2.2 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Pre-Pregnancy Questionnaire - Adult, Phase 2g

OMB Specification

Pre-Pregnancy Questionnaire - Adult

Event Category:	Trigger-Based
Event:	Pre-Pregnancy
Administration:	N/A
Instrument Target:	Pre-Pregnant Woman
Instrument Respondent:	Pre-Pregnant Woman
Domain:	Questionnaire
Document Category:	Questionnaire
Method:	Data Collector Administered
Mode (for this instrument*):	In-Person, CAI; Phone, CAI
OMB Approved Modes:	In-Person, CAI; Phone, CAI; Web-Based, CAI
Estimated Administration Time:	12 minutes
Multiple Child/Sibling Consideration:	Per Event
Special Considerations:	N/A
Recruitment Groups:	All
Version:	1.0
MDES Release:	4.0

*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.

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Pre-Pregnancy Questionnaire - Adult

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

INTERVIEW INTRODUCTION 3

MEDICAL HISTORY 7

HEALTH INSURANCE 11

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS 14

TRACING QUESTIONS 22

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Pre-Pregnancy Questionnaire - Adult

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

INTERVIEW INTRODUCTION

(TIME_STAMP_II_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PARTICIPANT ID (P_ID) AND RESPONDENT ID (R_P_ID) FOR ADULT.

• PRELOAD R_FNAME, R_LNAME, PERSON_DOB_MM, PERSON_DOB_DD, AND PERSON_DOB_YYYY.

II01000. Thank you for agreeing to participate in the National Children’s Study.  This interview will take about 12 minutes to complete.  Your answers are important to us.  There are no right or wrong answers, just those that help us understand your situation.  During this interview, we will ask about yourself, your health, where you live, and your feelings about being a part of the National Children’s Study.  You can skip over any questions or stop the interview at any time.  We will keep everything that you tell us confidential.

 

First, we’d like to make sure we have your correct name and birth date.

PROGRAMMER INSTRUCTIONS

• IF R_FNAME AND R_LNAME COLLECTED PREVIOUSLY AND ≠ -1 OR -2, GO TO NAME_CONFIRM.

• OTHERWISE, GO TO ​II03000.

II02000/(NAME_CONFIRM). Is your name {PARTICIPANT NAME}?

Label	Code	Go To
YES	1	DOB_CONFIRM
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Vanguard Phase

PROGRAMMER INSTRUCTIONS

• DISPLAY R_FNAME ​AS PARTICIPANT NAME.

II03000. What is your full name?

SOURCE

National Children’s Study, Legacy Phase (PregScreener)

(R_FNAME) _____________________    

FIRST NAME

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(R_LNAME) _____________________

LAST NAME

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

INTERVIEWER INSTRUCTIONS

• IF PARTICIPANT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS, ASK FOR INITIALS OR SOME OTHER NAME SHE WOULD LIKE TO BE CALLED

• CONFIRM SPELLING OF FIRST NAME IF NOT PREVIOUSLY COLLECTED AND OF LAST NAME.

PROGRAMMER INSTRUCTIONS

• IF PERSON_DOB_MM, PERSON_DOB_DD, AND PERSON_DOB_YYYY COLLECTED PREVIOUSLY AND ≠ -1 OR -2, GO TO DOB_CONFIRM.

• OTHERWISE, GO TO II05000.

II04000/(DOB_CONFIRM). Is your birth date {PARTICIPANT’S DATE OF BIRTH}?

Label	Code	Go To
YES	1	AGE_ELIG
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Vanguard Phase

PROGRAMMER INSTRUCTIONS

• DISPLAY PERSON_DOIB_MM, PERSON_DOB_DD, AND PERSON_DOB_YYYY AS PARTICIPANT'S DATE OF BIRTH.

• IF DOB_CONFIRM = 1, SET PERSON_DOB_MM, PERSON_DOB_DD, AND PERSON_DOB_YYYY TO KNOWN VALUE

INTERVIEWER INSTRUCTIONS

• IF PARTICIPANT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB IS REQUIRED TO DETERMINE ELIGIBILITY

II05000. What is your date of birth?

