PRAMS Livebirth Phase 9 Core Mail Questionnaire (English

Attachment 8e – PRAMS Livebirth Phase 9 Core Mail Questionnaire - English

Form Approved

OMB No. 0920-1273

Exp. Date xx/xx/xxxx

Pregnancy Risk Assessment Monitoring System (PRAMS)

Phase 9 Core Mail Questionnaire – English

Public reporting of this collection of information is estimated to average 25-35 minutes per response, including the time for reviewing instructions 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 current 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 CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1273)

Phase 9 English Mail
	Please check the box next to your answer or follow the directions included with the question. You may be asked to skip some questions that do not apply to you.
BEFORE PREGNANCY
	The first questions are about you.
Core 1.	What is your date of birth?
	________ / ________ / ________ Month Day Year
	Insertion points for Standard questions II2, II3, PP1, PP2
Core 2.	Before you got pregnant, did you… For each one, check No or Yes.
		No Yes
	Have serious difficulty hearing, or are you deaf?	* *
	Have serious difficulty seeing, even when wearing glasses, or are you blind?	* *
	Have serious difficulty walking or climbing stairs?	* *
	Have serious difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition?	* *
	Have difficulty with dressing or bathing yourself?	* *
	Have difficulty doing errands alone such as visiting a doctor’s office or shopping because of a physical, mental, or emotional condition?	* *
	The next questions are about the time before you got pregnant.
	Insertion points for Previous Pregnancy Outcomes Series: FF5-FF7, FF4
	Insertion point for Standard question L26
	Insertion point for Standard question L10
Core 3.	During the 3 months before you got pregnant with your new baby, did you have any of the following health conditions? For each one, check No if you did not have the condition or Yes if you did.
		No Yes
	Type 1 or Type 2 diabetes (not gestational diabetes or diabetes that starts during pregnancy)	* *
	High blood pressure or hypertension	* *
	Depression	* *
	Anxiety	* *
	Insertion point for options from Standard question L11
	Insertion point for Standard question G9, G8
Core 4.	In the 12 months before you got pregnant with your new baby, did you have any of the following healthcare visits? For each one, check No or Yes.
		No Yes
	Regular checkup with a family doctor	* *
	Regular checkup with an OB/GYN	* *
	Visit for an injury, illness, or chronic condition	* *
	Visit to urgent care or the emergency room	* *
	Visit for family planning or to get birth control	* *
	Visit for depression or anxiety	* *
	Visit to have my teeth cleaned	* *
	Other	* *
	⤷ Please tell us:
	If you didn’t have any healthcare visits in the 12 months before you got pregnant, go to Question [Core 6].
	Insertion point for Standard question J5
Core 5.	During any of your healthcare visits in the 12 months before you got pregnant, did a healthcare provider do any of the following things? For each one, check No or Yes.
		No Yes
	Talk to me about...
	My weight	* *
	Regularly checking my blood pressure	* *
	My desire to have or not have children	* *
	Birth control	* *
	How I could improve my health before a pregnancy	* *
	Sexually transmitted infections such as chlamydia, gonorrhea, syphilis, or HIV	* *
	Ask me....
	If I smoked cigarettes or used e-cigarettes (“vapes”) or other smokeless tobacco	* *
	If someone was hurting me emotionally or physically	* *
	If I felt depressed or anxious	* *
	Insertion points for Standard questions L27, L18
	The next questions are about your health insurance.
