSED r Go To End 11

lang = 6

OtherLang.

(STRING 20) Go To End 11

DESCRIPTION

DON’T KNOW d Go To End 11 REFUSED r Go To End 11

hello = 1 or 2 or whatabout = 1 or amphhone = 1 or calltty = 1

IF CENTER = MODEL 1: Recently, you signed up at [HEALTH CENTER NAME] to take part in a brief health survey Mathematica is conducting for the U.S. Department of Health and Human Services (HHS).

IF CENTER = MODEL 2: Recently, you gave [HEALTH CENTER NAME] permission to share your contact information with Mathematica, which is conducting a brief health survey for the U.S. Department of Health and Human Services (HHS).

SampMemb. [Recently, you signed up at [HEALTH CENTER NAME] to take part in a brief health survey Mathematica is conducting for the U.S. Department of Health and Human Services (HHS).]/[Recently, you gave [HEALTH CENTER NAME] permission to share your contact information with Mathematica, which is conducting a brief health survey for the U.S. Department of Health and Human Services (HHS)]. The survey is called the Healthy Pregnancy and Parenting survey. It will take about 15 to 20 minutes. To thank you for taking part, we will send you a gift card for $20. Is this a good time for the interview?

PROBE IF NEEDED: Mathematica Policy Research is a well-known non-partisan research firm with headquarters in Princeton, NJ. Mathematica has conducted numerous studies for the Department of Health and Human Services.

Your participation is completely voluntary, but very important. All your answers will be held in strict confidence. Let’s begin.

BEGIN INTERVIEW 1 Go to T0

DOES NOT RECALL SIGNING 2 Go to NoRecall

WANTS MORE INFORMATION 3 Go to MoreInfo

NOT A GOOD TIME 4 Go to Callback

HUNG UP DURING INTRODUCTION 5 Status 640, Exit

SUPERVISOR REVIEW 6 Status 380, Exit

REFUSED r Status 200, Exit

If SampMemb = 2 (NoRecall)

If CENTER = Model 1: consent form to participate in the Healthy Pregnancy and Parenting Survey...DATE OF CONSENT... The consent form explained that a Mathematica interviewer would call to interview you, and that Mathematica will send you a $20 gift card to thank you for taking part.

If CENTER = Model 2: permission to release your contact information...DATE OF PERMISSION...The permission form said you gave [HEALTHY CENTER] permission to share your contact information with Mathematica so we could call to ask you to take part in the Healthy Pregnancy and Parenting Survey.

NoRecall. You signed a [consent form to participate in the Healthy Pregnancy and Parenting survey/[permission form to release your contact information to Mathematica] on [DATE OF CONSENT/DATE OF PERMISSION]. [The consent form explained that a Mathematica interviewer would call to interview you, and that we will send you a $20 gift card to thank you for taking part.]/[The permission form said that you gave [HEALTH CENTER] permission to share your contact information with Mathematica so we could call to ask you to take part in the Healthy Pregnancy and Parenting Survey.] If you would like I can read you a copy of the entire form.

BEGIN INTERVIEW 1 Go to T0

STILL DOES NOT RECALL SIGNING 2 Go to Check

WANTS MORE INFORMATION 3 Go to MoreInfo

NOT A GOOD TIME 4 Go to Callback

HUNG UP DURING INTRODUCTION 5 Status 640, Exit

SUPERVISOR REVIEW 6 Status 380, Exit

REFUSED r Status 200, Exit

NoRecall= 2

S1 = FULLNAME

Check. Perhaps I am not speaking to the right person. I’d like to verify that your name is [FULLNAME].

YES, THIS IS [FULLNAME]/REMEMBERS SIGNING CONSENT/ GIVING PERMISSION 1 Go to T0

YES, BUT STILL DON”T REMEMBER 2 Go to MoreInfo

NO, WRONG PERSON 3 End 15 (Locating)

sampmemb = 3 or norecall = 3 OR CHECK = 2

[MORE INFO] Survey, please insert your survey-specific text here

MoreInfo. The survey is being done in four sites around the country with only a small number of women – about 960 in total. It asks about your experiences during pregnancy, including the information you got to help you have a healthy pregnancy. Your participation is really important. Can we start now?

YES, BEGIN INTERVIEW 1 Go to T0

NOT A GOOD TIME 2 Go to Callback

HUNG UP DURING INTRODUCTION 3 Status 640, Exit

REFUSED r Status 200, Exit

Hello = 4 or whatabout = 4 OR AMPTTY= d OR RESPAVAIL=0 or moreinfo=2

Callback. When would be a good time to call back?

INTERVIEWER: MAKE AN APPOINTMENT USING THE PARALLEL BLOCK. USE THE 'APPOINTMENT' TAB OR PRESS <CTRL-S> TO INVOKE THE APPOINTMENT MAKING DIALOG.

DOCALLBACK = YES (CALL BACK TO SAMPLE MEMBER AFTER INITIAL CONTACT)

AUTOFILL INTVNAME

S1 = FULLNAME

S2 = FIRSTNAME

Hello2. Hello, my name is [INTVNAME]. I am calling on behalf of the U.S. Department of Health and Human Services (HHS). May I please speak to [FULLNAME]?

SPEAKING TO [FIRSTNAME] 1 Go to SampMemb2

[FIRSTNAME] COMES TO THE PHONE 2 Go to SampMemb2

PERSON ASKS WHAT CALL IS ABOUT 3 Go to WhatAbout2

NEED TO CALLBACK 4 Go to Callback

NEVER HEARD OF [FULLNAME]/WRONG NUMBER 5 Go to PhoneCheck

REFUSED r Status 220, Exit

Hello2 = 3

S2 = FIRSTNAME

WhatAbout2. I'm calling to finish an interview we started with [FIRSTNAME] on [CB1 DATE]. Is she available now?

[FIRSTNAME] COMES TO THE PHONE 1 Go to Sampmemb2

NEED TO CALLBACK 2 Go to Callback

SUPERVISOR REVIEW 3 Status 380, Exit

REFUSED r Status 220, Exit

Hello2 = 1 or 2 OR WhatAbout2 = 1

SampMemb2. Hello, my name is [INTVNAME].] I'm calling to finish the interview we started recently. We will send you a gift card for $20 to thank you for participating.  I’m calling to see if this is a good time to finish the interview. 

As a reminder: your participation is completely voluntary, but very important. All your answers will be held in strict confidence. Let’s begin.

CONTINUE INTERVIEW 1 Go to T0

NOT A GOOD TIME 2 Go to Callback

SUPERVISOR REVIEW 3 Status 380, Exit

REFUSED r Status 200, Exit

Hello=5

S3 = PHONE

PhoneCheck2. I'm sorry, I must have misdialed. I thought I dialed [PHONE]. Is that the number I've reached?

RIGHT NUMBER, NO SUCH PERSON 1 GO TO WrongNumber

WRONG CONNECTION/MISDIAL 2 Status 530, Exit

SUPERVISOR REVIEW REQUIRED 3 Status 380, Exit

REFUSED TO CONFIRM NUMBER 4 Go to End 8

Hello2 = 5

PhoneCheck = 1

AUTOFILL INTVNAME

S1 = FULLNAME

WrongNumber. I'm [INTVNAME] from Mathematica Policy Research. My information was that we’d recently spoken to someone at your number and we were supposed to call back to interview [FULLNAME]. There must have been some mistake. Thank you for your help. I'll turn this over to my supervisor.

CONTINUE 1 Status 380

all callback

Q. When would be a good time to callback?

INTERVIEWER: MAKE AN APPOINTMENT USING THE PARALLEL BLOCK. USE THE 'APPOINTMENT' TAB OR PRESS <CTRL-S> TO INVOKE THE APPOINTMENT MAKING DIALOG.

Programmer: Section b.2 is used only for calls to parent/guardians with whom we were unable to speak when we contacted the “center = model 2 woman under 18 years of age” (question t1 = 2).

B.2 CONTACT PARENT/GUARDIAN

T1 = 2 or (Parent unable to come to phone)

AUTOFILL INTVNAME

S1 = FULLNAME

Hello P/G Hello, my name is [INTVNAME]. I am calling on behalf of the U.S. Department of Health and Human Services (HHS). May I please speak to [FULLNAME]’s parent or guardian?

