18.2 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/2013

6-Month Infant Feeding SAQ, Phase 2

6-Month Infant Feeding SAQ

Event:	6-Month
Participant:	Child
Domain:	Questionnaire
Type of Document:	Self-Administered Questionnaire
Recruitment Groups:	EH, PB, HI, PBS
Allowable Mode:	PAPI
Allowable Method: Version:	In-Person, Mail 2.3
Release:	MDES 3.0

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6-Month Infant Feeding SAQ

TABLE OF CONTENTS

INTERVIEW INTRODUCTION 1

CHILD FEEDING QUESTIONNAIRE 2

6-Month Infant Feeding SAQ

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

Interview Introduction

INTERVIEWER INSTRUCTION:

• IF COMPLETED AS A PAPI, ENTER THE CHILD’S 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. First, we will ask about the milk, formula, and food your child has eaten.

CFQ003/(BREAST_FEED). Did you ever breast feed your baby?

Yes 1

No 2 (PUMPED)

CFQ005/(BREAST_FEED_NOW). Are you currently breast feeding your baby?

Yes 1

No 2

CFQ007/(PUMPED). Did you ever feed your baby pumped or expressed breast milk?

Yes 1

No 2

PROGRAMMER INSTRUCTIONS:

• IF BREAST_FEED_NOW = 2 AND PUMPED = 2, GO TO (BREAST_STOP)/(BREAST_STOP_UNIT).

• IF BREAST_FEED_NOW = 1 AND PUMPED = 2, GO TO CFQ012.

• OTHERWISE, GO TO PUMPED_NOW.

CFQ009/(PUMPED_NOW). Are you currently feeding your baby pumped or expressed breast milk?

Yes 1 (CFQ012)

No 2 (CFQ012)

CFQ011/(BREAST_STOP) /(BREAST_STOP_UNIT). How old was your baby when you completely stopped feeding your baby breast milk?

|___|___|

Number

Weeks………….………………………………..…………………………………. 1

Months………..….………………………….…………..………………………… 2

Never fed breast milk ……………… -7

CFQ012. The next questions will ask about the milk, formula, and food your child has eaten. In the past 7 days, how often was your baby fed each item listed below?

PARTICIPANT INSTRUCTIONS:

• 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 spaces above “Number” and then circle “1” for “Day” below.

• If your baby was fed the item less than once a day, write the number of feedings per week in the spaces above “Number” and then circle “2” for “Week” below.

• If your baby was not fed the item at all during the past 7 days, write “00” in the spaces above “Number”.

CFQ012A/(BREAST_MILK/BREAST_UNIT) In the past 7 days, how often was your baby fed breast milk (include breast fed and expressed or pumped breast milk)?

|___|___|

Number

REFUSED -1

DON’T KNOW -2

Day 1

Week 2

CFQ012B/(FORMULA_OFTEN/FORMULA_OFTEN_UNIT) In the past 7 days, how often was your baby fed formula?

|___|___|

Number

REFUSED -1

DON’T KNOW -2

Day 1

Week 2

CFQ012C/(COW_MILK/COW_MILK_UNIT) In the past 7 days, how often was your baby fed cow’s milk?

|___|___|

Number

REFUSED -1

DON’T KNOW -2

Day 1

Week 2

CFQ012D/(MILK_OTHER/MILK_OTHER_UNIT) In the past 7 days, how often was your baby fed other milk (soy milk, rice milk, goat milk)?

|___|___|

Number

REFUSED -1

DON’T KNOW -2

Day 1

Week 2

PROGRAMMER INSTRUCTIONS:

• IF BREAST_MILK = 0, PUMPED = 2 OR PUMPED_NOW = 2, GO TO FORMULA.

• OTHERWISE, GO TO PUMPED_2.