SOURCE

National Children’s Study, Legacy Phase (P1 and T1 Mom)

(PERSON_DOB_MM) MONTH: |___|___|

                M   M

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(PERSON_DOB_DD) DAY: |___|___|

           D    D

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(PERSON_DOB_YYYY) YEAR: |___|___|___|___|

             Y    Y     Y     Y

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

INTERVIEWER INSTRUCTIONS

• IF PARTICIPANT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB IS REQUIRED TO DETERMINE ELIGIBILITY

• ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR

PROGRAMMER INSTRUCTIONS

• INCLUDE A SOFT EDIT/WARNING IF CALCULATED AGE IS LESS THAN LOCAL AGE OF MAJORITY OR GREATER THAN 50

II06000/(AGE_ELIG).

Label	Code	Go To
PARTICIPANT IS AGE-ELIGIBLE	1	TIME_STAMP_II_ET
PARTICIPANT IS YOUNGER THAN AGE OF MAJORITY	2
PARTICIPANT IS OVER AGE 49	3
AGE ELIGIBILITY IS UNKNOWN	-6	TIME_STAMP_II_ET

INTERVIEWER INSTRUCTIONS

• IF VALUE IS “REFUSED” OR “DON’T KNOW” FLAG CASE FOR SUPERVISOR REVIEW AT ROC TO CONFIRM AGE ELIGIBILITY POST-INTERVIEW.

PROGRAMMER INSTRUCTIONS

• BASED ON DOB_CONFIRM OR PERSON_DOB_MM, PERSON_DOB_DD, AND ​PERSON_DOB_YYYY CALCULATE AGE.  USING KNOWN LOCAL AGE OF MAJORITY DETERMINE IF SHE IS ELIGIBLE (AT LEAST AGE OF MAJORITY AND LESS THAN AGE 50); SET AGE_ELIG AS APPROPRIATE.

(TIME_STAMP_II_ET).

PROGRAMMER INSTRUCTIONS

• INSERT/TIMESTAMP

MEDICAL HISTORY

(TIME_STAMP_MH_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

MH01000. Next, I have some general questions about your health and health care.

MH02000/(HEALTH). Would you say your health in general is . . .

Label	Code	Go To
Excellent	1
Very good	2
Good	3
Fair	4
Poor	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System

MH03000/(EVER_PREG). Have you ever been pregnant?  Please include live births, miscarriages, stillbirths, ectopic pregnancies, and pregnancy terminations.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Avon Longitudinal Study of Parents and Children

MH04000. The next questions are about medical conditions or health problems you might have now or may have had in the past.

MH05000/(ASTHMA). Have you ever been told by a doctor or other health care provider that you had asthma?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

MH06000/(HIGHBP). (Have you ever been told by a doctor or other health care provider that you had)…

 

Hypertension or high blood pressure {when you’re not pregnant}?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT AS NEEDED

PROGRAMMER INSTRUCTIONS

• IF EVER_PREG ≠ 2 DISPLAY, “when you’re not pregnant"

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

MH07000/(DIABETES_1). (Have you ever been told by a doctor or other health care provider that you had)…

 

High blood sugar or Diabetes {when you’re not pregnant}?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT AS NEEDED

PROGRAMMER INSTRUCTIONS

• IF EVER_PREG ≠ 2 DISPLAY, “when you’re not pregnant”

Label	Code	Go To
YES	1
NO	2	THYROID_1
REFUSED	-1	THYROID_1
DON'T KNOW	-2	THYROID_1

SOURCE

National Health and Nutrition Examination Survey (modified)

MH08000/(DIABETES_2). Have you taken any medicine or received other medical treatment for diabetes in the past 12 months?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

MH09000/(DIABETES_3). Have you ever taken insulin?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

MH10000/(THYROID_1). (Have you ever been told by a doctor or other health care provider that you had) Hypothyroidism, that is, an under-active thyroid?

Label	Code	Go To
YES	1
NO	2	VITAMIN
REFUSED	-1	VITAMIN
DON'T KNOW	-2	VITAMIN

SOURCE

National Health and Nutrition Examination Survey (modified)

MH11000/(THYROID_2). Have you taken any medicine or received other medical treatment for a thyroid problem in the past 12 months?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

MH12000/(VITAMIN). Do you currently take multivitamins, prenatal vitamins, folic acid, or folate?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (modified)

MH13000. This next question is about where you go for routine health care.