SPEAKING TO PARENT/GUARDIAN 1 Go to T1a

PARENT/GUARDIAN COMES TO THE PHONE 2 Go to T1a

PERSON ASKS WHAT CALL IS ABOUT 3 Go to Whatabout P/G

NEED TO CALLBACK 4 Go to Callback P/G

[FIRSTNAME] HAS A HEALTH PROBLEM 5 Go to HealthProb P/G

[FIRSTNAME] IS IN AN INSTITUTION 6 Go to Institution P/G

[FIRSTNAME] HAS MOVED 7 Go to KnowWhere P/G

[FIRSTNAME] DOES NOT SPEAK ENGLISH 8 Go to Lang P/G

NEVER HEARD OF [FULLNAME]/WRONG # 9 Go to End 1

HUNG UP DURING INTRODUCTION 10 Status 640, Exit

REFUSED r Status 220, Exit

Hell0 P/G = 3

S2 = FIRSTNAME

WhatAbout P/G. [FIRSTNAME] has agreed to take part in a brief health survey. Because [she is under 18 years of age, I’m calling to ask her parent or guardian to give permission for her to take part in the survey. May I speak with her parent or guardian now?

PARENT/GUARDIAN COMES TO THE PHONE 1 Go to T1a

NEED TO CALLBACK 2 Go to Callback

PARENT/GUARDIAN HAS HEALTH PROBLEM/IS

DECEASED 3 Go to HealthProb P/G

PARENT/GUARDIAN IS IN AN INSTITUTION 4 Go to Institution P/G

PARENT/GUARDIAN MOVED 5 Go to KnowWhere P/G

PARENT/GUARDIAN DOES NOT SPEAK ENGLISH 6 Go to Lang P/G

HUNG UP DURING INTRODUCTION 7 Status 640, Exit

SUPERVISOR REVIEW 8 Status 380, Exit

REFUSED r Status 220, Exit

hello p/g = 5 OR WhatAbout P/G = 3

HealthProb P/G: ENTER TYPE OF HEALTH PROBLEM.

HEARING PROBLEM 1 Go to AmpTTY P/G

SPEECH PROBLEM 2 Go to AmpTTY P/G

PHYSICAL PROBLEM 3 Go to CallLater

COGNITIVE PROBLEM 4 Go to End 2

IN A COMA 5 Go to End 3

DECEASED 6 Go to Deceased

REFUSED r Status 210, Exit

HealthProb P/G = 1 OR 2

If HELLO = 5: S2 = FIRSTNAME; If HELLO P/G = 5, his or her

AmpTTY P/G. I can get on a phone that will amplify my voice or her parent or guardian’s voice, or we could use a TTY service. Would either of these help me to speak with the parent or guardian?

YES - USE AMPLIFIER PHONE 1 Go to RespAvail P/G

YES - USE TTY CAPABILITY 2 Go to RespAvail P/G

NO 0 Go to End 4

DON’T KNOW d Go to Callback

REFUSED r Go to End 4

amptty P/G = 1 or 2

RespAvail P/G. Is the parent or guardian available now?

YES 1

NO 0 Go to Callback

PROGRAMMER: If AmpTTY = 1, GoTo AmpPhone, else Go to CallTTY

amptty p/g = 1 AND RESPAVAIL p/g = 1

AmpPhone. Please hold while I get the amplifier phone.

INTERVIEWER: SET UP AMPLIFIER/WEAK SPEECH EQUIPMENT AND ASK GATEKEEPER TO CALL [FIRSTNAME] TO THE PHONE.

[FIRSTNAME] COMES TO THE PHONE 1 Go to SampMemb

NEED TO CALLBACK 2 Go to Callback

AMPTTY P/G = 2 AND respavail = 1

CallTTY P/G. I will call back in a few minutes after I have the help of the TTY operator.

ARRANGE CALL WITH OPERATOR 1 Go to SampMemb

UNSUCCESSFUL -- NEED TO CALLBACK 2 Go to Callback

healthprob P/G = 3

CallLater P/G. Will the parent or guardian be able to talk on the telephone if I call back in a week or two?

YES/MAYBE – CALLBACK 1 Go to Callback

NO 0 Go to End 4

DON’T KNOW d Go to Callback

REFUSED r Go to End 4

Hello P/G = 5 and healthprob p/g= 6

Deceased P/G. I am very sorry to hear that. When did that happen?

Thank you. Please accept my condolences. Goodbye.

| | | / | | | / | | | | | Status 440

MONTH DAY YEAR

1-12 1-31 2009- 2011

DON’T KNOW……………………………………………d Status 380 Sup Rev

REFUSED……………………………………………......r Status 380 Sup Rev

hello P/G = 6 or whatabout P/G= 4

Institution P/G. INTERVIEWER: ENTER TYPE OF INSTITUTION.

HOSPITAL 1

NURSING HOME 2 Go to End 6

ASSISTED LIVING FACILITY 3 Go to End 6

GROUP HOME 4 Go to End 6

JAIL OR PRISON 5 Go to End 6

institution p/g = 1

S2 = FIRSTNAME

HomeSoon P/G. Do you expect [FIRSTNAME]’s parent or guardian to come home from the hospital within a week or two?

YES ARRANGE CALLBACK 1 Go to Callback

NO 2 Go to End 7

[FIRSTNAME] UNABLE TO RESPOND OVER THE TELEPHONE 3 Status 410

Hello P/G = 7 or whatabout P/G = 5

IF S2 = FIRSTNAME

KnowWhere P/G. Do you or anyone there know how we can reach [FIRSTNAME]/s parent or guardian?

YES 1

NO 0 Go to End 8

DON’T KNOW d Go to End 8

REFUSED r Go to End 8

Hello p/g= 7 or whatabout p/g = 5

NewPhone P/G.

| | | | - | | | | - | | | | | Go To NewAddr

RANGE RANGE RANGE

OUT OF COUNTRY 2 Go to End 9

DON’T KNOW d Go To NewAddr

REFUSED r Go To NewAddr

Hello p/g = 7 or whatabout p/g = 5 and knowwhere p/g = 1

NewAddr P/G. May I please have that new address address?

(STRING 25)

STREET

(STRING 25)

CITY

(STRING 25)

STATE

| | | | | | - | | | | |

ZIP CODE

00501-99950 0001-9999

DON’T KNOW d Go to End 8

REFUSED r Go to End 8

Hello p/g = 8 OR or whatabout p/g = 6:

programmer: Lang p/g 02 - 06 should be reviewed by a supervisor

Lang P/G.

CODE LANGUAGE NEEDED TO COMPLETE INTERVIEW IF KNOWN

SPANISH 1 Go to End 10

FRENCH 2 Go To End 11

CHINESE 3 Go To End 11

RUSSIAN 4 Go To End 11

GERMAN 5 Go To End 11

OTHER LANGUAGE SPECIFY 6 Go To End 11 ________________________________ (STRING 20)

DON’T KNOW d Go To End 11 REFUSED r Go To End 11

lang p/g = 6

OtherLang P/G

(STRING 20) Go To End 11

DESCRIPTION

DON’T KNOW d Go To End 11 REFUSED r Go To End 11

C. Consent

ALL

T0. First, I’d like to ask if you are speaking on a cell phone right now?

YES 1

NO 0 GO TO Box T1

T0=1

T0a. Are you driving?

YES 1

NO 0 Go to Box T1

T0a=1

T0b. Since you are driving, we will need to call you back.

OKAY 1 Go to Callback DON’T CALL BACK 0 Status 200, Exit

T0 = 0 OR T0a = 0

Box T1

If CENTER = Model 2 and age (S4) = less than 18 years of age, go to T1....1

If CENTER = Model 2 and age (S4) = 18 years or older, go to T2 ................ 2

If CENTER = Model 1, go to T2..................................................................... 3

Box T1 = 1

T1. Because you are less than 18 years of age, I need to get permission from your parent or guardian before I can interview you. May I please speak to a parent or guardian for a moment?

CODE ONE ONLY

YES 1

NOT AVAILABLE NOW 2 GO TO CALLBACK

DK d GO TO END 14

REF r GO TO END 14

SPEAKING TO PARENT/GUARDIAN

T1=1

FIRST NAME from S2

T1a. Hello, I’m [INTERVIEWER NAME]. [FIRSTNAME] would like to take part in a brief health survey. Each survey will take 15 to 20 minutes. To thank her for taking part, we will send her a gift card for $20 for each survey she completes. Because she is under the age of 18, I need a parent or guardian’s permission to interview her. Do you give permission for [FIRSTNAME] to take part in this study?

YES 1

PARENT CANNOT COME TO PHONE 2 GO TO CALLBACK

PARENT REFUSES PERMISSION r GO TO END 13

T1a =1

FIRST NAME from S2

T1b. Thanks very much. May I please speak with [FIRSTNAME] again to begin the interview?

