NCS
Herald
Cohort
Study
Instrument
#
4
Partner
Questionnaire
Preconception
Initial
Visit
Eligibility:
All
partners
enrolled
while
woman
was
not
pregnant
Mode
of
administration:
Interviewer,
home
visit
8/
4/
2005
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
40
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:
Dr.
Pauline
Mendola,
US
EPA,
MD­
58A,
Research
Triangle
Park,
NC
27711.
E­
mail:
mendola.
pauline@
epa.
gov.
Partner
Preconception
1
(
Instrument
#
4)

1
PRELOADED
DATA:

Today's
date
Language
of
interview
(
English/
Spanish)

Female
Name
Female
Address
and
Phone
Spouse/
Partner's
Name
(
Preload
from
screener)

Spouse/
Partner's
Address
and
Phone
(
Preload
from
screener)

QUESTIONNAIRE:
Partner
Preconception
1
(
Instrument
#
4)

2
Occupation
(
Full)

Next,
I'm
going
to
ask
you
about
your
education
and
employment.

1.
Are
you
currently
a
full­
or
part­
time
student?

1
NO,
NOT
A
STUDENT

SKIP
TO
Q3
2
YES,
FULL­
TIME
STUDENT
3
YES,
PART­
TIME
STUDENT
2.
What
type
of
school
are
you
currently
attending?

1
HIGH
SCHOOL
2
TECHNICAL
SCHOOL
3
COLLEGE
OR
UNIVERSITY
4
GRADUATE
SCHOOL
5
PROFESSIONAL
SCHOOL
(
FOR
EXAMPLE,
MEDICAL
SCHOOL)
6
OTHER
(
SPECIFY)_________________

3.
Are
you
currently 

1
Working
at
a
job
or
business,

SKIP
TO
PARAGRAPH
BEFORE
Q5
2
Looking
for
work,
or
3
Not
working
at
a
job
or
business?

4.
Were
you
working
at
a
job
or
business
at
any
time
during
the
last
12
months?

1
YES
2
NO

GO
TO
NEXT
MODULE
Now,
I'd
like
to
ask
you
a
few
questions
about
jobs
you
held
in
the
last
year.
I
will
collect
information
on
your
last
3
jobs,
if
they
occurred
in
the
last
12
months.
Let's
start
with
your
(
FILL:
current/
most
recent/
next)
job.

5.
On
what
date
did
you
start
this
job?

MM/
DD/
YYYY
6.
[
SKIP
AND
PREFILL
WITH
`
1'
IF
CURRENT
JOB]
On
what
date
did
you
stop
working
at
this
job?

MM/
DD/
YYYY
1
=
STILL
EMPLOYED
7.
What
kind
of
business
or
industry
(
FILL:
is/
was)
this?
(
For
example:
TV
and
radio
management,
retail
shoe
store,
state
labor
department,
farm.)

_________________________________
ENTER
NAME
OF
BUSINESS,
JOB,
OR
INDUSTRY
Partner
Preconception
1
(
Instrument
#
4)

3
8.
What
kind
of
work
(
FILL:
are/
were)
you
doing?
(
For
example:
farming,
mail
clerk,
computer
specialist.)

_________________________________
ENTER
NAME
OF
OCCUPATION
9.
How
many
hours
a
week
(
FILL:
do/
did)
you
usually
work
at
this
job?

____
HOURS
10.
(
FILL:
Do/
Did)
you
do
shift
work
for
this
job?

1
YES
2
NO

SKIP
TO
Q12
11.
(
FILL:
Does/
Did)
this
include
the
night
shift?

1
YES
2
NO
12.
Did
you
have
any
other
jobs
in
the
last
12
months?

1
YES
[
REPEAT
Q5­
Q11
FOR
UP
TO
3
JOBS]
2
NO

GO
TO
NEXT
MODULE
{
END
OF
OCCUPATION
MODULE}
Partner
Preconception
1
(
Instrument
#
4)

4
Chemical
Exposures
Module
Now
I'm
going
to
ask
you
about
chemicals
you
may
have
used
at
work,
at
home,
or
for
any
hobbies.

A.
Have
you
been
exposed
to
[
HAND
SHOW
CARD
TO
PARTICIPANT
FOR
EACH
EXPOSURE
FROM
TABLE
BELOW]
in
the
last
12
months?

If
Yes,
ASK:

B.
Are
you
currently
exposed
to
[
INSERT
EXPOSURE]
YES
NO

SKIP
TO
NEXT
EXPOSURE
C.
How
often
are
you
exposed
to
[
INSERT
EXPOSURE]
?
Would
you
say.
.
.