MH14000/(HLTH_CARE). What kind of place do you usually go to when you need routine or preventive care, such as a physical examination or check-up?

Label	Code	Go To
Clinic or health center	1
Doctor's office or Health Maintenance Organization (HMO)	2
Hospital emergency room	3
Hospital outpatient department	4
Some other place	5
DOESN'T GO TO ONE PLACE MOST OFTEN	6
DOESN'T GET PREVENTIVE CARE ANYWHERE	-7
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Vanguard Phase

(TIME_STAMP_MH_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

HEALTH INSURANCE

(TIME_STAMP_HI_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

HI01000. Now I’m going to switch to another subject and ask about health insurance.

HI02000/(INSURE). Are you currently covered by any kind of health insurance or some other kind of health care plan?

Label	Code	Go To
YES	1
NO	2	TIME_STAMP_HI_ET
REFUSED	-1	TIME_STAMP_HI_ET
DON'T KNOW	-2	TIME_STAMP_HI_ET

SOURCE

National Health Interview Survey (modified)

HI03000. Now I’ll read a list of different types of insurance. Please tell me which types you currently have.

HI04000/(INS_EMPLOY). Insurance through an employer or union either through yourself or another family member?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (Do you currently have...) AS NEEDED

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey (modified)

HI05000/(INS_MEDICAID). Medicaid or any government-assistance plan for those with low incomes or a disability?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (Do you currently have...) AS NEEDED

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey (modified)

HI06000/(INS_TRICARE). TRICARE, VA, or other military health care?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (Do you currently have...) AS NEEDED

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey (modified)

HI07000/(INS_IHS). Indian Health Service?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (Do you currently have...) AS NEEDED

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey (modified)

HI08000/(INS_MEDICARE). Medicare, for people with certain disabilities?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (Do you currently have...) AS NEEDED

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey (modified)

HI09000/(INS_OTH). Any other type of health insurance or health coverage plan?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (Do you currently have...) AS NEEDED

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey (modified)

(TIME_STAMP_HI_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS

(TIME_STAMP_HCA_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

HCA01000. Now, I’d like to ask some questions about your schooling and employment.

HCA02000/(EDUC). What is the highest degree or level of school that you have completed?

INTERVIEWER INSTRUCTIONS

• IF USING SHOW CARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOW CARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
LESS THAN A HIGH SCHOOL DIPLOMA OR GED	1
HIGH SCHOOL DIPLOMA OR GED	2
SOME COLLEGE BUT NO DEGREE	3
ASSOCIATE DEGREE	4
BACHELOR’S DEGREE (E.G., BA, BS)	5
POST GRADUATE DEGREE (E.G., MASTERS OR DOCTORAL)	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Decennial Census

HCA03000/(WORK_CURRENTLY). Are you currently employed?

Label	Code	Go To
YES	1
NO	2	HCA06000
REFUSED	-1	HCA06000
DON'T KNOW	-2	HCA06000

SOURCE

Pregnancy, Infection, and Nutrition Study

HCA04000/(HOURS). Approximately how many hours each week are you working?

 

|___|___|___|

NUMBER OF HOURS

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Pregnancy, Infection and Nutrition Study

PROGRAMMER INSTRUCTIONS

• INCLUDE A SOFT EDIT IF RESPONSE > 60

HCA05000/(SHIFT_WORK). Do you currently work a shift that starts after 2pm?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Avon Longitudinal Study of Parents and Children (modified)

HCA06000. The next questions may be similar to those asked the last time we contacted you, but we are asking them again because sometimes the answers change.

HCA07000/(MARISTAT). I’d like to ask about your marital status. Are you:

INTERVIEWER INSTRUCTIONS

• PROBE FOR CURRENT MARITAL STATUS.

Label	Code	Go To
Married,	1
Not married but living together with a partner	2
Never been married,	3	TIME_STAMP_HCA_ET
Divorced,	4	TIME_STAMP_HCA_ET
Separated, or	5	TIME_STAMP_HCA_ET
Widowed?	6	TIME_STAMP_HCA_ET
REFUSED	-1	TIME_STAMP_HCA_ET
DON'T KNOW	-2	TIME_STAMP_HCA_ET

SOURCE

National Survey of Family Growth

HCA08000/(SP_EDUC). What is the highest degree or level of school that your spouse or partner has completed?