YES 1 GO TO T2

NO, SHE’S NOT HERE/NO LONGER HERE 0 GO TO CALLBACK

T1b = 1

If T1b = 1: Your parent/guardian gave permission for you to take part in the survey, so let’s continue.

T2. [Your parent/guardian gave permission for you to take part in the survey, so let’s continue.] This is a study about women who are pregnant. May I confirm that you are currently pregnant?

YES 1

NO 0 GO TO END 12

DK d GO TO END 12

REF r GO TO END 12

T2 = 1

T3. May I ask what is your due date?

__ __ __ __ 2 0 __ __

MONTH DAY YEAR

Answered 1 GO TO T4

DK d

REF r GO TO END 14

T2=1

IF CENTER = MODEL 1, Before we start, let’s briefly review the consent form you signed at [HEALTH CENTER].

IF CENTER = MODEL 2 Before we start, I must tell you about your rights as a respondent in this survey.

T4. [Before we start, let’s briefly review the consent form you signed at [HEALTH CENTER]./Before we start, I must tell you about your rights as a respondent in this survey.]

• You were selected for the survey because you received services from [HEALTH CENTER NAME] and are pregnant. Your name and survey answers will be kept private from everyone except the research team unless prescribed by law. At the end of the survey, we will destroy the information.

• There are no risks from taking part in the survey, other than the possible disclosure of your name, which we have taken steps to avoid.

• While there are no direct benefits to you from taking part, by answering the questions you may help other women have healthier pregnancies.

• Taking part is voluntary. You may refuse to answer any question you don’t like. You might consider some questions, like your health status or services, to be sensitive.

• If you wish to speak to a researcher about the study, I can give you the contact information for Margo Rosenbach, the Principal Investigator.

• If you want to speak to someone about your rights as a participant in the survey, I can give you the contact information for Margo Campbell, the Institutional Board Representative.

• We will mail you a $20 gift card, when you complete this survey. We will mail you a second $20 gift card if you complete a survey about your baby in about 9 months.

Do you have any questions about anything I just told you?

INSTRUCTIONS: ANSWER ANY QUESTIONS.

YES 1

NO 0 GO TO Box T4

REF R Status 200, Exit

Box T4

If CENTER = Model 1, go to Start1

If CENTER = Model 2, go to T4

T4. Do you agree to take part in the survey?

YES 1 GO TO Start 1

NO 0 GO TO END 14

D. TEXT4BABY ENROLLMENT AND USE OF SERVICES

ALL

S

New

question

tart 1. These first questions ask about your cell phone use.

Do you have your own cell phone?

YES 1

NO 0 GO TO Q1.1

DON’T KNOW d GO TO Q1.1

REFUSED r GO TO Q1.1

Start1 = 1

S

New

question

tart 2. Does anyone else ever use your cell phone?

YES 1

NO 0

DON’T KNOW d

REFUSED r

Start1 = 1

S

Pew Cell Phones American Adults Q17 modified

tart 3. Do you ever use your cell phone to…

	CODE ONE RESPONSE FOR EACH ROW
	yes	no	DK	REF
a send or receive text messages?	1	0	d	r
b look at a social networking site like MySpace, Facebook or LinkedIn.com?	1	0	d	r
c look at Twitter?	1	0	d	r
d go to the internet directly on your cell phone?	1	0	d	r

If Start 3a = 1

IF START3a = 0, d, r, GO TO Q1.1

S

New question

tart 4. What is your preferred language for receiving text messages?

english 1

SPANISH 2

OTHER (SPECIFY) __________________________ 9

DON’T KNOW d

REFUSED r

ALL

1

.1 Before today, did you ever hear of a program called text4baby that sends pregnant women and new mothers free text messages on their cell phones?

PROBE IF R SAYS NOT SURE OR SEEMS UNCERTAIN: Women can sign up to receive free text messages about having a healthy pregnancy and baby. The messages include health tips, reminders, and information about other resources. Did you ever hear of the text4baby program before today?

YES 1

NO 0 GO TO Q4.1

DON’T KNOW d GO TO Q4.1

REFUSED r GO TO Q4.1

Q1.1=1

1

2001 CHIP Enrollees Disenrollees 2.13 modified

.2 Have you ever signed up to receive free text4baby messages on your cell phone?

PROBE: Text4baby gives women tips about have a healthy pregnancy and baby.

INSTRUCTIONS: CODE YES IF R SAYS SOMEONE ELSE SIGNED HER UP.

CODE YES IF r WAS SIGNED UP IN THE PAST BUT IS NOT CURRENTLY SIGNED UP.

YES 1

TRIED BUT WAS UNABLE TO SIGN UP 2 GO TO Q1.2c

NO 0 GO TO Q1.2d

DON’T KNOW d GO TO Q1.4

REFUSED r GO TO Q1.4

Q.1.2=1

1

New question

.2a How did you sign up for text4baby? Did you send a text message on your cell phone, sign up on the Internet, or sign up some other way?

CELL PHONE 1

INTERNET 2

someone ELSE signed me up 3

OTHER (SPECIFY) ___________(STRING 200) 99

DON’T KNOW d

REFUSED r

Q1.2=1

1

New question

.2b Did you sign up to get text4baby messages in English or in Spanish?

english 1 GO TO Q1.2d

SPANISH 2 GO TO Q1.3

DON’T KNOW d GO TO Q1.3

REFUSED r GO TO Q1.3

Q.1.2=2

1

New question

.2c Why were you unable to sign up for text4baby when you tried?

Specify: ___________________________________ GO TO Q1.4

1.2b = 1 and Q1.2=0

1

New question

.2d Are you aware that text4baby messages are available in Spanish?

yes 1

NO 2

DON’T KNOW d

REFUSED r

BOX 1.3

IF Q1.2 = 1, GO TO Q1.3

IF Q1.2 = 0,2,D,R GO TO Q1.4

Q.1.2=1

1

New

question

.3 About how long ago did you sign up for text4baby messages? Would you say…

PROBE: Your best estimate is fine.

In the past month? 1

Between one and two months ago? 2

Between three and four months ago? 3

Between five and six months ago? 4

More than six months ago? 5

DON’T KNOW d

REFUSED r

Q1.2=1

1

New

question

.3a About how far along in your pregnancy were you when you signed up for text4baby?

PROBE: Your best estimate is fine.

3 months or less, 1

4 to 6 months, or 2

7 to 9 months? 3

DON’T KNOW d

REFUSED r

Q.1.1=1

1

HK LA Baseline B1 modified

.4 I’m going to read a list of ways you might have heard about text4baby. Did you hear about it from…

a doctor or midwife? 1

another health care provider? 2

a friend or family member? 3

a billboard, flyer, newspaper, or magazine? 4

on TV or radio? 5

on the internet? 6

something you received in the mail? 7

or from another source? (SPECIFY)_____________

(STRING 200) 99

DON’T KNOW d

REFUSED r

BOX 1.5

IF Q1.2 = D,R, GO TO Q5.1

IF Q1.2 = 0, GO TO Q2.6

IF Q1.2=1,2 and Q1.4 = only one responses coded, GO TO Q1.6. Else CONTINUE TO Q1.5.

Q1.2=1,2 AND Q1.4 HAS MORE THAN ONE RESPONSE (1-7 and 999)

Display in Q1.5 only the responses selected in Q1.4.

If Q1.2=2: Of the ways you just mentioned, which one was the most useful or helpful in deciding to try to sign up for text4baby? Was it …

If Q1.2=1: Of the ways you just mentioned, which one was the most useful or helpful in deciding to sign up for text4baby? Was it…

1

1001 CHIP 2.2.1 modified

.5 Of the ways you just mentioned, which one was the most useful or helpful in deciding to [try to] sign up for text4baby? Was it [READ LIST OF SOURCES CODED IN Q1.4],..

DISPLAY ONLY MULTIPLE RESPONSES FROM Q1.4 AND ALLOW CODE ONE ONLY

CODE ONE: |__|__|

DON’T KNOW d

REFUSED r

Q1.2=1 ,2

In Q1.6 display the reasons in random order for each interview.