D.
Did
the
exposure
occur
while
you
were
at
work?

A.
Exposed
in
last
12
months
Yes=
01
No
=
02
B.
Currently
Exposed
Yes
=
01
No
=
02
C.
Frequency
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
D.
At
work
Yes
=
01
No
=
02
1.
Fuels,
solvents,
dry
cleaning
fluids,
degreasers,
or
adhesives
2.
Lead,
including
paints
with
lead
in
them
3.
Fumes
or
gases
(
e.
g.,
nitrous
oxide,
ethylene
oxide,
anesthetic
gases)
4.
Radiation
(
e.
g.,
fluoroscopy,
radioisotopes,
highintensity
microwaves,
x­
rays)
5.
Mercury
6.
Metal
fumes
or
particles
7.
Pesticides
that
you've
mixed
or
applied
8.
Paints,
strippers,
or
varnishes
9.
Hair
and
nail
products
(
e.
g,
hair
dye,
bleach,
hair
relaxer,
nail
polish
and
remover)
10.
Cleaning
products
(
e.
g.,
oven
cleaner,
disinfectant,
carpet
cleaner,
bleach)
11.
Carbon
black
from
copying
machines
12.
Coal
or
coal
products
from
hot
asphalt,
tar,
or
roofing
material
{
END
OF
CHEMICAL
EXPOSURES
MODULE}
Partner
Preconception
1
(
Instrument
#
4)

5
Personal
and
Family
Medical
History
(
full)

Now
I'd
like
to
ask
you
some
questions
about
your
general
health.

1.
Are
you
allergic
to 
(
CODE
ALL
THAT
APPLY)

1
cats?
2
pollen?
3
dust?
4
insect
bites
or
stings?
5
any
foods?
(
SPECIFY)
___________________
6
anything
else?
(
SPECIFY)
__________________

2.
Have
you
ever
had
a
condition
called
"
hayfever"
or
an
allergy
that
makes
your
nose
runny
or
stuffy
or
your
eyes
itchy
when
you
do
not
have
a
cold?

1
YES
2
NO

SKIP
TO
Q4
3.
Did
a
doctor
or
other
medical
provider
ever
say
that
this
was
hayfever
or
allergy?

1
YES
2
NO
4.
Did
a
doctor
or
other
medical
provider
ever
tell
you
that
you
had
a
skin
allergy
or
eczema?

1
YES
2
NO
5.
Did
a
doctor
or
other
medical
provider
ever
tell
you
that
you
had
asthma?

1
YES
2
NO

SKIP
TO
Q8
6.
In
the
past
6
months,
have
you
used
any
inhalers
or
taken
any
pills
for
asthma
or
wheezing
or
whistling
in
your
chest?

1
YES
2
NO
7.
Have
you
ever
gone
to
an
emergency
room
or
stayed
overnight
in
a
hospital
for
your
asthma?

1
YES
2
NO
8.
Do
you
have
any
of
the
following
health
problems?
(
CODE
ALL
THAT
APPLY)

1
High
blood
pressure
or
hypertension
2
High
blood
sugar
or
diabetes
3
High
cholesterol
4
Anemia
(
poor
blood,
low
iron)
5
Heart
problems
Partner
Preconception
1
(
Instrument
#
4)

6
9.
Have
you
ever
been
diagnosed
with
any
other
serious
illnesses
that
I
haven't
asked
about?

1
YES
2
NO

SKIP
TO
Q10
9a.
What
were
those
illnesses?
(
ENTER
VERBATIM)

_______________________

10.
During
the
past
6
months,
have
you
been
hospitalized
for
any
reason?

1
YES
2
NO

SKIP
TO
Q11
10a.
Why
were
you
hospitalized?
(
ENTER
VERBATIM)

_______________________

11.
Have
any
of
your
blood
relatives
 
your
mother,
father,
sisters
or
brothers
 
ever
had 
(
CODE
ALL
THAT
APPLY)

1
High
blood
pressure
or
hypertension?
2
High
blood
sugar
or
diabetes?
3
High
cholesterol?
4
Heart
problems?

{
END
OF
PERSONAL
AND
FAMILY
MEDICAL
HISTORY
MODULE}
Partner
Preconception
1
(
Instrument
#
4)

7
Demographics
(
Full)

1.
What
is
your
date
of
birth?

MM/
DD/
YYYY

(
calculate
age;
Ineligible
if
less
than
18
years
of
age)

2.
Are
you
of
Hispanic
or
Spanish
origin?

1
YES
2
NO

SKIP
TO
Q3
2a.
Are
you 
(
Interviewer,
read
responses.
Code
all
that
apply.)