INTERVIEWER INSTRUCTIONS

• IF USING SHOW CARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOW CARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
LESS THAN A HIGH SCHOOL DIPLOMA OR GED	1
HIGH SCHOOL DIPLOMA OR GED	2
SOME COLLEGE BUT NO DEGREE	3
ASSOCIATE DEGREE	5
BACHELOR’S DEGREE (E.G., BA, BS)	5
POST GRADUATE DEGREE (E.G., MASTERS OR DOCTORAL)	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Decennial Census

HCA09000/(SP_ETHNIC_1). Is your spouse or partner of Hispanic, Latino/a, or Spanish origin?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (modified)

PROGRAMMER INSTRUCTIONS

• IF SP_ETHNIC_1 = 1, GO TO SP_ETHNIC_2.

• IF SP_ETHNIC_1 ≠ 1, AND
  
  

• IF MODE = CAPI, GO TO SP_RACE_NEW.

• IF MODE = CATI, GO TO SP_RACE_1.​

HCA10000/(SP_ETHNIC_2). Is your spouse or partner one or more of the following?

INTERVIEWER INSTRUCTIONS

• SELECT ALL THAT APPLY.

• PROBE: Anything else?

Label	Code	Go To
Mexican, Mexican American, Chicano/a	1
Puerto Rican	2
Cuban	3
Another Hispanic, Latino/a, or Spanish origin	4
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (modified)

PROGRAMMER INSTRUCTIONS

• IF SP_ETHNIC_2 = -5, OR ANY COMBINATION OF 1 THROUGH 4 AND -5, GO TO SP_ETHNIC_2_OTH.

• IF SP_ETHNIC_2 = ANY COMBINATION OF 1 THROUGH 4, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING SP_ETHNIC_2_OTH. 

• IF SP_ETHNIC_2 = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PROGRAMMER INSTRUCTIONS FOLLOWING SP_ETHNIC_2_OTH.

HCA11000/(SP_ETHNIC_2_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (modified)

PROGRAMMER INSTRUCTIONS

• IF MODE = CAPI, GO TO SP_RACE_NEW.

• IF MODE = CATI, GO TO SP_RACE_1.

HCA12000/(SP_RACE_NEW). What is your spouse or partner’s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• IF USING SHOW CARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOW CARDS, READ RESPONSE OPTIONS.

• PROBE FOR ANY OTHER RESPONSES.

• ONLY USE “SOME OTHER RACE” IF VOLUNTEERED.

• SELECT ALL THAT APPLY. 

Label	Code	Go To
WHITE	1
BLACK OR AFRICAN AMERICAN	2
AMERICAN INDIAN OR ALASKA NATIVE	3
ASIAN INDIAN	4
CHINESE	5
FILIPINO	6
JAPANESE	7
KOREAN	8
VIETNAMESE	9
OTHER ASIAN	10
NATIVE HAWAIIAN	11
GUAMANIAN OR CHAMORRO	12
SAMOAN	13
OTHER PACIFIC ISLANDER	14
SOME OTHER RACE	-5
REFUSED	-1
DON't KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (modified)

PROGRAMMER INSTRUCTIONS

• IF SP_RACE_NEW = ANY COMBINATION OF 1 THROUGH 14, GO TO TIME_STAMP_HCA_ET.

• IF SP_RACE_NEW = -5 OR ANY COMBINATION OF 1 THROUGH 14 AND -5, GO TO SP_RACE_NEW_OTH.

• IF SP_RACE_NEW = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO TIME_STAMP_HCA_ET.

HCA13000/(SP_RACE_NEW_OTH). SPECIFY: _____________________________ 

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (modified)

PROGRAMMER INSTRUCTIONS

• GO TO TIME_STAMP_HCA_ET.

HCA14000/(SP_RACE_1). ​What is your spouse or partner’s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• ONLY USE  “SOME OTHER RACE” IF VOLUNTEERED.

• SELECT ALL THAT APPLY. 

