PRAMS ZPER 2.0 – IN-HOSPITAL MATERNAL SURVEY: English version
Form Approved
OMB No.0920-XXXX
Exp. Date xx/xx/20xx
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PRAMS-ZPER 2.0 In-Hospital Maternal Survey (English) |
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The first questions are about you. |
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MONTH/DAY/YEAR
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Less than high school diploma High school diploma or General Education Diploma (GED) Some college or technical school Completed college Some graduate school Completed graduate school
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____weeks ____ I don’t know
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_____________________Name of municipality
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Yes No
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(Check all that apply.)
I do not have health insurance of any kind Private health insurance from my job or the job of my husband or partner Private health insurance from my parents Private health insurance that I paid for myself or that someone else paid for me Government health insurance/Medicaid (also known as Mi Salud or Reforma) Other health insurance Please tell us: _____________________________
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The following questions are about Zika virus. |
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Very worried Somewhat worried Not at all worried
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Very worried Somewhat worried Not at all worried
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Healthcare worker (for example, a family doctor, OB/GYN, midwife, other medical professionals) Other pregnant women Family or friends The Centers for Disease Control and Prevention (CDC) The Puerto Rico Department of Health Television or radio news Social network sites like Facebook WIC or the Special Supplemental Nutrition Program for Women, Infants, and Children Websites about pregnancy or other topics Please tell us: ________________ Some other source Please tell us: ___________________
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Yes, a healthcare worker talked with me without my asking about it Yes, a healthcare worker talked with me, but only after I asked about it No Go to Question 16
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If you did not get tested for Zika virus infection, go to Question 15. |
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The following questions are about avoiding mosquito bites. |
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Always Sometimes Rarely or when I saw mosquitos Never Go to Question 20
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More than once a day Once a day
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I did not like the way it smelled or it made me nauseous I did not like the way it made my skin feel I worried about the chemicals in the repellent harming me I worried about the chemicals in the repellent harming my baby I forgot to apply it I had an allergy or it made my skin itch I didn’t think I needed it I was rarely outside Mosquito repellent was too expensive Other reason Please tell us: ________________
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Every day Go to Question 23 Most days Some days Never
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It was too hot to wear long sleeves or long pants I did not have clothes with long sleeves or long pants My clothes with long sleeves or long pants no longer fit due to pregnancy I was rarely outside Other Please tell us: ____________________________________________
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The following questions are about your husband or any male partner. |
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Yes Go to Question 25 No
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I didn’t have a partner Go to Question 30 I was trying to avoid Zika infection Go to Question 28 I didn’t want to have sex Go to Question 28 Some other reason Please tell us: ____________ Go to Question 28
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If you used condoms every time you had sex during your most recent pregnancy, go to Question 28. Otherwise go to Question 27. |
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I didn’t know I was pregnant I didn’t think I needed to use condoms during pregnancy I didn’t think a condom would prevent Zika infection I didn’t think Zika was still a problem I didn’t think my partner had Zika virus I was not worried about getting the Zika virus I didn’t want to use condoms My partner didn’t want to use condoms I could not get condoms when I needed them I could not afford condoms I forgot to use condoms My partner or I had an allergy Other Please tell us: ___________________
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Yes No I don’t know |
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The following questions are about the time before your pregnancy. |
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I wanted to be pregnant later, because of the risks associated with Zika virus I wanted to be pregnant later, because of other reasons I wanted to be pregnant sooner I wanted to be pregnant then I didn’t want to be pregnant then or at any time in the future I wasn’t sure what I wanted
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He was my husband (legally married) He was my partner (not legally married, but a long-term partner) He was my boyfriend (a casual partner) Other Please tell us: ________________________
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He wanted me to be pregnant later, because of the risks associated with Zika virus He wanted me to be pregnant later, because of other reasons He wanted me to be pregnant sooner He wanted me to be pregnant then He didn’t want me to be pregnant then or at any time in the future He wasn’t sure what he wanted I don’t know
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No Yes |
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Yes Go to Question 36 No
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I didn’t mind if I got pregnant I thought I could not get pregnant at that time I had side effects from the birth control method I was using I had problems getting birth control when I needed it I thought my husband or partner or I was sterile (could not get pregnant at all) My husband or partner didn’t want to use anything I forgot to use a birth control method Other Please tell us: _________________________
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If you or your husband or partner were not doing anything to keep from getting pregnant, go to Question 37. |
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Birth control pills Condoms Shots or injections (Depo-Provera®) Contraceptive implant in the arm (Nexplanon® or Implanon®) Contraceptive patch (OrthoEvra®) or vaginal ring (NuvaRing®) IUD (including Mirena®, ParaGard®, Liletta®, or Skyla®) Natural family planning (including rhythm method) Withdrawal (pulling out) Other Please tell us: ____________________________
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The last questions are about health care you received during your pregnancy and after delivery. |
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_______ Weeks OR _______ Months
I didn’t go for prenatal care Go to Question 41
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Yes, my husband or partner Yes, someone else Go to question 41 No Go to question 41
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Every time Sometimes Only when I was going to have a procedure (such as an ultrasound) Never
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Every time Sometimes Only when I was going to have a procedure (such as an ultrasound) Never
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Thank you for answering these questions! Your answers will help us keep pregnant women and their babies healthy. |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | D'Angelo, Denise V. (CDC/ONDIEH/NCCDPHP) |
File Modified | 0000-00-00 |
File Created | 2021-01-21 |