1
Mexican,
Mexican­
American,
or
Chicano
2
Puerto­
Rican
3
Cuban
4
Other
(
specify)

3.
What
is
your
race?
(
Code
all
that
apply)

1
WHITE
2
BLACK
OR
AFRICAN­
AMERICAN
3
AMERICAN
INDIAN
OR
ALASKA
NATIVE
4
NATIVE
HAWAIIAN
5
GUAMANIAN
OR
CHAMORRO
6
SAMOAN
7
OTHER
PACIFIC
ISLANDER
(
SPECIFY)
_______________
8
ASIAN
INDIAN
9
CHINESE
10
FILIPINO
11
JAPANESE
12
KOREAN
13
VIETNAMESE
14
OTHER
ASIAN
(
SPECIFY)
_______________
15
OTHER
RACE
(
SPECIFY)
________________

4.
In
what
country
were
you
born?

1
USA
2
OTHER
(
SPECIFY)
__________

5.
What
is
the
highest
grade
or
level
of
school
that
you
have
completed
or
the
highest
degree
you
have
received?

1
NO
HGH
SCHOOL
DEGREE

What
is
the
highest
grade
of
school
you
completed?
(
Enter
grade)
_______
2
HIGH
SCHOOL
DIPLOMA
3
GED
OR
EQUIVALENT
4
SOME
COLLEGE
5
ASSOCIATE
(
2­
YEAR)
DEGREE
6
BACHELOR'S
DEGREE
7
MASTER'S
DEGREE
8
PROFESSIONAL
DEGREE
9
DOCTORAL
DEGREE
Partner
Preconception
1
(
Instrument
#
4)

8
Partner
Preconception
1
(
Instrument
#
4)

9
6.
What
is
the
approximate
gross
annual
income
for
all
members
in
this
household?
(
INTERVIEWER:
USE
SHOW
CARD)

1
Less
than
$
9,999,
2
$
10,000
­
$
19,999,
3
$
20,000
­
$
29,999,
4
$
30,000
­
$
39,999,
5
$
40,000
­
$
49,999,
6
$
50,000
­
$
74,999,
7
$
75,000
­
$
99,999,
or
8
$
100,000
or
more?

{
END
OF
DEMOGRAPHICS
MODULE}
Partner
Preconception
1
(
Instrument
#
4)

10
Alcohol
(
Full)

The
next
few
questions
are
about
alcohol
consumption.
A
"
drink"
is
a
can
or
bottle
of
beer,
a
glass
of
wine
or
a
wine
cooler,
a
shot
of
liquor,
or
a
mixed
drink
with
liquor
in
it.
We
are
not
asking
about
times
when
you
only
had
a
sip
or
two
from
a
drink.

1.
Have
you
had
any
alcoholic
drinks
in
the
past
2
years?

1
YES
2
NO

SKIP
TO
NEXT
MODULE
2.
Have
you
had
any
alcoholic
drinks
in
the
past
3
months?

1
YES
2
NO

SKIP
TO
NEXT
MODULE
3.
During
the
past
3
months,
how
many
alcoholic
drinks
did
you
have
in
an
average
week?
Would
you
say 

1
Less
than
1
drink
a
week,
2
1
to
3
drinks
a
week,
3
4
to
6
drinks
a
week,
4
7
to
13
drinks
a
week,
or
5
14
drinks
or
more
a
week?

4.
During
the
past
3
months,
how
many
times
did
you
drink
5
alcoholic
drinks
or
more
in
one
sitting?
Would
you
say 

1
Never,
2
1
time,
3
2
or
3
times,
4
4
or
5
times,
or
5
6
or
more
times?

5.
During
the
past
3
months,
what
one
type
of
alcohol
did
you
drink
most
often?

1
BEER
2
LIQUOR
3
WINE
4
OTHER
(
SPECIFY)_________________

{
END
OF
ALCOHOL
MODULE}
Partner
Preconception
1
(
Instrument
#
4)

11
Tobacco
(
Full)

These
next
questions
are
about
your
use
of
tobacco
products.
This
includes
cigarettes,
chewing
tobacco,
snuff,
cigars,
and
pipe
tobacco.