CFQ013/(PUMPED_2). 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 -7 (FORMULA)

1 time per week 2

2 to 4 times per week 3

Nearly every day 4

1 to 3 times per day 5

More than 4 times per day 6

CFQ015/(BREAST_MILK_STORED). 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 1

2-3 days 2

4-5 days 3

More than 6 days 4

Did not store breast milk in refrigerator -7

CFQ017/(BREAST_MILK_TEMP). 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 1

2-4 hours 2

5-8 hours 3

More than 8 hours 4

Did not keep breast milk at room temperature -7

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

Less than one week 1

7 to 13 days 2

14 to 31 days 3

More than 31 days 4

Never fed formula -7 (CFQ048)

CFQ027/(FORMULA_IRON). Was the formula fed to your baby within the past 7 days with iron or a low iron formula?

With iron 1

Low iron 2

CFQ031/(FORMULA_TYPE). 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?

PARTICIPANT INSTRUCTION:

• Select all that apply.

Ready-to-feed 1

Liquid concentrate 2

Powder from a can that makes more than one bottle 3

Powder from single serving packets 4

PROGRAMMER INSTRUCTIONS:

• If FORMULA_TYPE = 1 , GO TO OUNCES.

• IF FORMULA_TYPE = ANY COMBINATION OF 2 THROUGH 4, GO TO FORMULA_LABEL.

• IF FORMULA_TYPE = ANY COMBINATION OF 2 THROUGH 4 AND 1, GO TO FORMULA_LABEL.

CFQ034/(FORMULA_LABEL). When the formula was mixed, was it made according to the directions on the formula label?

Yes 1 (WATER_1)

No 2

CFQ035/(FORMULA_AMT)/(FORMULA_UNIT)(WATER_AMT)/(WATER_UNIT). When the formula was mixed, how much formula and how much water were used?

|___|___|

Number

Tablespoon 1

Teaspoon 2

Ounce 3

Cup 4

Packet…………………………………………………………….. 5

Formula Can…………………………………………………….. 6

|___|___|

Number

Tablespoon 1

Teaspoon 2

Ounce 3

CFQ036/(WATER_1). 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?

PARTICIPANT INSTRUCTION:

• Select all that apply.

Tap water from the cold faucet 1

Warm tap water from the hot faucet 2

Bottled water 3

No water used 4 (OUNCES)

CFQ038/(WATER_2). In the past 7 days, was the water used to mix the formula ALWAYS boiled?

Yes 1

No 2

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

|__|__| Ounces

CFQ044. 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:

PROGRAMMER INSTRUCTION:

• DISPLAY ABOVE INTRODUCTORY STATEMENT FOR CLEAN_HANDS_1, CLEAN_HANDS_2, CLEAN_HANDS_3, CLEAN_HANDS_4, & CLEAN_HANDS_5.

CFQ044A/(CLEAN_HANDS_1). Rinse hands with water only.

Never 1

Sometimes 2

Most of the Time 3

Always 4

CFQ044B/(CLEAN_HANDS_2). Wipe hands only.

Never 1

Sometimes 2

Most of the Time 3

Always 4

CFQ044C/(CLEAN_HANDS_3). Wash hands with soap.

Never 1

Sometimes 2

Most of the Time 3

Always 4

CFQ044D/(CLEAN_HANDS_4). Use a hand sanitizer (such as gel or wipes).

Never 1

Sometimes 2

Most of the Time 3

Always 4

CFQ044E/(CLEAN_HANDS_5). Prepare formula without cleaning your hands.

Never 1

Sometimes 2

Most of the Time 3

Always 4

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

PROGRAMMER INSTRUCTION:

• DISPLAY ABOVE INTRODUCTORY STATEMENT FOR B_TYPE_1, B_TYPE_2, B_TYPE_3, B_TYPE_4, & B_TYPE_5.

CFQ048A/(B_TYPE_1). Plastic baby bottle with disposable bottle liner.

Never 1

Sometimes 2

Most of the Time 3

Always 4

CFQ048B/(B_TYPE_2). Plastic baby bottle without disposable liner.