If Q1.2=1: decided

If Q1.2=2: tried

1

New

question

.6 When you [decided/tried] to sign up for text4baby, how important were these reasons…

READ EACH REASON, THEN ASK FOR EACH, Was that very important, somewhat important, or not very important?

	code one response per row
REASONS	VeRY IMPORTANT	SOMEWHAT IMPORTANT	NOT very IMPORTANT	DK	REF
a Getting text4baby messages is free	1	2	3	d	r
b Getting text4baby messages is convenient	1	2	3	d	r
c Your doctor or midwife suggested you sign up	1	2	3	d	r
d A friend or family member suggested you sign up	1	2	3	d	r
e You wanted to get tips about having a healthy baby	1	2	3	d	r
f You wanted to get phone numbers to call for information about specific health topics	1	2	3	d	r
g You thought the reminders about prenatal care and other appointments would be helpful	1	2	3	d	r

Q1.2=1,2

If Q1.2=1: decided

If Q1.2=2: tried

1

New

question

.6a Were there other important reasons why you [decided/tried] to sign up for text4baby? RECORD VERBATIM

(STRING 400)

DESCRIPTION

NO OTHER REASON 0

DON’T KNOW d

REFUSED r

BOX 1.7

IF Q1.2=2, GO TO Q2.7.

Q1.2=1

1

New

question

.7 How easy or hard was it to sign up for text4baby? Would you say it was…

very easy, 1

somewhat easy, 2

somewhat hard, or 3

very hard? 4

DON’T KNOW d

REFUSED r

Q1.2=1

1

New

question

.8 Text4baby sends some text messages that include a phone number to call if you want more information on topics like smoking, drug use, breastfeeding, installing car seats, or getting health care. Did you ever call one of the phone numbers included in a message?

YES 1

NO 0 GO TO Q1.10

DON’T KNOW d GO TO Q1.10

REFUSED r GO TO Q1.10

Q1.8=1

S5 = 2: STATE MEDICAID PROGRAM NAME

Display TOPICS AND EVER CALLED COLUMN. FOR EACH YES AT EVER CALLED, DISPLAY Was the information very useful, somewhat useful, or not useful?

1

New question

.9 Thinking about the phone numbers in the messages, have you ever called about….

INTERVIEWER: READ EACH TOPIC FIRST. THEN FOR EACH “YES” RESPONSE TO “EVER CALLED,” ASK: Was the information you got very useful, somewhat useful, or not very useful?

	ever called?		HOW USEFUL?
TOPICS	Yes	NO	very useful	somewhat useful	not very useful	DK	REF
a Finding a doctor or midwife	1	0	1	2	3	d	r
b Quitting smoking	1	0	1	2	3	d	r
c Getting information about alcohol or drug use	1	0	1	2	3	d	r
d Getting health coverage from Medicaid or [STATE PROGRAM NAME]	1	0	1	2	3	d	r
e Getting information about WIC	1	0	1	2	3	d	r
f Getting information about breastfeeding	1	0	1	2	3	d	r
g Some other topic I haven’t mentioned? (SPECIFY)_____________ (STRING 400)	1	0	1	2	3	d	r

Q1.8 = 1

1

New question

.9a Did you ever save one or more of the phone numbers included in a message so you could call it in the future?

YES 1

NO 0

DON’T KNOW d

REFUSED r

Q1.2=1

1

New

question

.10 The next questions are about your current experience with text4baby.

Have you received one or more messages from text4baby in the past two weeks?

YES 1

NO 0 GO TO BOX 2.1

DON’T KNOW d GO TO BOX 2.1

REFUSED r GO TO BOX 2.1

Q1.10=1

1

SMS Sexual Health 19 modified

.11 About how many text4baby messages did you get in the past two weeks? Would you say…

one or two, 1

three or four, 2

five or six, or 3

more than six? 4

DON’T KNOW d GO TO BOX 2.1

REFUSED r GO TO BOX 2.1

[Question 1.12 has been moved question 3.7.]

Q1.11=1-4

1

SMS Sexual Health 21 & 22 modified

.13 Thinking about the text4baby messages that you got in the past two weeks, have you forwarded or shown any of the messages to…

INTERVIEWER: READ LIST AND CODE ONE RESPONSE PER ROW

	YES	NO	DK	REF
a a friend?	1	0	d	r
b a family member?	1	0	d	r
c someone you work with?	1	0	d	r
d your doctor or midwife?	1	0	d	r
e someone else? (SPECIFY) _____________ (STRING 200)	1	0	d	r

Q1.11=1-4

1

New

question

.14 Since you first signed up for text4baby, was there ever a time when you did not get any text4baby messages for a week or more?

YES 1

NO 0 GO TO BOX 2.1

DON’T KNOW d GO TO BOX 2.1

REFUSED r GO TO BOX 2.1

Q1.14=1

1.15 Why weren’t you getting any text4baby messages during that time? Was it because…

New

question

Your cell phone was lost or stolen? 1

A friend or relative borrowed your cell phone? 2

You didn’t have enough money to continue cell

phone service? 3

You were somewhere with no cell

phone service? 4

You texted STOP to stop receiving messages? 5

Some other reason? (SPECIFY) ___ (STRING 400) 99

DON’T KNOW d

REFUSED r

E. TEXT4BABY DISENROLLMENT AND NEVER ENROLLMENT

BOX 2.1

IF Q1.10=1, GO TO Q 3.1

IF Q1.10=0,D,R, GO TO Q2.1

Q1.10=0,D,R

2.1 Have you ever texted STOP to stop receiving text4baby messages?

New

question

YES 1

NO 0 GO TO BOX 3.1

DON’T KNOW d GO TO BOX 3.1

REFUSED r GO TO BOX 3.1

Q2.1=1

2

New

question

.2 Why did you want to stop receiving text4baby messages? Was it because…

you didn’t have time to read the messages, 1

there were too many messages, 2

you didn’t find the messages useful, 3

you had enough information from other sources, 4

Another reason? (SPECIFY) _______(STRING 400) 5

DON’T KNOW d

REFUSED r

Q2.1=1

2

New

question

.3 About how long ago did you stop receiving text4baby messages? Was it…

In the past month 1

2 or 3 months ago, or 2

More than 3 months ago? 3

DON’T KNOW d

REFUSED r

Q2.1=1

2

New

question

.4 What was the topic of the last message you remember getting from text4baby before you stopped getting messages? RECORD VERBATIM

(STRING 400)

DESCRIPTION

DON’T KNOW d

REFUSED r

Q2.1=1

2

New

question

.5 Would you consider signing up for text4baby messages again?

YES 1

NO 0 GO TO 2.5b

DON’T KNOW d GO TO BOX 2.6

REFUSED r GO TO BOX 2.6

Q2.5 = 1

2

New

question

.5a Why would you consider signing up for text4baby messages again? RECORD VERBATIM

(STRING 400) GO TO BOX 2.6

DESCRIPTION

DON’T KNOW d GO TO BOX 2.6

REFUSED r GO TO BOX 2.6

Q2.5 = 0

2

New

question

.5b Why would you not consider signing up for text4baby messages again? RECORD VERBATIM

(STRING 400)

DESCRIPTION

DON’T KNOW d

REFUSED r

Box 2.6

IF Q1.2=1, GO TO BOX 3.1

Q1.2=0

Display reasons in random order for each interview. Display reasons and Yes/No column first. For each YES, display: How important was this reason in your decision not to sign up? Was it very important, somewhat important, or not very important?

2

New

question

.6 Why did you decide not to sign up for text4baby? Was it because….

READ EACH REASON FIRST. FOR EACH ‘YES’ ASK, How important was this reason in your decision not to sign up? Was it very important, somewhat important, or not very important?

	reason?		code one response FOR EACH YES
	YES	NO	VeRY IMPORTANT	SOMEWHAT IMPORTANT	NOT VERY IMPORTANT	DK	REF
a Your cell phone has no text messaging capability?	1	0	1	2	3	d	r
b You don’t know how to use text messaging?	1	0	1	2	3	d	r
c You don’t like text messaging?	1	0	1	2	3	d	r
d You have other sources of information about having a healthy pregnancy?	1	0	1	2	3	d	r
e A friend or family member advised you not to sign up?	1	0	1	2	3	d	r
f Your doctor, midwife, or another health care provider advised you not to sign up?	1	0	1	2	3	d	r
g Text4baby messages are not available in your preferred language	1	0	1	2	3	d	r

Q1.2=0

2

New

question

.6a Were there any other important reasons why you decided not to sign up for text4baby? RECORD VERBATIM

(STRING 400)

DESCRIPTION

NO OTHER REASON 0

DON’T KNOW d

REFUSED r

Q1.2=0,2

If Q1.2=0: to sign up for the text4baby program in the future

If Q1.2=2: to try to sign up for the the text4baby program again

2

New

question

.7 What would encourage you [to sign up for the text4baby program in the future/ to try to sign up for the the text4baby program again]? RECORD VERBATIM

(STRING 400)

