12.3 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

6M Questionnaire - Child, Phase 2g

OMB Specification

6M Questionnaire - Child

Event Category:	Time-Based
Event:	6M
Administration:	N/A
Instrument Target:	Child
Instrument Respondent:	Primary Caregiver
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:	5 minutes
Multiple Child/Sibling Consideration:	Per Child
Special Considerations:	N/A
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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6M Questionnaire - Child

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

CHILD DEVELOPMENT - TEETH 3

SLEEP ENVIRONMENT AND ROUTINE 5

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6M Questionnaire - Child

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.

CHILD DEVELOPMENT - TEETH

(TIME_STAMP_CDT_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PARTICIPANT ID (P_ID) FOR CHILD AND RESPONDENT ID (R_P_ID) FOR PARENT/CAREGIVER.

• PRELOAD FIRST NAME OF CHILD (C_FNAME) FROM  PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE AND DISPLAY APPROPRIATE NAME IN “C_FNAME” THROUGHOUT THE INSTRUMENT.

• OTHERWISE, IF C_FNAME IN PARTICIPANT VERIFICATION, SCHEDULING, & TRACING = -1 OR -2, DISPLAY “the child” IN APPROPRIATE FIELDS THROUGHOUT THE INSTRUMENT.

• IF CHILD_SEX IN PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE = 1, DISPLAY “his”, “he”, OR “himself” IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

• IF CHILD_SEX IN PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE = 2, DISPLAY “her”, “she”, OR “herself” IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

• PRELOAD SEC_RES FROM PARTICIPANT VERIFICATION, SCHEDULING & TRACING QUESTIONNAIRE.

CDT01000/(CHILD_HAVE_TEETH). Does {C_FNAME/the child} have any teeth?

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

SOURCE

New

CDT02000/(CHILD_TEETH_NUM). How many teeth does {he/she} have?

 

         |___|___|

         NUMBER OF TEETH

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

SOURCE

Avon Longitudinal Study of Parents And Children 15 Month Questionnaire (modified)

(TIME_STAMP_CDT_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

SLEEP ENVIRONMENT AND ROUTINE

(TIME_STAMP_SE_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

SE01000. Now I would like to ask you a few questions about {C_FNAME/the child}’s sleeping habits.  {When responding to the questions in this section, please think about the responses in relation to {C_FNAME/the child}’s primary address or the place where {he/she} spends most of the time.}

INTERVIEWER INSTRUCTIONS

• IF NECESSARY, REMIND THE PARENT/CAREGIVER THAT THE RESPONSES TO THIS SECTION SHOULD BE IN REFERENCE TO THE CHILD’S PRIMARY RESIDENCE, THE PLACE WHERE THE CHILD SPENDS MOST OF HIS OR HER TIME.    

SOURCE

National Children’s Study, Vanguard 2.0 Phase (Core)

PROGRAMMER INSTRUCTIONS

• IF SEC_RES = 1, DISPLAY "When responding to the questions in this section, please think about the responses in relation to {C_FNAME/the child}’s primary address or the place where {he/she} spends most of the time."

SE02000/(SLEEP_ROOM). In which room does the child sleep?

Label	Code	Go To
In {his/her} own room on {his/her} own	1	CHILD_SLEEP_OFTEN
In a room with other children	2	CHILD_SLEEP_OFTEN
In your bedroom	3	CHILD_SLEEP_OFTEN
OTHER	-5
REFUSED	-1	CHILD_SLEEP_OFTEN
DON'T KNOW	-2	CHILD_SLEEP_OFTEN

SOURCE

Avon Longitudinal Survey of Parents And Children My Young Baby Girl Questionnaire (modified)

SE03000/(SLEEP_ROOM_OTH). SPECIFY: __________________________________

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

SOURCE

Avon Longitudinal Survey of Parents And Children My Young Baby Girl Questionnaire (modified)

SE04000/(CHILD_SLEEP_OFTEN). Please tell me where {C_FNAME/the child} usually sleeps at night. 