1.
During
the
past
30
days,
have
you
used
snuff,
dip,
or
chewing
tobacco,
even
once?

1
YES
2
NO
2.
During
the
past
30
days,
have
you
smoked
a
cigar
or
tobacco
pipe,
even
once?

1
YES
2
NO

SKIP
TO
Q3
2a.
How
often
do
you
smoke
cigars
or
tobacco
pipes?

_____
NUMBER
OF
TIMES
ENTER
UNIT
1
DAY
2
WEEK
3
MONTH
3.
Have
you
smoked
at
least
100
cigarettes
in
the
past
2
years?

1
YES
2
NO

SKIP
TO
Q7
4.
Do
you
currently
smoke
cigarettes?

1
YES

SKIP
TO
Q6
2
NO
5.
When
did
you
last
stop
smoking?

___
MONTH
___
YEAR
SKIP
TO
Q7
6.
How
many
cigarettes
do
you
smoke
on
an
average
day
now?
Would
you
say 
[
INTERVIEWER
PROBE:
ONE
PACK
IS
20
CIGARETTES]

1
Less
than
1
cigarette
per
day,
2
1
to
5
cigarettes,
3
6
to
10
cigarettes,
4
11
to
20
cigarettes,
5
21
to
40
cigarettes,
or
6
41
cigarettes
or
more?
Partner
Preconception
1
(
Instrument
#
4)

12
7.
Does
your
wife
or
partner
currently
smoke
cigarettes?

1
YES
2
NO
8.
Not
including
yourself,
how
many
cigarette
smokers
live
in
your
home
now?

_____

9.
About
how
many
hours
per
day
are
you
in
the
same
room
with
someone
who
is
smoking
cigarettes,
cigars,
or
tobacco
pipes?

_____
Hours
999
Less
than
1
hour
a
day
10.
Which
of
the
following
statements
describes
the
rules
about
smoking
inside
your
home
now?

1
No
one
is
allowed
to
smoke
anywhere
inside
my
home.
2
Smoking
is
allowed
in
some
rooms
or
at
some
times.
3
Smoking
is
permitted
anywhere
inside
my
home.

{
END
OF
TOBACCO
MODULE}
Partner
Preconception
1
(
Instrument
#
4)

13
Acceptability
(
To
be
administered
at
the
end
of
the
home
visit)

This
study
will
be
able
to
answer
health
questions
best
if
we
are
able
to
keep
people
involved
in
the
study.
To
do
this,
we
would
like
to
get
some
feedback
from
you
about
the
study
overall
and
this
visit
today
to
help
improve
the
study
in
the
future.

1.
Was
participating
in
the
visit
today
convenient
for
you?

1
YES

SKIP
TO
Q6
2
NO
2.
Did
you
have
to
take
time
off
from
work
to
have
this
interview
today?

1
YES
2
NO
3.
Did
you
need
to
find
childcare
to
have
this
interview
today?

1
YES
2
NO
4.
Were
there
any
other
major
obstacles
for
you
to
have
this
interview
today?

1
YES
2
NO

SKIP
TO
Q6
5.
What
were
they?
(
ENTER
VERBATIM)

____________________________

6.
Why
did
you
decide
to
participate
in
this
study?
(
CODE
ALL
THAT
APPLY)

1
THE
STUDY
WOULD
BENEFIT
MYSELF
OR
MY
CHILD
2
CONTRIBUTE
TO
IMPROVE
HEALTH
OF
CHILDREN
AND
PREGNANT
WOMEN
IN
THE
FUTURE
3
INTERESTING
PROJECT
TO
BE
INVOLVED
IN
4
CURIOSITY
5
DESIRE
TO
BELONG
TO
A
GROUP
OR
COMMUNITY
OF
SIMILAR
PEOPLE
6
DIDN'T
FEEL
COMFORTABLE
SAYING
NO
7
OTHER
REASON
(
SPECIFY)
__________________________

7.
Is
there
anything
that
you
especially
like
about
participating
in
this
study?
(
ENTER
VERBATIM)

____________________________

8.
Is
there
anything
you
especially
dislike
about
participating
in
this
study?
(
ENTER
VERBATIM)

____________________________
Partner
Preconception
1
(
Instrument
#
4)

14
9.
Finally,
do
you
have
any
recommendations
as
to
what
we
could
do
differently
in
the
overall
study
or
in
these
interviews?
(
ENTER
VERBATIM)

____________________________

{
END
OF
ACCEPTABILITY
MODULE}