DESCRIPTION

NOTHING/NOT INTERESTED 0

DON’T KNOW d

REFUSED r

F. SATISFACTION WITH TEXT4BABY

Box 3.1

IF Q1.2=0,2,D,R or Q1.10=D, R, GO TO Q5.1

Q1.10=1 or Q1.10=0

If Q1.10=0: When you were getting text4baby messages, how satisfied were you with how often you received

If Q1.10=1: How satisfied are you with how often you receive

3

New

question

.1 [When you were getting text4baby messages, how satisfied were you with how often you received/How satisfied are you with how often you receive] text4baby messages? Would you say…

very satisfied, 1

somewhat satisfied, 2

somewhat dissatisfied, or 3

very dissatisfied? 4

DON’T KNOW d

REFUSED r

Q1.10=1 or Q1.10=0

If Q1.10=0: was, received

If Q1.10=1: is, receive

3

PS A21B modified

.2 Overall, how easy or hard [was/is] it to understand the text4baby messages you [received/receive]? Would you say…

very easy, 1

somewhat easy, 2

somewhat hard, or 3

very hard? 4

DON’T KNOW d

REFUSED r

Q1.10=1 or Q1.10=0

If Q1.10=0: were

If Q1.10=1: are

3

PS A20 modified

.3 How useful [were/are] the text4baby messages in helping you to have a healthy pregnancy? Would you say…

very useful, 1

somewhat useful, or 2

not very useful? 3

DON’T KNOW d

REFUSED r

Q1.10=1 or Q1.10=0

3

HS B12

.4 Would you recommend the text4baby program to a friend or family member?

YES 1

NO 0 GO TO Q3.4b

DON’T KNOW d GO TO Q3.5

REFUSED r GO TO Q3.5

Q3.4=1

3

HS B12a

.4a Why would you recommend the text4baby program to a friend or family member? RECORD VERBATIM.

(STRING 400) GO TO Q3.5

DESCRIPTION

DON’T KNOW d GO TO Q3.5

REFUSED r GO TO Q3.5

Q3.4=0

3

HS B12b

.4b Why would you not recommend the text4baby program to a friend or family member? RECORD VERBATIM.

(STRING 400)

DESCRIPTION

DON’T KNOW d

REFUSED r

Q1.10=1 or Q1.10=0

3.5 What suggestions do you have for improving text4baby? RECORD VERBATIM.

P

New question

ROBE: “What else” until respondent answers “nothing.”

(STRING 400)

DESCRIPTION

NONE 0

DON’T KNOW d

REFUSED r

Box 3.6

IF Q1.10=0, Go TO 5.1

Q1.10=1

3

Cocosila modified

.6 If you had to pay the same amount for text4baby text messages as you pay for other text messages under your cell phone plan, would you continue using text4baby?

PROBE: At this time, text4baby messages are free.

YES 1

NO 0

DON’T KNOW d

REFUSED r

Q1.10 = 1

3

SMS Sexual Health 20 modified

.7 Thinking about the text4baby messages that you got in the past two weeks, how strongly do you agree or disagree with the following statements?

FOR EACH STATEMENT, Do you strongly agree, somewhat agree, somewhat disagree, or strongly disagree?

	STRONGLY AGREE	SOMEWHAT AGREE	SOMEWHAT DISAGREE	STRONGLY DISAGREE	DK	REF
a You learned something from them	1	2	3	4	d	r
b You trusted them	1	2	3	4	d	r
c They were interesting	1	2	3	4	d	r
d They were annoying	1	2	3	4	d	r

BOX 3.8

IF Q3.7d = 3, 4, d, r, GO TO Q5.1

Q3.7d = 1 or 2

3.8 Why were the text4baby messages annoying?

New question

(STRING 400)

DESCRIPTION

DON’T KNOW d

REFUSED r

G. SECTION G DELETED.

H. HEALTH CARE ACCESS, UTILIZATION, KNOWLEDGE, AND BEHAVIOR

ALL

5

[NMIHS1989 Part A:2] Adapted Healthy Start

.1 During this pregnancy, did you get any prenatal care from a doctor, nurse, midwife, or other health care provider?

PROBE: Prenatal care is the medical care a woman gets from a doctor, midwife, or nurse while she is pregnant. It usually includes checking the woman’s weight and blood pressure and the baby’s heart beat.

INSTRUCTION: If respondent received some but not all of these services, code YES.

YES 1

NO 0 GO TO Q5.5

DON’T KNOW d GO TO Q5.5

REFUSED r GO TO Q5.5

Q5.1=1

5

NMIHS1989 Part A:3 modified

.2 How many months pregnant were you when you went for your first prenatal care visit? Were you…

PROBE: Your best estimate is fine.

3 months or less, 1

4 to 6 months, or 2

7 to 9 months pregnant? 3

DON’T KNOW d

REFUSED r

Q5.1=1

5

New

question

.3 Do you have one place where you usually go for your prenatal care?

YES 1

NO 0 GO TO Q5.5

DON’T KNOW d GO TO Q5.5

REFUSED r GO TO Q5.5

Q5.3=1

5

New

question

.4 Where do you usually go for prenatal care? Is it a…

hospital clinic, 1

health department clinic, 2

community health center, 3

private doctor’s office or HMO clinic, or 4

some other place? (SPECIFY) 99

________________________________(STRING 400)

DON’T KNOW d

REFUSED r

ALL

Randomize sources of information

If Q1.10=0,1, display Q5.5f, ELSE do not.

5

New

question

.5 Have you ever gotten information about having a healthy pregnancy from the following sources?

	used source
SOURCE OF INFORMATION	Yes	NO	dk	ref
a A doctor or midwife	1	0	d	r
b Your partner or spouse	1	0	d	r
c A parent	1	0	d	r
d A friend	1	0	d	r
e Books or online sources	1	0	d	r
f Text4baby	1	0	d	r
g Another source (SPECIFY)	1	0	d	r
______________________(STRING 400)

Box 5.6

If response to Q5.5a-Q5.5g is all ‘NO’ or only one ‘YES’ response, GO TO Q5.7.

Q5.5 = More than one ‘YES’ response

5

New question

.6 Now, thinking about all of the sources of information you just mentioned, which one do you find most useful in helping you have a healthy pregnancy?

INTERVIEWER: READ THE LIST.

Response #1..n 1

DON’T KNOW d

REFUSED r

All

Randomize topics in each interview.

5

New question

.7 During this pregnancy, did you ever get information about the following topics?

	got information about…
TOPIC	YES	NO		DK	R
a Taking prenatal vitamins	1	0	d		r
b Eating healthy foods	1	0	d		r
c Seeing a dentist	1	0	d		r
d Becoming aware of pregnancy health risks, such as high blood pressure and preterm birth	1	0	d		r
e Avoiding stress	1	0	d		r
f Getting a flu shot	1	0	d		r
g Using a seat belt	1	0	d		r
h Calling a help line if you are feeling depressed	1	0	d		r
i Finding out if you are eligible for Medicaid or [STATE PROGRAM NAME]	1	0	d		r
j Finding out if you are eligible for WIC	1	0	d		r
k Breastfeeding your baby........	1	0	d		r
l Quitting smoking during pregnancy	1	0	d		r
m Avoiding alcohol or other drugs	1	0	d		r
n Getting exercise........	1	0	d		r

IF Q1.10 = 1,0

IF Q1.1=0,D,R or Q1.2=0, D, R or Q1.10=D,R, GO TO 5.8

1) FOR ANY YES IN q5.7, DISPLAY ANSWERS IN Q5.7a and ask in column A: Did you get this information from text4baby?

2) FOR ANY YES IN COLUMN A of Q5.7A, ask COLUMN B: Was the text4baby message about [TOPIC] very useful, somewhat useful, or not very useful?

5

New question

.7a Now, for each of the topics you just mentioned, I would like to ask you whether you got this information from text4baby, and if so, whether this information was very useful, somewhat useful, or not very useful. Did you get information about [TOPIC] from text4baby?

FOR ANY YES IN Q5.7, ASK: Did you get information about [TOPIC] from text4baby?

FOR ANY YES IN COLUMN A, ASK: Was the text4baby message about [TOPIC] very useful, somewhat useful, or not very useful?

	Column A Got info from text4baby		Column B USEFULNESS OF INFO FROM TEXT4BABY
			Very useful	SOMEWHAT USEFUL	Not very useful	DK	REF
TOPIC	YES	NO
a Topic #1	1	0	1	2	3	d	r
b Topic #2	1	0	1	2	3	d	r
c Topic #3	1	0	1	2	3	d	r
d Topic #4	1	0	1	2	3	d	r

ALL

5

Healthy Start C.2 modified

.8 What information do you feel you needed during this pregnancy but did not get?