Core 6.	During the month before you got pregnant with your new baby, what kind of health insurance did you have? Check ALL that apply
	Private health insurance (paid for by me, someone else, or through a job)
	Medicaid (site Medicaid name)
	Site-specific option (Other government plan or program such as SCHIP/CHIP)
	Site-specific option (Other government plan or program not listed above such as MCH program, indigent program or family planning program)
	Site-specific option (TRICARE or other military health care)
	Site-specific option (I or tribal)
	Other health insurance
	⤷ Please tell us:
	I didn’t have any health insurance during the month before I got pregnant
	Insertion point for Standard questions DD7
Core 7.	During your most recent pregnancy, what kind of health insurance did you have? Check ALL that apply
	Private health insurance (paid for by me, someone else, or through a job)
	Medicaid (site Medicaid name)
	Site-specific option (Other government plan or program such as SCHIP/CHIP)
	Site-specific option (Other government plan or program not listed above such as MCH program, indigent program or family planning program)
	Site-specific option (TRICARE or other military health care)
	Site-specific option (I or tribal)
	Other health insurance
	⤷ Please tell us: __________________
	I didn’t have health insurance during my pregnancy
	Insertion point for Standard questions DD11
Core 8.	What kind of health insurance do you have now? Check ALL that apply
	Private health insurance (paid for by me, someone else, or through a job)
	Medicaid (state Medicaid name)
	State-specific option (Other government plan or program such as SCHIP/CHIP)
	State-specific option (Other government plan or program not listed above such as MCH program, indigent program or family planning program)
	State-specific option (TRICARE or other military health care)
	State-specific option (I or tribal)
	Other health insurance
	⤷ Please tell us: __________________
	I don’t have health insurance now
	Insertion point for Standard questions DD20
Core 9.	Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant? Check ONE answer
	I wanted to be pregnant later
	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
	Insertion point for Standard question Q4
	Insertion point for Preconception Contraception Series E5, E6, E7, E3
	Insertion point for Fertility & Fertility Treatment Series E5, Q7, A1, A2, A4, A5
DURING PREGNANCY
	The next questions are about your prenatal care. This can include visits to a doctor, nurse, or other healthcare worker before your baby was born to get checkups and advice about pregnancy. (It may help to look at the calendar to answer these questions.)
	Insertion point for Standard question R19
Core 10.	Did you get prenatal care during your most recent pregnancy?
	No → Go to Question [Core 12]
	Yes
	Insertion point for Standard questions R24, R20, R21
	Insertion point for Standard question R15
	Insertion point for Standard questions R6, R7, R8, R12, R14
Core 11.	During any of your prenatal care visits, did a healthcare provider do any of the following things? For each one, check No or Yes.
		No Yes
	Talk to me about…
	How much weight I should gain during pregnancy	* *
	Doing tests to screen for birth defects or diseases that run in my family	* *
	The signs and symptoms of preterm labor (labor more than 3 weeks before the baby is due)	* *
	What to do if I feel depressed or anxious during my pregnancy or after my baby is born	* *
	Ask me…
	If I planned to breastfeed my new baby	* *
	If I planned to use birth control after my baby was born	* *
	If I was taking any prescription medication	* *
	If I smoked cigarettes or used e-cigarettes ("vapes") or other smokeless tobacco	* *
	If I was drinking alcohol	* *
	If someone was hurting me emotionally or physically	* *
	If I was using illegal drugs	* *
	If I was using marijuana	* *
	If I wanted to be tested for HIV	* *
	Insertion points for Standard questions R13, K4
	Insertion point for HIV Testing Series: I8, I9
	Insertion point for Standard questions G5
Core 12.	During the 12 months before your new baby was born, did a healthcare provider offer you the following shots or vaccinations? For each one, check No or Yes.
		No Yes
	Flu shot	* *
	Tdap shot (protects against tetanus, diphtheria, and pertussis (whooping cough))	* *
	COVID-19 shot	* *
Core 13.	Did you get the following shots or vaccinations before or during your pregnancy? For each one, check: B for 3 Months before pregnancy D for During pregnancy N for Did not get a shot before or during pregnancy
		B D N
	Flu shot	* * *
	Tdap shot	* * *
	COVID-19 shot	* * *
	Insertion point for Standard questions L19, L14
Core 14.	During your most recent pregnancy, did you have your teeth cleaned by a dentist or dental hygienist?
	No
	Yes
	Insertion point for Oral Health Series: Y7, Y5, Y8, Y6
	Insertion point for Childbirth Class & Home Visitation Series: R23, V21, V13, V14, V15, V20
	Insertion point for Standard question R16, R25
	Insertion point for Standard questions B12, B8, B7, B4
Core 15.	During your most recent pregnancy, did a healthcare provider tell you that you had any of the following health conditions? For each one, check No or Yes.