Label	Code	Go To
White	1
Black or African American	2
American Indian or Alaska native	3
Asian	4
Native Hawaiian or other Pacific Islander	5
SOME OTHER RACE	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

​U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (modified)

PROGRAMMER INSTRUCTIONS

• IF SP_RACE_1 = ANY COMBINATION OF 1 THROUGH 3, GO TO TIME_STAMP_HCA_ET.
  IF SP_RACE_1 = 4 OR ANY COMBINATION OF 4 AND 1, 2, 3, AND/OR 5, GO TO SP_RACE_2.
  IF SP_RACE_1 = 5 OR ANY COMBINATION OF 5 AND 1 THROUGH 3, GO TO SP_RACE_3.
  IF SP_RACE_1 = -5, OR ANY COMBINATION OF 1 THROUGH 5 AND -5, GO TO SP_RACE_1_OTH.
  IF SP_RACE_1 =  -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO TIME_STAMP_HCA_ET.

HCA15000/(SP_RACE_1_OTH). SPECIFY ___________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

​U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (modified)

PROGRAMMER INSTRUCTIONS

• IF SP_RACE_1 = 4 OR 4 AND ANY COMBINATION OF 1, 2, 3, AND/OR 5, GO TO SP_RACE_2.

• IF SP_RACE_1 = 5 OR 5 AND ANY COMBINATION OF 1 THROUGH 3, GO TO SP_RACE_3.

• OTHERWISE, GO TO TIME_STAMP_HCA_ET.

HCA16000/(SP_RACE_2). ​What is your spouse or partner’s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY. 

Label	Code	Go To
Asian Indian	1
Chinese	2
Filipino	3
Japanese	4
Korean	5
Vietnamese	6
Other Asian	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

​U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (modified)

PROGRAMMER INSTRUCTIONS

• IF SP_RACE_1 = ANY COMBINATION WITH 4 AND 5, GO TO SP_RACE_3.

• OTHERWISE, GO TO ​TIME_STAMP_HCA_ET.

HCA17000/(SP_RACE_3). ​What is your spouse or partner’s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY. 

Label	Code	Go To
Native Hawaiian	1
Guamanian or Chamorro	2
Samoan	3
Other Pacific Islander	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

​U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (modified)

(TIME_STAMP_HCA_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

TRACING QUESTIONS

(TIME_STAMP_TQ_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

TQ01000. The next set of questions asks about different ways we might be able to keep in touch with you.  Please remember that all the information you provide is confidential and will not be provided to anyone outside the National Children’s Study.

TQ02000/(HAVE_EMAIL). Do you have an email address?

Label	Code	Go To
YES	1
NO	2	CELL_PHONE_1
REFUSED	-1	CELL_PHONE_1
DON'T KNOW	-2	CELL_PHONE_1

SOURCE

National Children’s Study, Vanguard Phase (modified)

TQ03000/(EMAIL_2). May we use your personal email address to make future study appointments or send appointment reminders?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Vanguard Phase

TQ04000/(EMAIL_3). May we use your personal email address for questionnaires (like this one) that you can answer over the Internet?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Vanguard Phase

TQ05000/(EMAIL). What is the best email address to reach you?

 

ENTER E-MAIL ADDRESS: ___________________________________

PROGRAMMER INSTRUCTIONS

• DISPLAY EXAMPLE OF VALID EMAIL ADDRESS SUCH AS JANEDOE@EMAIL.COM

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Vanguard Phase

TQ06000/(CELL_PHONE_1). Do you have a personal cell phone?

Label	Code	Go To
YES	1
NO	2	CONTACT_1
REFUSED	-1	CONTACT_1
DON'T KNOW	-2	CONTACT_1

SOURCE

National Children’s Study, Vanguard Phase (modified)

TQ07000/(CELL_PHONE_2). May we use your personal cell phone to make future study appointments or for appointment reminders?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Vanguard Phase

TQ08000/(CELL_PHONE_3). Do you send and receive text messages on your personal cell phone?

Label	Code	Go To
YES	1
NO	2	CELL_PHONE
REFUSED	-1	CELL_PHONE
DON'T KNOW	-2	CELL_PHONE

SOURCE

National Children’s Study, Vanguard Phase

TQ09000/(CELL_PHONE_4). May we send text messages to make future study appointments or for appointment reminders?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Vanguard Phase

TQ10000/(CELL_PHONE). What is your personal cell phone number?