5

Healthy Start C.2 modified

.8 Is there any health-related information you feel you needed during this pregnancy but did not get?

YES 1

NO 0 GO TO Q5.9

DON’T KNOW d GO TO Q5.9

REFUSED r GO TO Q5.9

Q5.8=1

5

Healthy Start C.2 modified

.8a What information do you feel you needed during this pregnancy but did not get? RECORD VERBATIM

(STRING 400)

DESCRIPTION

DON’T KNOW d

REFUSED r

ALL

5

HS E7

.9 The next few questions ask about your experiences during this pregnancy.

During this pregnancy, about how many alcoholic drinks do you have in an average week? Would you say…

PROMPT IF NEEDED, ‘in an average week.’ STOP WHEN RESPONDENT INDICATES NUMBER OF DRINKS.

RESPONDENT HAS NO DRINKS IN AN AVERAGE WEEK 1

less than 1 drink in an average week, 2

1 to 3 drinks in an average week, 3

4 to 6, 4

7 or more, or 5

DON’T KNOW d

REFUSED r

ALL

5

HS E3 modified

.10 During this pregnancy, about how many cigarettes do you smoke on an average day? Would you say…

INSTRUCTION: STOP WHEN YOU REACH ONE CODED CATEGORY

PROBE: A pack has 20 cigarettes.

RESPONDENT DOES NOT SMOKE 1

1 to 5 per day, 2

6 to 10, 3

11 to 20, or 4

more than 20? 5

DON’T KNOW d

REFUSED r

ALL

5

PRAMS Standard Phase 6 AA4

.11 During this pregnancy, about how many hours a day, on average, are you in the same room or vehicle with another person who is smoking?

PROBE: IF RESPONDENT SAYS 2 OR 3, ASK “Is that 2 or 3?”

| | | HOURS (00-24)

LESS THAN 1 HOUR A DAY 1

I AM NEVER IN THE SAME ROOM OR VEHICLE WITH SOMEONE WHO IS SMOKING 2

DON’T KNOW d

REFUSED r

ALL

5

PRAMS Standard Phase 6 S4 modified

.12 During this pregnancy, how often do you wear a seat belt when you drive or ride in a car? Would you say…

Always 1

Usually 2

Sometimes 3

Rarely 4

Never 5

DON’T KNOW d

REFUSED r

ALL

5

PRAMS Standard Phase 6 CoreQ3 modified

.13 During this pregnancy, how many times a week do you take a multivitamin, prenatal vitamin, or folic acid vitamin? Would you say…

Never, 0

1 to 3 times a week, 1

4 to 6 times a week, or 2

Every day of the week? 3

DON’T KNOW d

REFUSED r

ALL

5.14 During the past 12 months, have you had a flu shot?

PRAMS Standard Phase 6 L13 modified

PROBE: A flu shot is a shot you get to prevent you from getting the flu. It’s usually given in the fall and protects against influenza for the flu season.

PROBE: IF R SAYS SHE TOOK A LIQUID OR PILL, CODE YES.

YES 1

NO 0 GO TO Q5.14b

DON’T KNOW d GO TO Q5.15

REFUSED r GO TO Q5.15

Box 5.14a

If Q5.14=1 AND (Q1.1=0,D,R or Q1.2=0, 2, D, R) GO TO Q5.15

Q5.14=1 and Q1.2 = 1

5.14a Did text4baby help you decide to get a flu shot?

New question

YES 1 GO TO Q5.15

NO 0 GO TO Q5.15

DON’T KNOW d GO TO Q5.15

REFUSED r GO TO Q5.15

If 5.14 = 0

5.14b Why didn’t you get a flu shot during the past 12 months? Was it because…

PRAMS L14 adapted

Your doctor or midwife didn’t mention anything about getting a flu shot 1

You were worried that it might harm your baby 2

You were worried about side effects for your own health 3

You didn’t know where to get a flu shot 4

Were there any other reasons you didn’t get a flu shot (SPECIFY) ___________(STRING 400) 5

DON’T KNOW d

REFUSED r

ALL

5

NSCH K4Q21 modified

.15 During the past 12 months, did you go to a dentist or dental hygienist for preventive dental care, such as a check-up or dental cleaning?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

5

Goldenberg et al 2009

.16 Now I have some questions about your baby’s birth. During what week of your pregnancy will your baby be full term? Would you say…

34 to 36 weeks, 1

37 to 38 weeks, 2

or 39 to 40 weeks? 3

DON’T KNOW d

REFUSED r

ALL

5

Goldenberg et al 2009

.16a If there are no medical problems in your pregnancy, when is the best time to deliver your baby? Would you say…

CODE ONE ONLY

34 to 36 weeks, 1

37 to 38 weeks, 2

or 39 to 40 weeks? 3

DON’T KNOW d

REFUSED r

ALL

5

PRAMS

.17 When your baby is born, do you plan to breastfeed or feed pumped breast milk to your baby?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

5

New

question

.17a When your baby is born, how do you plan to lay him or her down to sleep? Would you say, on [his/her]…

side, 1

back, 2

or stomach? 3

DON’T KNOW d

REFUSED r

ALL

5

NSCH

K4Q27.

Adapted

.18 Sometimes people have difficulty getting health care when they need it. Health care includes services like prenatal care, medical care, dental care, vision care, and mental health services. During the past 6 months, was there any time when you or a doctor thought you needed health care but you didn’t get it?

YES 1

NO 0 GO TO Q5.21

DON’T KNOW d GO TO Q5.21

REFUSED r GO TO Q5.21

IF Q5.18 = 1

5

NSCH

K4Q28.

Adapted

.19 What kind of health care did you need but not get? Was it…

	unmet need
TYPE OF SERVICE	Yes	NO	dk	ref
a Prenatal care	1	0	d	r
b Medical care	1	0	d	r
c Dental care	1	0	d	r
d Vision care	1	0	d	r
e Mental health services	1	0	d	r
f Another kind of care (SPECIFY) ______________________(STRING 200)	1	0	d	r

IF Q5.18 = 1

5

New question

.20 How much of a problem was it that you did not get the health care you or a doctor thought you needed? Would you say it was…

A big problem 1

A small problem 2

Not a problem 3

DON’T KNOW d

REFUSED r

ALL

Rotate reasons for delayed care (a-f)

5

NHIS 2011 AHCDLY Adapted

.21 There are many reasons people delay getting health care. During the past 6 months, have you delayed getting health care for any of the following reasons?

PROBE: Health care includes services like prenatal care, medical care, dental care, vision care, and mental health services.

	DELAYED CARE
REASON FOR DELAYED CARE	Yes	NO	dk	ref
a You couldn’t get through on the telephone	1	0	d	r
b You couldn’t get an appointment soon enough	1	0	d	r
c You would have to wait too long at the clinic or doctor’s office	1	0	d	r
d The clinic or doctor’s office wasn’t open when you could get there	1	0	d	r
e You didn’t have transportation	1	0	d	r
f You couldn’t afford it	1	0	d	r
g Another reason for delaying care (SPECIFY)	1	0	d	r
______________________(STRING 200)

ALL

5

CAHPS Medicaid Survey

Q8

Adapted

.22 Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care in the last 6 months?

| | |

DON’T KNOW d

REFUSED r

I. HEALTH STATUS

ALL

6.1 The next questions are about your pregnancy history and health status.

HS H1 adapted to delete [child] and make ‘current’

Other than your current pregnancy, have you ever been pregnant before?

IF ASKED: Please include pregnancies that ended in still-birth or abortion.

YES 1

NO 0 GO TO BOX 6.5

DON’T KNOW d GO TO BOX 6.5

REFUSED r GO TO BOX 6.5

Q6.1=1

6

HS H2 modified

.2 Not counting your current pregnancy, how many times have you been pregnant before? Would you say…

INSTRUCTION: PAUSE AFTER EACH RESPONSE CATEGORY: STOP WHEN RESPONDENT GIVES AN ANSWER.

1 or 2 times, 1

3 or 4, 2

5 or 6, or 3

more than 6 other times? 4

DON’T KNOW d GO TO Q6.5

REFUSED r GO TO Q6.5

Q6.1=1 AND 6.2=ANSWERED (1,2,3,4)

6.3 Were all the babies from your previous pregnancies born alive?

Y

HS H3 [PRAMS 7] modified

ES 1

NO 0 GO TO BOX 6.5

DON’T KNOW d GO TO BOX 6.5

REFUSED r GO TO BOX 6.5

Q6.3=1

6.4 Did any of the babies die before their first birthday?

Y

HS H4 modified

ES 1

NO 0

DON’T KNOW d

REFUSED r

Box 6.5

IF Q6.3=0 or Q6.4=1: display: I’m very sorry for your loss. Please accept my condolences.