Label	Code	Go To
A CRIB	1	CHILD_POSITION_USUAL
A BASSINETTE	2	CHILD_POSITION_USUAL
A CRADLE	3	CHILD_POSITION_USUAL
A CARRY COT OR TRAVELING BED	4	CHILD_POSITION_USUAL
AN ADULT BED OR MATTRESS	5	CHILD_SLEEP_ALONE
A SOFA	6	CHILD_POSITION_USUAL
A PLAYPEN	7	CHILD_POSITION_USUAL
A CAR OR INFANT SEAT	8	CHILD_POSITION_USUAL
A COT	9	CHILD_POSITION_USUAL
A DRAWER	10	CHILD_POSITION_USUAL
A BOX	11	CHILD_POSITION_USUAL
THE FLOOR	12	CHILD_POSITION_USUAL
A BABY BED	13	CHILD_POSITION_USUAL
A SWING	14	CHILD_POSITION_USUAL
A STROLLER OR BUGGY	15	CHILD_POSITION_USUAL
SOMEPLACE ELSE	-5
REFUSED	-1	CHILD_POSITION_USUAL
DON'T KNOW	-2	CHILD_POSITION_USUAL

SOURCE

National Infant Sleep Position, Survey of Households with Children 0-7 Months (modified)

SE05000/(CHILD_SLEEP_OFTEN_OTH). SPECIFY: __________________________________

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

SOURCE

National Infant Sleep Position, Survey of Households with Children 0-7 Months (modified)

PROGRAMMER INSTRUCTIONS

• GO TO CHILD_POSITION_USUAL.

SE06000/(CHILD_SLEEP_ALONE). Does {C_FNAME/the child} usually sleep alone on an adult bed or mattress or share it with another person? 

Label	Code	Go To
ALONE	1	CHILD_SHARE_SOMETIMES
SHARES WITH PARENT(S) OR GUARDIAN	2
SHARES WITH ANOTHER ADULT	3
SHARES WITH ANOTHER CHILD	4
SHARES WITH ADULT AND OTHER CHILD(REN)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Infant Sleep Position, Survey of Households with Children 0-7 Months

SE07000/(CHILD_SHARE_NUM). Counting {C_FNAME/the child}, how many {people/children} ​usually sleep on an adult bed or mattress with {him/her}?

 

|___|___|

NUMBER

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

SOURCE

National Infant Sleep Position, Survey of Households with Children 0-7 Months (modified)

PROGRAMMER INSTRUCTIONS

• IF CHILD_SLEEP_ALONE = 2, 3, OR 5, DISPLAY "people".

• IF CHILD_SLEEP_ALONE = 4, DISPLAY "children".

• GO TO CHILD_POSITION_USUAL.

SE08000/(CHILD_SHARE_SOMETIMES). You said {C_FNAME/the child} usually sleeps alone. Does {C_FNAME/the child}, sometimes share a bed with another person? 

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

SOURCE

National Infant Sleep Position, Survey of Households with Children 0-7 Months

SE09000/(CHILD_POSITION_USUAL). There are a number of positions that babies can be put to sleep in. Do you have a position that you ​usually place {C_FNAME/the child} in? 

INTERVIEWER INSTRUCTIONS

• IF PARENT/CAREGIVER SAYS "YES", PROBE: "Would that be on [his/her] side, on [his/her] stomach - with [his/her] head face down, on [his/her] stomach - with [his/her] head turned to the side, on [his/her] back or in some other position?"

• IF PARENT/CAREGIVER SAYS "ON THE STOMACH", PROBE: "When you place the baby on [his/her] stomach is [his/her] head face down in the bed or is [his/her] head turned to the side?")

• IF PARENT/CAREGIVER SAYS "In my arms" or "I rock [him/her] to sleep", PROBE: "In what position do you place [him/her] to sleep?"

Label	Code	Go To
YES, ON {HIS/HER} SIDE	1	CHILD_SLEEP_WITH
YES, ON {HIS/HER} STOMACH, FACE DOWN	2	CHILD_SLEEP_WITH
YES, ON {HIS/HER} STOMACH, HEAD TO THE SIDE	3	CHILD_SLEEP_WITH
YES, ON {HIS/HER} BACK	4	CHILD_SLEEP_WITH
YES, SOME OTHER POSITION	-5
NO	5	CHILD_SLEEP_WITH
REFUSED	-1	CHILD_SLEEP_WITH
DON'T KNOW	-2	CHILD_SLEEP_WITH

SOURCE

National Infant Sleep Position, Survey of Households with Children 0-7 Months

SE10000/(CHILD_POSITION_USUAL_OTH). SPECIFY: ____________________________________

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

SOURCE

National Infant Sleep Position, Survey of Households with Children 0-7 Months

SE11000/(CHILD_SLEEP_WITH). During the past two weeks, which of the following items were usually under {C_FNAME/the child}, while {he/she} slept? Please answer yes or no to each one. 