 

|___|___|___|___|___|___|___|___|___|___|

PHONE NUMBER

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Vanguard Phase

TQ11000/(CONTACT_1). Sometimes if people move or change their telephone number, we have difficulty reaching them.  Could I have the name of a friend or relative not currently living with you who should know where you could be reached in case we have trouble contacting you?

Label	Code	Go To
YES	1
NO	2	TQ21100
REFUSED	-1	TQ21100
DON'T KNOW	-2	TQ21100

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

TQ12000. What is this person’s name?

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

(CONTACT_FNAME_1) __________________             

FIRST NAME                    

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(CONTACT_LNAME_1) __________________   

     LAST NAME

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

INTERVIEWER INSTRUCTIONS

• IF PARTICIPANT DOES NOT WANT TO PROVIDE NAME OF CONTACT, ASK FOR INITIALS

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

TQ13000/(CONTACT_RELATE_1). What is his/her relationship to you?

Label	Code	Go To
MOTHER/FATHER	1
BROTHER/SISTER	2
AUNT/UNCLE	3
GRANDPARENT	4
NEIGHBOR	5
FRIEND	6
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

TQ14000/(CONTACT_RELATE1_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

TQ15000. What is his/her address?

INTERVIEWER INSTRUCTIONS

• PROMPT AS NECESSARY TO COMPLETE INFORMATION

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

(C_ADDR1_1) ____________________________________________________

STREET

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(C_ADDR_2_1) ____________________________________________________

STREET

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(C_UNIT_1) ____________________________________________________

UNIT

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(C_CITY_1) ____________________________________________________

CITY 

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(C_STATE_1)

|___|___|  

STATE 

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(C_ZIPCODE_1) |___|___|___|___|___| 

ZIP CODE

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(C_ZIP4_1) - |___|___|___|___|

   +4

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

TQ16000/(CONTACT_PHONE_1). What is his/her telephone number?

 

|___|___|___|___|___|___|___|___|___|___|

PHONE NUMBER

Label	Code	Go To
CONTACT HAS NO TELEPHONE	1
REFUSED	-1
DON'T KNOW	-2

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

INTERVIEWER INSTRUCTIONS

• IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

TQ17000. Now I’d like to collect information on a second contact who does not currently live with you. What is this person’s name?

INTERVIEWER INSTRUCTIONS

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

(CONTACT_FNAME_2) ______________        

FIRST NAME              

Label	Code	Go To
NO SECOND CONTACT PROVIDED	-7	TQ21100
REFUSED	-1	TQ21100
DON'T KNOW	-2	TQ21100

(CONTACT_LNAME_2) __________________

LAST NAME

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

INTERVIEWER INSTRUCTIONS

• IF PARTICIPANT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

TQ18000/(CONTACT_RELATE_2). What is his/her relationship to you?

Label	Code	Go To
MOTHER/FATHER	1
BROTHER/SISTER	2
AUNT/UNCLE	3
GRANDPARENT	4
NEIGHBOR	5
FRIEND	6
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

TQ19000/(CONTACT_RELATE2_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

TQ20000. What is his/her address?

INTERVIEWER INSTRUCTIONS

• PROMPT AS NECESSARY TO COMPLETE INFORMATION

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

(C_ADDR1_2) ____________________________________________________

STREET

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(C_ADDR_2_2) ____________________________________________________

STREET

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(C_UNIT_2) ____________________________________________________

UNIT

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(C_CITY_2) ____________________________________________________

CITY

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(C_STATE_2) |___|___|  

STATE 

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(C_ZIPCODE_2)

|___|___|___|___|___| 

ZIP CODE

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(C_ZIP4_2) |___|___|___|___|

+4

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

TQ21000/(CONTACT_PHONE_2). |___|___|___|___|___|___|___|___|___|___|

PHONE NUMBER

Label	Code	Go To
CONTACT HAS NO TELEPHONE	-7
REFUSED	-1
DON'T KNOW	-2

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

INTERVIEWER INSTRUCTIONS

• IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

TQ21100. Thank you for participating in the National Children’s Study and for taking the time to complete this survey.  This concludes the interview portion of our visit.

INTERVIEWER INSTRUCTIONS

EXPLAIN SAQS AND RETURN PROCESS

(TIME_STAMP_TQ_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 12 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.