INTERVIEWER, IF NEEDED, OFFER GRIEF COUNSELING REFERRAL. If you would like, I can offer you a phone number where you can talk with somebody about your loss. We have only a few questions left.

ALL

6

NSCH, K9Q20

.5 Now I have a couple of questions about your health. Would you say that, in general, your health is excellent, very good, good, fair, or poor?

EXCELLENT 1

VERY GOOD 2

GOOD 3

FAIR 4

POOR 5

DON’T KNOW d

REFUSED r

all

6

NSCH K9Q23 modified

.6 Would you say that, in general, your mental and emotional health is excellent, very good, good, fair, or poor?

EXCELLENT 1

VERY GOOD 2

GOOD 3

FAIR 4

POOR 5

DON’T KNOW d

REFUSED r

J. PARTICIPANT BACKGROUND

ALL

7

HS A10b modified

.1 The next few questions ask about your background.

What is your date of birth?

| | | / | | | / | | | | | GO TO Q7.2

MONTH DAY YEAR

(1-12) (1-31) (1956-1997)

DON’T KNOW d

REFUSED r

Q7.1 = D, R

7.1a How old were you on your last birthday?

|__|__| Years

DON’T KNOW d

REFUSED r

ALL

7

HS J1

.2 Are you currently…

married 1

separated, 2

divorced, 3

widowed, 4

never married, or 5

living with a partner? 6

DON’T KNOW d

REFUSED r

ALL

7.3 Are you of Hispanic or Latino origin?

Y

HS J3

ES, HISPANIC OR LATINo 1

NO, NOT HISPANIC OR LATINo 0

DON’T KNOW d

REFUSED r

ALL

7

HS J5

.4 What is your race? You may choose more than one. Are you…
INTERVIEWER: DO NOT READ “OTHER.” CODE ONLY IF NECESSARY.

CODE ALL THAT APPLY

American Indian and Alaska Native 1

Asian, 2

Black or African American, 3

Native Hawaiian or other Pacific Islander, or 4

White? 5

OTHER (SPECIFY) ___________ (STRING 200) 6

DON’T KNOW d

REFUSED r

ALL

7

HS J6 modified

.5 In what country were you born?

United States 1 GO TO Q7.7

PROBE: One of the 50 states or the District of Columbia

One of the U.S. territories 2

PROBE: Puerto Rico, Guam, American Samoa, U.S. Virgin Islands, Mariana Islands, or Solomon Islands

Another country? (SPECIFY) ___________(STRING 100) 3

DON’T KNOW d GO TO Q7.7

REFUSED r GO TO Q7.7

Q7.5=2 or 3

7

HS J7

.6 How old were you when you first moved to the United States?

PROBE: Your best estimate is fine.

INTERVIEWER: CODE LESS THAN ONE YEAR OLD = 0, ROUND UP OR DOWN TO THE NEAREST YEAR

| | | AGE (0-55)

DON’T KNOW d

REFUSED r

SOFT CHECK: CALCULATE AGE AT Q7.1. IF Q7.1 is less than Q7.6. I must have entered your birthday wrong. According to what I entered, you are [age at Q7.1] years old. You just said you moved to the U.S. when you were [age at Q7.6] years old. Which is correct?

all

7

American Community Survey

.7 Do you speak a language other than English at home?

YES 1

NO 0 GO TO 7.8

DON’T KNOW d GO TO 7.8

REFUSED r GO TO 7.8

q7.7=1

7

American Community Survey (Adapted)

.7a What language do you speak at home?

(STRING 100)

DON’T KNOW d

REFUSED r

all

7

ECLS 9 month parent HE025a-d modified Var

.8 How well do you feel you read English?

Very well 1

Somewhat well 2

Not very well 3

DON’T KNOW d

REFUSED r

all

7

2001 CHIP, 6,17 modified

.9 What is the highest grade or level of school that you have completed? Is it…

PROBE: IF RESPONDENT SAYS SHE WAS HOME SCHOOLED, PROBE FOR HIGHEST YEAR, GRADE, DEGREE, OR CERTIFICATE COMPLETED.

8th grade or less, 1

some high school but did not graduate, 2

high school graduate or GED, 3

some college or 2-year degree, 4

4-year college graduate, or 5

more than 4-year college degree? 6

DON’T KNOW d

REFUSED r

ALL

7

2001 CHIP 7.70.1

.10a The next questions are about your health insurance during your current pregnancy.

Are you currently covered by insurance from a current or past employer or union?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

s6 = 1: state chip program name

7

2001 CHIP 7.70.2

.10b Are you currently covered by a private insurance plan purchased directly from an insurance company? Do not include plans that only provide extra cash while in the hospital or those that cover only one type of service, such as dental care, vision care, nursing home care, or accidents?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

FILL State medicaid program name

If state = georgia, display first probe on screen

If state = illinois, display second probe on screen

7

2001 CHIP 7.70.3

.10c Are you currently covered by [STATE MEDICAID PROGRAM NAME], the government assistance program for people in need?

IF STATE = GEORGIA, PROBE: You may also call this Georgia Families, Amerigroup, Peach State Health Plan, WellCare or Georgia Better Health Care (GBHC)

IF STATE = ILLINOIS, PROBE: You may also call this KidCare or Medical Assistance Program.

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

state chip program name

if state = georgia, display first probe on screen

if state = illinois, display second probe on screen

7

2001 CHIP 7.70.4

.10d Are you currently covered by [STATE CHIP program]?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF STATE = GEORGIA, PROBE: You may also call this Georgia Families, Amerigroup, Peach State Health Plan or WellCare.

IF STATE = ILLINOIS, PROBE: You may also call this KidCare or Medical Assistance Program.

ALL

7

2001 CHIP 7.70.5

.10e Are you currently covered by some other type of coverage I have not yet mentioned?

YES (SPECIFY)_______________(STRING 100) 1

NO 0

DON’T KNOW d

REFUSED r

Box 7.10F

If any question Q7.10a–e=1 (R has some type of health insurance), go to box 7.10h; else go to Q7.10f.

If Q7.10a-e = 0, d, r

7

HS K8

.10f It appears that you do not currently have health insurance coverage to help pay for services from hospitals, doctors, and other health care providers. Is that correct?

CORRECT, HAS NO COVERAGE 1 GO TO Q7.11

WRONG, HAS SOME COVERAGE 0 GO TO Q7.10g

DON’T KNOW d GO TO Q7.11

REFUSED r GO TO Q7.11

Q7.10f=0

7

HS K9

.10g What kind of health coverage do you have?

INTERVIEWER: Read and Code All That Apply

	yes	no	DK	REF
a Insurance through an employer or union	1	0	d	r
b Insurance you purchased from a private insurance company	1	0	d	r
c State CHIP insurance	1	0	d	r
d Medicaid or Medicaid HMO	1	0	d	r
e Some other coverage (SPECIFY)	1	0	d	r
___________________________(STRING 200)

all

7

HS J9

HSJ9

.11 Are you currently working 35 hours or more per week, less than 35 hours per week, or are you not working?

PROBE: IF R SAYS ON MATERNITY LEAVE OR ON VACATION, PROBE IF SHE IS USUALLY EMPLOYED FULL OR PART-TIME.

CODE ONE ONLY

35 OR MORE HOURS PER WEEK 1 GO TO Q8.1

LESS THAN 35 HOURS PER WEEK 2

NOT WORKING (INCLUDES RETIRED, HOMEMAKER, STUDENT, DISABLED) 3

DON’T KNOW d

REFUSED r

iF q7.11 = 2, 3, D, R

7.12 Are you currently actively looking for work?

YES 1

NO 0

DON’T KNOW d

REFUSED r

K. FUTURE CONTACT INFORMATION

all

Prepoluate name and address fields

8

LA

New question

.1 Thank you very much for taking part in this survey! I’d like to send you the $20 gift card in appreciation of your help. May I please confirm your full name and address so I can have it mailed to you?

NAME: FIRST, MIDDLE, LAST

ADDRESS 1

ADDRESS 2

CITY, STATE, ZIP

all

8

New question

.2 I would like to ask your permission for our study team to access your electronic health records to collect a small amount of health information. Do I have your permission for the study team to do that?

PROBE IF NEEDED: We will be collecting information about the number and types of health care visits you had during your pregnancy.