		No Yes
	Gestational diabetes (diabetes that started during this pregnancy)	* *
	High blood pressure (that started during this pregnancy), pre-eclampsia, or eclampsia	* *
	Depression	* *
	Anxiety	* *
	Insertion point for options from Standard question L11
	Insertion point for Standard questions N7
	If you had high blood pressure before or during your pregnancy, go to Question [Core 16]. If not, go to Question [Core 17].
Core 16.	During your most recent pregnancy, did a healthcare provider do any of the following things to help you manage your high blood pressure? For each one, check No or Yes.
		No Yes
	Refer me to a different healthcare provider	* *
	Tell me to regularly check my blood pressure during pregnancy	* *
	Talk to me about getting to a healthy weight after pregnancy	* *
	Talk to me about regularly checking my blood pressure after pregnancy	* *
	Talk to me about the risk for having high blood pressure (chronic hypertension) and heart disease after pregnancy	* *
Core 17.	During your most recent pregnancy, did you get information about “warning signs” you should watch for during and after your pregnancy that require immediate medical attention? Some of these “warning signs” include fever, frequent or severe headaches, or severe stomach pain.
	No → Go to Question [Core 19]
	Yes
Core 18.	During your most recent pregnancy, did you get information about warning signs from any of the following sources? For each one, check No or Yes.
		No Yes
a.	A healthcare provider (such as a doctor, nurse, or midwife)	* *
b.	Websites or social media (such as Facebook, Instagram, or Twitter)	* *
c.	Any source of information that used the slogan ‘Hear Her’ (such as a website, social media, or paper handout)	* *
d.	Family or friends	* *
	Insertion point for Standard questions M4, M9, M8
	Insertion point for Standard questions M14, M18, M17
	Insertion point for Standard questions N9, N1-N4
	Insertion point for Standard questions N5, EE3
The next questions are about cigarettes, e-cigarettes, and other tobacco products.
Core 19.	Have you smoked any cigarettes in the past 2 years?
	No → Go to Question [Core 23]
	Yes
Core 20.	In the 3 months before you got pregnant, how many cigarettes did you smoke on an average day?
	More than one pack (21 or more cigarettes)
	One-half to one pack (11 to 20 cigarettes)
	Less than half a pack (1 to 10 cigarettes)
	I didn’t smoke then
Core 21.	In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day?
	More than one pack (21 or more cigarettes)
	One-half to one pack (11 to 20 cigarettes)
	Less than half a pack (1 to 10 cigarettes)
	I didn’t smoke then
	Insertion point for Standard questions AA1, AA3
	Insertion point for Standard questions AA2, AA6, AA10
Core 22.	How many cigarettes do you smoke on an average day now?
	More than one pack (21 or more cigarettes)
	One-half to one pack (11 to 20 cigarettes)
	Less than half a pack (1 to 10 cigarettes)
	I don’t smoke now
	Insertion point for Standard questions AA8, AA5
	Insertion point for Standard questions AA9, AA7
Core 23.	In the past 2 years, have you used e-cigarettes (“vapes”) or other electronic nicotine products?
	No → Go to Question [Core 27]
	Yes
Core 24.	During the 3 months before you got pregnant, on average, how often did you use e-cigarettes (“vapes”) or other electronic nicotine products?
	Every day
	Some days
	I didn’t use e-cigarettes or other electronic nicotine products then
Core 25.	During the last 3 months of your pregnancy, on average, how often did you use e-cigarettes (“vapes”) or other electronic nicotine products?
	Every day
	Some days
	I didn’t use e-cigarettes or other electronic nicotine products then
Core 26.	In the past 2 years, did you ever use e-cigarettes or other electronic nicotine products as a way of cutting down or stopping cigarette smoking?
	No
	Yes
	The next questions are about drinking alcohol. A drink can be 1 glass of wine, hard seltzer, can or bottle of beer, shot of liquor, or mixed drink.
	Insertion point for Standard questions JJ5, JJ1
Core 27.	During your most recent pregnancy, did you have any alcoholic drinks during… For each one, check No or Yes.