INTERVIEWER INSTRUCTIONS

• PROBE: "Would that be YES or NO?"

Label	Code	Go To
A blanket	1
A sheet	2
A bean bag	3
A waterbed	4
A mattress	5
A thin pad	6
A rug	7
A sheepskin	8
A cushion	9
A sleeping bag	10
A pillow	11
Mattress pad	12
Cloth diaper/towel	13
Waterproof pad	14
Triangle prop	15
Anything else	-5
NONE OF THE ABOVE	16
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Infant Sleep Position, Survey of Households with Children 0-7 Months

PROGRAMMER INSTRUCTIONS

• IF CHILD_SLEEP_WITH = 16, -1 OR -2, DO NOT ALLOW SELECTION OF OTHER VALUES AND GO TO CHILD_WEAR_BED.

• IF CHILD_SLEEP_WITH = ANY COMBINATION OF 1 THROUGH 15, GO TO CHILD_WEAR_BED. 

• IF CHILD_SLEEP_WITH = -5 OR ANY COMBINATION OF 1 THROUGH 15 AND -5, GO TO CHILD_SLEEP_WITH_OTH.

SE12000/(CHILD_SLEEP_WITH_OTH). SPECIFY: ___________________________________

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

SOURCE

National Infant Sleep Position, Survey of Households with Children 0-7 Months

SE13000/(CHILD_WEAR_BED). On an average night during the past two weeks, how many layers of clothing, not including diapers, did {C_FNAME/the child} usually wear to bed at night? 

INTERVIEWER INSTRUCTIONS

• READ LIST IF NECESSARY.

Label	Code	Go To
NONE	1
ONE	2
TWO	3
MORE THAN TWO	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Infant Sleep Position, Survey of Households with Children 0-7 Months

SE14000/(USUAL_COVER_CHILD). During the past two weeks, which of the following were usually used to cover {C_FNAME/the child} when {he/she} slept at night? Please answer yes or no to each one.

Label	Code	Go To
A blanket	1
A sheet	2
A quilt or comforter	3
A sheepskin	4
A pillow	5
Anything else	-5
NOTHING	-7
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Infant Sleep Position, Survey of Households with Children 0-7 Months

PROGRAMMER INSTRUCTIONS

• IF USUAL_COVER_CHILD = -7, -1 OR -2,DO NOT ALLOW SELECTION OF OTHER VALUES AND GO TO TIME_STAMP_SE_ET.

• IF USUAL_COVER_CHILD = ANY COMBINATION OF 1 THROUGH 5, GO TO BLANKET_TYPE.

• IF USUAL_COVER_CHILD = 5 ONLY, GO TO COVERS_CHILD_NUM.

• IF USUAL_COVER_CHILD = -5 OR ANY COMBINATION OF 1 THROUGH 5 AND -5, GO TO USUAL_COVER_CHILD_OTH.

SE15000/(USUAL_COVER_CHILD_OTH). SPECIFY: ________________________________________

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

SOURCE

National Infant Sleep Position, Survey of Households with Children 0-7 Months

PROGRAMMER INSTRUCTIONS

• IF USUAL_COVER_CHILD = ANY COMBINATION OF 1 THROUGH 5 AND -5, GO TO BLANKET_TYPE.

• IF USUAL_COVER_CHILD = 5 AND -5, GO TO COVERS_CHILD_NUM.

SE16000/(BLANKET_TYPE). Would you describe the blanket you used during the past two weeks as ...

Label	Code	Go To
Thin, like a receiving blanket	1
Thick, like a regular blanket	2
Or did you use both types of blankets	3
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Infant Sleep Position, Survey of Households with Children 0-7 Months (modified)

SE17000/(COVERS_CHILD_NUM). On an average night during the past two weeks, how many covers did {C_FNAME/the child} usually have on at one time?

Label	Code	Go To
NONE	1
ONE	2
TWO	3
MORE THAN TWO	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Infant Sleep Position, Survey of Households with Children 0-7 Months

(TIME_STAMP_SE_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 5 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.