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

8

New question

.3 We would like to call you again in about 9 months to talk about your experiences with your new baby. We will give you another $20 gift card at that time for completing a brief survey with us.

Will we be able to contact you at the same address and phone number that you just gave me?

YES, NOT PLANNING TO MOVE 1 GO TO Q8.4

NO, PLANNING TO MOVE 2

NOT SURE 3

DON’T KNOW d GO TO Q8.4

REFUSED r GO TO Q8.4

Q8.3=2, 3

8

New question

.3a Do you already know the address or town where you’re planning to move?

YES 1

NO 0 GO TO Q8.4

DON’T KNOW d GO TO Q8.4

REFUSED r GO TO Q8.4

Q8.3a=1

8

New question

.3b May I please have that address and phone number so we can contact you in 9 months? If you are planning to change your name, please tell me the new name as well.

PROBE: IF RESPONDENT ONLY KNOWS THE GENERAL LOCALE OF THE NEW LOCATION, RECORD AS MUCH INFORMATION YOU CAN.

NAME: FIRST, MIDDLE, LAST

ADDRESS 1

ADDRESS 2

CITY, STATE, ZIP

TELEPHONE NUMBER WITH AREA CODE: | | | | - | | | | - | | | | |

CELL PHONE NUMBER: | | | | - | | | | - | | | | |

WORK NUMBER: | | | | - | | | | - | | | | |

DON’T KNOW d

REFUSED r

SOFT CHECK: IF PROGRAMMER DETERMINES THE ZIP OR AREA CODE IS OUT OF RANGE: I may have recorded the [ZIP CODE/AREA CODE] wrong. Can you please repeat it for me?

ALL

8

LA Healthy Families P2

.4 Please give me the name and address information for two relatives or close friends who will know how to reach you in case we have trouble finding you? These should be people you don’t currently live with.

CONTACT 1: ASK THE RESPONDENT TO SPELL THE NAME

NAME: FIRST, MIDDLE, LAST

ADDRESS 1

ADDRESS 2

CITY, STATE, ZIP

DON’T KNOW d

REFUSED r

SOFT CHECK: IF AREA CODE OR ZIP CODE IS OUT OF RANGE: I may have entered the [AREA CODE/ZIP CODE] wrong. Can you please repeat it?

all

8

LA Healthy Families P4

.4a What is his or her relationship to you?

(STRING (NUM))

RELATIONSHIP

DON’T KNOW d

REFUSED r

all

8

LA Healthy Families P5

.4b What is his or her telephone number?

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF THIS IS OUT OF RANGE: I may have entered the area code wrong. Can you please repeat it?

ALL

8

LA Healthy Families P6

.4c Is the phone listed in [CONTACT 1]’s name?

YES 1 GO TO Q8.8

NO 0

DON’T KNOW d

REFUSED r

ALL

8

LA Healthy Families P7

.4d In whose name is the phone listed?

NAME: FIRST, MIDDLE, LAST

DON’T KNOW d

REFUSED r

ALL

8

LA Healthy Families P2

.5 Please give me the name and address information for a second relative or close friend who will know how to reach you in case we have trouble finding you?

CONTACT 2: ASK THE RESPONDENT TO SPELL THE NAME

NAME: FIRST, MIDDLE, LAST

ADDRESS 1

ADDRESS 2

CITY, STATE, ZIP

DON’T KNOW d

REFUSED r

SOFT CHECK: IF AREA CODE OR ZIP CODE IS OUT OF RANGE: I may have entered the [AREA CODE/ZIP CODE] wrong. Can you please repeat it?

all

8

LA Healthy Families P4

.5a What is his or her relationship to you?

(STRING (NUM))

RELATIONSHIP

DON’T KNOW d

REFUSED r

all

8

LA Healthy Families P5

.5b What is his or her telephone number?

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF THIS IS OUT OF RANGE: I may have entered the area code wrong. Can you please repeat it?

ALL

8

LA Healthy Families P6

.5c Is the phone listed in [CONTACT 2]’s name?

YES 1 GO TO Q8.8

NO 0

DON’T KNOW d

REFUSED r

ALL

8

LA Healthy Families P7

.5d In whose name is the phone listed?

(STRING (NUM))

FIRST NAME

(STRING (NUM))

MIDDLE INITIAL/NAME

(STRING (NUM))

LAST NAME

DON’T KNOW d

REFUSED r

Box 8.6

If Q5.9 = 5 ASK Q8.6

ELSE GO TO BOX BEFORE Q8.7

Q5.9 = 5

8

New7

.6 You mentioned earlier that you have more than 7 alcoholic drinks in an average week during this pregnancy. I can give you a toll-free number to call to get information to help you quit drinking. Would you like the phone number?

YES 1

NO 0 GO TO Q8.7

DON’T KNOW d GO TO Q8.7

REFUSED r GO TO Q8.7

8

New

.6a You’ll need a pen or pencil to write down the toll-free number: 800-662-4357. You can call this number at any time.

Box 8.7

If Q5.10 = 5 ASK Q8.7

Else go to Q8.8

Q5.10 = 5

IF Q5.9 =1, 2, 3, 4, d, r and Q5.10 = 5: You mentioned earlier

IF Q5.9 = 5 and Q5.10 = 5: You also mentioned

8

New

.7 [You mentioned earlier/You also mentioned] that you smoke more than 20 cigarettes a day on average. I can give you a toll-free number to call to get information to help you quit smoking. Would you like the phone number?

YES 1

NO 0 GO TO Q8.8

DON’T KNOW d GO TO Q8.8

REFUSED r GO TO Q8.8

Q8.7 = 1

IF Q8.6 ne 1 and Q8.7 = 1: You’ll need a pen or pencil to write down this

IF Q8.6 = 1 and Q8.7 = 1: Here is the

8

New

.7a [You’ll need a pen or pencil to write down this/Here is the] toll-free number: 800-784-8669. You can call this number at any time.

all

8

New

.8 This ends our survey. Thank you for speaking with me today. If you have any questions please call our helpline toll-free number at 800-xxx-xxxx. Have a very nice (day/night/weekend). Good-bye.

L. Survey Backend

Hello = 9

End 1 = Sorry for disturbing you. Thanks for your time. Good-bye. Status 530

HealthProb = 4

End 2 = Thanks for explaining about [NAME]’s condition. We won’t be able to interview her and will remove her name from our call list. Good-bye.

If HealthProb = 4 (COGNITIVE PROBLEM) Status 412

HealthProb = 5

End 3 = Thanks for explaining about [NAME]’s condition. We won’t be able to interview her and will remove her name from our call list. Good-bye.

If HealthProb = 5 (COMA) Status 420

AmpTTY = 0 or 4, CallLater = 0 or r

End 4 = Thanks for your time. Good-bye. Status 210

(Gatekeeper refusal for R to use AmpTTY etc, will be called back by converter)

Deceased = d, r

End 5 = I’m very sorry for your loss. Please accept my condolences. Status 440

[If needed, I can give you a phone number to call if you’d like to receive grief counseling.]

Institution = 2, 3, 4, or 5

End 6 = Since [NAME] does not live at home, we are not able to interview her. We will remove her name from our call list.

If Institution = 2,3,4 Status 420

If Institution = 5 (jail/prison) Status 421

HomeSoon = 0

End 7 = I’m sorry to hear [NAME] won’t be home anytime soon. We’ll call back later to learn if she’s home yet. Status 380

KnowWhere = 0, d, r or NewPhone = 2 or NewAddr = d, r or SendLetter = d or PhoneCheck = 4

End 8 = Thank you for your time. Good-bye Status 530

NewPhone = 2

End 9 = Thank you for your time. We won’t be able to interview [NAME] as she’s out of

the country. We’ll remove her name from our call list Status 450

Lang = 1

End 10 = Thank you for your time. An interviewer who speaks Spanish will call you back later..

[Status 401]

Lang = 2 – 7 or OtherLang = d, r

End 11 = Thanks for your time. An interpreter will call back later .. Status 400

T1 = 0, d, r

End 12 = Thanks for your time. We are not interviewing women who are not currently pregnant. Good-bye. Status 460

T1 = 0, d, r (parent/guardian refusal)

End 13 = Thanks for your time. We won’t be interviewing [FIRST NAME] and will remove her name from our calling list.

Good-bye. Status 210

T1 = d, r or (respondent dk, refusal), T1a = d, r, T1b = d, k, T3 = r

End 14 = Thanks for your time. Good-bye. Status 210

(Note: this respondent will be called again)

Check = 0 (Speaking to wrong person)

End 15 = I’m sorry to bother you. Thank you. Goodbye Status Locating