		No Yes
a.	The first 3 months of pregnancy (1st trimester)? This includes the time before knowing you were pregnant	* *
b.	The second 3 months of pregnancy (2nd trimester)?	* *
c.	The last 3 months of pregnancy (3rd trimester)?	* *
	If you didn’t have any alcoholic drinks during your pregnancy, go to Question [Core 29].
Core 28.	During your most recent pregnancy, did you have 4 or more alcoholic drinks in a 2-hour time span during… For each one, check No or Yes.
		No Yes
a.	The first 3 months of pregnancy (1st trimester)? This includes the time before knowing you were pregnant	* *
b.	The second 3 months of pregnancy (2nd trimester)?	* *
c.	The last 3 months of pregnancy (3rd trimester)?	* *
	Insertion points for Standard questions JJ3, JJ2, JJ6
	Pregnancy can be a difficult time. The next questions are about things that may have happened before and during your most recent pregnancy.
Core 29.	Did any of the following things happen during the 12 months before your new baby was born? For each one, check No or Yes.
		No Yes
	I got separated or divorced	* *
	I was evicted or forced to move	* *
	I didn’t have a regular place to sleep	* *
	I was homeless, or had to sleep outside, in a car, or in a shelter	* *
	My spouse, partner, or I lost a job	* *
	My spouse, partner, or I had a cut in work hours or pay	* *
	I had problems paying the rent, mortgage, or other bills	* *
	My spouse or partner went to jail	* *
	I went to jail	* *
	Someone close to me had a problem with drinking or drugs	* *
	Someone close to me was very sick or died	* *
	Insertion points for Standard questions P14, P17, P20, P21, P22, P15
	Insertion point for Standard question BB1
Core 30.	In the 12 months before you got pregnant with your new baby, did any of the following people push, hit, slap, kick, choke, or physically hurt you in any other way? For each one, check No or Yes.
		No Yes
	My spouse or partner	* *
	My ex-spouse or ex-partner	* *
	Site option (Another family member)	* *
	Site option (Someone else)	* *
Core 31.	During your most recent pregnancy, did any of the following people push, hit, slap, kick, choke, or physically hurt you in any other way? For each one, check No or Yes.
		No Yes
a.	My spouse or partner	* *
b.	My ex-spouse or ex-partner	* *
c.	Site option (Another family member)	* *
d.	Site option (Someone else)	* *
Insertion point for Standard question Z1
AFTER PREGNANCY
	The next questions are about the time since your new baby was born.
	Insertion point for Standard question II4
	Insertion point for Labor Interventions Series: K9, K10, K8, K3, K7, K6, K17
	Insertion point for Standard questions II1
	Insertion point for Standard question K16
Core 32.	After the delivery, how long did your new baby stay in the hospital?
	Less than 3 days
	3 to 5 days
	6 to 14 days
	More than 14 days
	My baby was not born in a hospital
	My baby is still in the hospital → Go to Question [Core 35]
Core 33.	Is your baby alive now?
	No → We are very sorry for your loss. Go to Question [Core 41]
	Yes
Core 34.	Is your baby living with you now?
	No → Go to Question [Core 41]
	Yes
	Insertion point for Standard question B9, B17
Core 35.	How many weeks or months did you breastfeed or feed pumped milk to your new baby? Check ONE answer
	I didn’t breastfeed my baby
	I breastfed my baby for less than 1 week
	I breastfed my baby for:
	______Week(s) OR
	______Month(s)
	I'm still breastfeeding or feeding pumped milk to my new baby
	Insertion point for Standard question B1
	Insertion point for Standard question B13
	Insertion point for Standard questions B2, B14, B16
	Insertion point for Standard questions B10, B11, B3
	Insertion point for Standard questions H2
	Insertion point for Standard question S13
	If your baby is still in the hospital, go to Question [Core 41].
Core 36.	In the past 2 weeks, how did you place your new baby to sleep at night and during naps? For each one, check No or Yes.
		No Yes
	On their side	* *
	On their back	* *
	On their stomach	* *
Core 37.	In the past 2 weeks, when you were sleeping, how often has your new baby slept alone in their own crib or bed?
