38.6 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Woman Abuse Screening Tool (WAST) (CASI), Phase 2g

OMB Specification

Woman Abuse Screening Tool (WAST) (CASI)

Event Category:	Time-Based
Event:	36M
Administration:	N/A
Instrument Target:	Primary Caregiver
Instrument Respondent:	Primary Caregiver
Domain:	Neuro-Psychosocial
Document Category:	Scored Assessment
Method:	Self-Administered
Mode (for this instrument*):	In-Person, CAI
OMB Approved Modes:	In-person, CAI; Web, CAI
Estimated Administration Time:	3 minutes
Multiple Child/Sibling Consideration:	Per Event
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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Woman Abuse Screening Tool (WAST) (CASI)

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

WAST TRAINING SCREENS 3

WAST QUESTIONNAIRE 6

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Woman Abuse Screening Tool (WAST) (CASI)

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.

WAST TRAINING SCREENS

(TIME_STAMP_WTS_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

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

• FOR SECTION WTS, ALLOW PARTICIPANT/RESPONDENT TO PROGRESS THROUGH THE SECTION BY SELECTING "NEXT" EVEN IF THEY HAVE NOT SELECTED A RESPONSE TO THE QUESTION.

DATA COLLECTOR INSTRUCTIONS

CASI FORMATTING INSTRUCTIONS

 

• DISPLAY NCS CASI BANNER THROUGHOUT QUESTIONNAIRE.

• CONFIGURE QUESTIONNAIRE BASED ON CASI BEST PRACTICES AND GUIDELINES.

• DISPLAY ONE QUESTION/ITEM PER SCREEN THROUGHOUT.

• "NEXT" BUTTONS SHOULD BEGIN ON THE FIRST SCREEN AND SHOULD BE DISPLAYED AT THE BOTTOM RIGHTHAND CORNER OF THE SCREEN.

• "BACK" BUTTONS SHOULD BEGIN ON THE SECOND SCREEN AND SHOULD BE DISPLAYED AT THE BOTTOM LEFTHAND CORNER OF THE SCREEN.

• DISPLAY "LANGUAGE" AND "HELP" BUTTONS AT THE TOP OF EACH SCREEN.

• RESPONSE OPTIONS SHOULD BE DISPLAYED WITHIN THE ANSWER FIELD AND SHADED TO DISTINGUISH FROM OTHER FIELDS.

• ALL PARTICIPANT INSTRUCTIONS SHOULD BE DISPLAYED IN RED TEXT BETWEEN THE QUESTION FIELD AND ANSWER FIELD.

• USE FONT CALIBRI, SIZE 18, BOLD FOR ALL QUESTIONS, INSTRUCTIONS, AND ANSWERS.

• EACH SCREEN SHOULD CONTAIN AT MINIMUM A QUESTION BOX AND AN ANSWER BOX.  IF INDICATED, PLACE AN INSTRUCTIONS BOX BETWEEN THE QUESTION BOX AND ANSWER BOX.

• ANSWER BOXES SHOULD BE SHADED LIGHT PURPLE.

• "BACK" AND "NEXT" BUTTONS SHOULD HAVE A BLACK LINE BORDER AND BE LOCATED AT THE BOTTOM LEFT AND BOTTOM RIGHT (RESPECTIVELY) OF THE SCREEN.

• "HELP" BUTTON WITH BLACK LINE BORDER LOCATED AT TOP LEFT OF SCREEN.

• LANGUAGE TOGGLE "ENGLISH/ESPAÑOL" WITH BLACK LINE BORDER LOCATED AT TOP RIGHT OF SCREEN.

• EACH NEW ITEM NUMBER TRIGGERS A NEW SCREEN.

WTS01000/(TRAINING_W1). Now we want to teach you how to use this computer.  The interviewer will be here to answer any questions you have. The computer will ask you a series of questions.  Some people may consider some of the following questions to be personal, so you will be able to answer these on your own in complete privacy. Like all other questions that you have answered today, your responses will be kept confidential.  If you are not sure about an answer, choose the best option.  Answer each question by selecting your response on the screen.  After you answer a question, go to the next question by touching the button marked NEXT in the lower right-hand corner of the screen.  Try selecting that button now to move on.

SOURCE

New

WTS02000/(TRAINING_W2). If you want to go back and change your answer to an earlier question, touch the button marked BACK in the lower left-hand corner of the screen.  Touch the BACK button now to return to the last screen.  Then touch the NEXT button to return to this screen, and again to move on.

PARTICIPANT INSTRUCTIONS

• Select/touch the box beside your answer.

• Then select the NEXT button to go to the next page.

• Select/touch the BACK button to go back to the previous page.

• Press the HELP button to get helpful tips for completing the questions.

SOURCE

New

WTS03000/(TRAINING_W3). This question is a practice question and is not part of the study.  This practice question will help you learn how to use the computer.  If you want to change your answer to a multiple choice question, you may simply select another option.

 

What is your favorite season of the year?

Label	Code	Go To
Spring	1
Summer	2
Fall	3
Winter	4

SOURCE

New

WTS04000/(TRAINING_W4). If you skip a question for any reason, the computer will say you didn't answer the question, and will ask whether you really meant to answer, would rather not answer, or don't know the answer.  If you choose, "I really meant to answer," the screen will go back so you can answer the question.