Never 1

Sometimes 2

Most of the Time 3

Always 4

CFQ048C/(B_TYPE_3). Other plastic bottle (for example, a water bottle).

Never 1

Sometimes 2

Most of the Time 3

Always 4

CFQ048D/(B_TYPE_4). Glass baby bottle.

Never 1

Sometimes 2

Most of the Time 3

Always 4

CFQ048E/(B_TYPE_5.) Plastic “no spill” cup.

Never 1

Sometimes 2

Most of the Time 3

Always 4

CFQ050/(PACIFIER). Has your baby used a pacifier in the past 7 days?

Yes 1

No 2

CFQ052/(COWS_MILK_1). 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 1

No 2 (JUICE)

CFQ054/(COWS_MILK_2/COWS_MILK_2_UNIT). How old was your baby when he/she was first fed cow’s milk that was not sold especially for babies?

|___|___|

Number

Days 1

Weeks………………………………………………………………………………..2

CFQ056/(JUICE). Have you ever fed your baby fruit juice that was not sold especially for babies?

Yes 1

No 2 (CFQ062)

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

|___|___|

Number

Days 1

Weeks 2

CFQ060/(JUICE_CALCIUM). About how often was the fruit juice fortified with calcium?

Always 1

Sometimes 2

Rarely 3

Never 4

Don’t know -2

CFQ062. 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.)

PROGRAMMER INSTRUCTION:

• DISPLAY ABOVE INTRODUCTORY STATEMENT FOR C_FOOD1, C_FOOD2, C_FOOD3, C_FOOD4, & C_FOOD5

CFQ062A/(C_FOOD1). Fruit and vegetable juice.

Always 1

Usually 2

Sometimes 3

Never 4

Not Fed to My Baby 5

CFQ062B/(C_FOOD2). Fruit.

Always 1

Usually 2

Sometimes 3

Never 4

Not Fed to My Baby 5

CFQ062C/(C_FOOD3). Vegetable.

Always 1

Usually 2

Sometimes 3

Never 4

Not Fed to My Baby 5

CFQ062D/(C_FOOD4). Meat, chicken and turkey.

Always 1

Usually 2

Sometimes 3

Never 4

Not Fed to My Baby 5

CFQ062E/(C_FOOD5). Combination dinner (for example, Spaghetti Dinner, Pasta and Vegetable Dinner, or a Turkey and Rice Dinner).

Always 1

Usually 2

Sometimes 3

Never 4

Not Fed to My Baby 5

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

Always 1

Sometimes 2

Rarely 3

Never 4

Don’t know -2

CFQ066/(SUPPLEMENT). Which of the following supplements was your child given at least three days a week during the past 2 weeks?

PARTICIPANT INSTRUCTION:

• Select all that apply.

Fluoride 1

Iron 2

Vitamin D 3

Other vitamins or supplements -5

None 5

PROGRAMMER INSTRUCTIONS:

• IF SUPPLEMENT =ANY COMBINATION OF 1 THROUGH 3, GO TO SUPP_FORM.

• IF SUPPLEMENT = -5 OR ANY OTHER COMBINATION OF 1 THROUGH 3 AND -5, GO TO SUPPLEMENT_OTH.

• IF SUPPLEMENT = 5, GO TO HERBAL.

• OTHERWISE, GO TO SUPP_FORM.

CFQ067/(SUPPLEMENT_OTH)

Specify: _______________________

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

CFQ068/(SUPP_FORM). Were the supplements you gave your baby in the form of drops or pills?

PARTICIPANT INSTRUCTION:

• Mark crushed pills mixed with liquid as “pills”.

Drops 1

Pills 2

CFQ070/(HERBAL). 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 1

No 2 (TIME_STAMP_2)

CFQ071/(HERBAL_OTH). 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.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

(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 PARTICIPANT TO RETURN.

Public reporting burden for this collection of information is estimated to average 10 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.