	Always
	Often
	Sometimes
	Rarely
	Never → Go to Question [Core 39]
	Insertion point for Standard question F4
Core 38.	In the past 2 weeks, was your baby’s crib or bed in the same room where you or another adult slept?
	No
	Yes
Core 39.	In the past 2 weeks, where have you placed your new baby to sleep at night or during naps? For each one, check No or Yes.
		No Yes
	In a crib, portable crib, or bassinet	* *
	On a twin or larger mattress or bed	* *
	On a couch, sofa, or armchair	* *
	In an infant car seat	* *
	In a swing, rocker, or other inclined sleeper	* *
	In an in-bed sleeper	* *
	In a baby board or cradle board	* *
	Other	* *
	⤷ Please tell us: __________________
Core 40.	In the past 2 weeks, has your new baby been placed to sleep with the following? For each one, check No or Yes.
		No Yes
	In a sleeping sack or wearable blanket	* *
	In a swaddled blanket	* *
	Comforters, quilts, blankets, or non-fitted sheets	* *
	Soft toys, cushions, or pillows, including nursing pillows	* *
	Crib bumper pads (mesh or non-mesh)	* *
	Other	* *
	⤷ Please tell us: __________________
	Insertion point for Standard question F5, F6, F7
	Insertion point for Infant Well Care Visit Series: X10, X9, X2
	Insertion point for Infant Sick Care Series: T1, T3, T8
	Insertion point for Postpartum Home Visitation Series: V22, V16, V18, V19
Core 41.	Are you or your spouse or partner doing anything now to keep from getting pregnant? This can include having your tubes tied, using birth control pills, condoms, natural family planning, or other methods.
	No
	Yes → Go to Question [Core 43]
Core 42.	What are your reasons for not doing anything to keep from getting pregnant now? Check ALL that apply
	I’m pregnant now → Go to Question [Core 44]
	I want to get pregnant or don’t mind if I do
	I had my tubes tied or blocked
	My spouse or partner had a vasectomy
	I don’t want to use birth control
	I’m worried about side effects from birth control
	My spouse or partner doesn’t want to use condoms
	My spouse or partner doesn't want me to use birth control
	We are same-sex spouses/partners
	I have problems getting birth control I want
	I don't think I can get pregnant, because I'm breastfeeding
	I’m not having sex
	Other
	⤷ Please tell us: __________________
	If you or your spouse or partner is not doing anything to keep from getting pregnant now, go to Question [Core 44].
Core 43.	What kind of birth control are you or your spouse or partner using now to keep from getting pregnant? Check ALL that apply
	Tubes tied or blocked
	My spouse or partner had a vasectomy
	Birth control pills
	Condoms
	Shots or injections
	Contraceptive patch or vaginal ring
	IUD
	Contraceptive implant in the arm
	Withdrawal (pulling out)
	Natural family planning or fertility awareness methods (such as rhythm or calendar method, or fertility apps)
	Breastfeeding for birth control (Lactational amenorrhea or LAM)
	Other
	⤷ Please tell us: __________________
Core 44.	Since your new baby was born, have you had a postpartum checkup for yourself? A postpartum checkup is a regular health checkup you have up to 12 weeks after giving birth.
	No → Go to Question [Core 46]
	Yes
	Insertion point for Standard question J3
Core 45.	During your postpartum checkup, did a healthcare provider do any of the following things? For each one, check No or Yes.
		No Yes
	Talk to me about...
	Healthy eating, exercise, and losing weight gained during pregnancy	* *
	How long to wait before getting pregnant again	* *
	Birth control	* *
	Warning signs of medical problems I might be at risk for due to my pregnancy	* *
	Regularly checking my blood pressure	* *
	What to do if I feel depressed or anxious	* *
	Ask me...
	If I was smoking cigarettes or using e-cigarettes (“vapes”) or other smokeless tobacco	* *
	If someone was hurting me emotionally or physically	* *
	Did they…
	Test for diabetes	* *
	Prescribe medication for depression or anxiety	* *
	Insertion point for Standard question J6, O4
Core 46.	Since your new baby was born, how often have you felt down, depressed, or hopeless?