PROGRAMMER INSTRUCTIONS

• INSERT SCREENSHOT OF REDO SCREEN.

WTS05000/(TRAINING_W5). If there is anything that you do not understand, or if you have any problems during the interview, please ask the interviewer to help you.  If you are ready to begin the interview, press the NEXT button now.

(TIME_STAMP_WTS_ET).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

WAST QUESTIONNAIRE

(TIME_STAMP_WAS_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• INSERT THE WORD "Question:" FOLLOWED BY A RETURN BEFORE QUESTION TEXT IN EACH QUESTION FIELD.

PROGRAMMER INSTRUCTIONS

INSTRUCTIONS FOR HARD EDITS

• HARD EDITS SHOULD BE PROGRAMMED AS POP-UP SCREENS.

INTERVIEWER INSTRUCTIONS

• LAUNCH CASI MODULE AND THEN SET UP PARTICIPANT SO THEY ARE SITTING DOWN IN FRONT OF THE COMPUTER SCREEN.

• AFTER CASI HAS STARTED, TURN THE TABLET TOWARDS THE PARTICIPANT AND ASSIST WITH PRACTICE QUESTIONS IF NEEDED.

• EXPLAIN CASI SAQ TO PARTICIPANT AND DEMONSTRATE HOW THE PARTICIPANT CAN RESPOND TO ITEMS USING THE COMPUTER.

WAS00100. DISPLAY IN QUESTION FIELD: You did not select an answer to the question on the previous page {INSERT QUESTION BOX TEXT FROM PREVIOUS QUESTION}.  Would you like to go back to the previous page and answer the question?

PROGRAMMER INSTRUCTIONS

INSTRUCTIONS FOR REDO/RF/DK SCREENS:

• CASI VARIABLE ANSWER OPTIONS SHOWN TO THE PARTICIPANT DO NOT INCLUDE "REFUSED" OR "DON'T KNOW" OPTIONS.

• IF A PARTICIPANT ATTEMPTS TO MOVE ON TO THE NEXT ITEM (BY SELECTING THE "NEXT" BUTTON AT THE BOTTOM RIGHT OF SCREEN) WITHOUT ENTERING A VALID ANSWER, DISPLAY CASI REDO SCREEN.

• CASI REDO SCREENS FOLLOW THE FOLLOWING FORMAT:

Label	Code	Go To
Yes, I would like to go back and answer the question	1
No, I do not want to answer that question	2
No, I do not know the answer to that question	3

PROGRAMMER INSTRUCTIONS

• IF = 1, ROUTE RESPONDENT BACK TO PREVIOUS SCREEN.

• IF = 2, SET ANSWER TO PREVIOUS QUESTION AS -1 ("REFUSED").

• IF = 3, SET ANSWER TO PREVIOUS QUESTION AS -2 ("DON'T KNOW").

WAS01000. You have now completed the training screens and are ready to begin the interview questions.  Let your interviewer know if you need help while answering the questions on your own.

WAS02000. Now, we will ask about your relationship with your partner.

WAS03000/(DESCRIB_REL). In general, how would you describe your relationship?

PARTICIPANT INSTRUCTIONS

• Select/touch the box beside your answer.

• Then select/touch the NEXT button to go to the next page.

Label	Code	Go To
A lot of tension	1
Some tension	2
No tension	3
NOT APPLICABLE	-7

SOURCE

Woman Abuse Screening Tool

WAS04000/(ARGUMENTS_WORK_OUT). Do you and your partner work out arguments with:

Label	Code	Go To
Great difficulty	1
Some difficulty, or	2
No difficulty	3

SOURCE

Woman Abuse Screening Tool

WAS05000/(ARGUMENTS_FEEL_DOWN). Do arguments ever result in your feeling down or bad about yourself?

Label	Code	Go To
Often	1
Sometimes	2
Never	3

SOURCE

Woman Abuse Screening Tool

WAS06000/(ARGUMENTS_HITTING). Do arguments ever result in hitting, kicking, or pushing?

Label	Code	Go To
Often	1
Sometimes	2
Never	3

SOURCE

Woman Abuse Screening Tool

WAS07000/(PARTNER_FRIGHTENED). Do you ever feel frightened by what your partner says or does?

Label	Code	Go To
Often	1
Sometimes	2
Never	3

SOURCE

Woman Abuse Screening Tool

WAS08000/(PARTNER_ABUSE_PHYSICALLY). Has your partner ever abused you physically?

Label	Code	Go To
Often	1
Sometimes	2
Never	3

SOURCE

Woman Abuse Screening Tool

WAS09000/(PARTNER_ABUSE_EMOTIONALLY). Has your partner ever abused you emotionally?

Label	Code	Go To
Often	1
Sometimes	2
Never	3

SOURCE

Woman Abuse Screening Tool

WAS10000/(PARTNER_ABUSE_SEXUALLY). Has your partner ever abused you sexually?

Label	Code	Go To
Often	1
Sometimes	2
Never	3

SOURCE

Woman Abuse Screening Tool

WAS11000/(WAS1100). Thank you for participating in the National Children's Study and for taking the time to complete this interview.

(TIME_STAMP_WAS_ET).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 3 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 30892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.