	Always
	Often
	Sometimes
	Rarely
	Never
Core 47.	Since your new baby was born, how often have you had little interest or little pleasure in doing things?
	Always
	Often
	Sometimes
	Rarely
	Never
Core 48.	Since your new baby was born, how often have you felt nervous, anxious, or on edge?
	Always
	Often
	Sometimes
	Rarely
	Never
Core 49.	Since your new baby was born, how often have you not been able to stop or control worrying?
	Always
	Often
	Sometimes
	Rarely
	Never
Core 50.	Has a healthcare provider asked you a series of questions, in person or on a form, to know if you were feeling down, depressed, anxious, or irritable during the following time periods? For each one, check No or Yes.
		No Yes
	During my most recent pregnancy	* *
	Since my new baby was born	* *
	Insertion points for Standard questions M6, M5, M11, M10
	Insertion points for Standard questions M16, M15, M20, M19
	Insertion points for Standard questions M22, M23, M24
	Insertion points for Standard question J7
	Insertion points for Standard questions Z13, Z2
OTHER EXPERIENCES
	The next questions are on a variety of topics.
	Insertion points for Site-Specific Questions
Core 51.	Please tell us how often each of the following happened during the 12 months before your new baby was born.
	I worried whether my food would run out before I got money to buy more
	Often
	Sometimes
	Never
	The food that I bought just didn't last, and I didn’t have money to get more
	Often
	Sometimes
	Never
	Insertion points for Standard question BB3
Core 52.	During the 12 months before your new baby was born, did lack of transportation keep you from any of the following? For each one, check No or Yes.
		No Yes
	Medical appointments	* *
	Non-medical appointments, meetings, or work	* *
	Doing errands	* *
Core 53.	While getting healthcare during your pregnancy, at delivery, or at postpartum care, did you experience discrimination or were you prevented from doing something, hassled, or made to feel inferior? For each item, check No if you did not experience discrimination because of it or Yes if you did.
		No Yes
	My race, ethnicity, or skin color	* *
	My disability status	* *
	My immigration status	* *
	My age	* *
	My weight	* *
	My income	* *
	My sex or gender	* *
	My sexual orientation	* *
	My religion	* *
	My language or accent	* *
	My type or lack of health insurance	* *
	My use of substances (alcohol, tobacco, or other drugs)	* *
	My involvement with the justice system (jail or prison)	* *
	Another reason	* *
	⤷ Please tell us: __________________
	Insertion points for Standard question BB6
Core 54.	During your life until now, how often have you been discriminated against, prevented from doing something, hassled, or made to feel inferior because of your race, ethnicity, or skin color?
	Very often
	Somewhat often
	Not very often
	Never
	Insertion points for Standard question BB4, BB5
Core 55.	Have you ever been treated unfairly due to your race, ethnicity, or skin color in any of the following situations? For each one, check No or Yes.
		No Yes
	Job (hiring, promotion, firing)	* *
	Housing (renting, buying mortgage)	* *
	Police (stopped, searched, threatened)	* *
	In the courts	* *
	At school or my child’s school	* *
	Getting medical care	* *
	The last questions are about the time during the 12 months before your new baby was born.
Core 56.	During the 12 months before your new baby was born, what was your yearly total household income before taxes? Include your income, your spouse or partner’s income, and any other income you may have received. All information will be kept private and will not affect any services you are now getting.
	(Note: Sites can add additional categories as long as the categories are collapsible back to the existing core categories.)
	$0 to $16,000
	$16,001 to $20,000
	$20,001 to $24,000
	$24,001 to $32,000
	$32,001 to $48,000
	$48,001 to $60,000
	$60,001 to $85,000
	$85,001 or more
Core 57.	During the 12 months before your new baby was born, how many people, including yourself, depended on this income?
	______ Number of People
Core 58.	What is today's date?
	________ / ________ / ________ Month Day Year
We would love to hear more about your story! Is there anything else you would like to share with us about your experiences around the time of your pregnancy? Please use this space to tell us.
_________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Thank you for answering our questions. Your answers will help us work to make <STATE> mothers and babies healthier. Thank you for answering our questions. Your answers will help us work to make <STATE> mothers and babies healthier.