NCS
Herald
Cohort
Study
Instrument
#
17
Female
Questionnaire
Pregnancy
Third
Trimester
Clinic
Visit
Eligibility:
All
pregnant
women
3rd
trimester
Mode
of
administration:
Interviewer,
clinic
visit
8/
4/
2005
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
45
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.
Female
Pregnancy
3
(
instrument
#
17)

1
PRELOADED
DATA:

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

Respondent
Name
Respondent
Address
and
Phone
Spouse/
Partner's
Name
Spouse/
Partner's
Address
and
Phone
Biological
father's
name
Marital
status
Baby
due
date
OB/
GYN
name
Hospital
planning
to
deliver
Last
interview
date
Student
status
Employment
status
Smoking
status
Chemical
exposures
Medications
QUESTIONNAIRE:
Female
Pregnancy
3
(
instrument
#
17)

2
Pregnancy
Status
(
Update,
revised
for
pregnancy)

1.
What
is
your
due
date?

MM/
DD/
YYYY
2.
[
IF
DELIVERY
HOSPITAL
PRELOADED
ASK]
Do
you
still
plan
on
having
your
baby
at
[
FILL
HOSPITAL
NAME]?

1
YES

GO
TO
NEXT
MODULE
2
NO
3.
Where
do
you
plan
to
deliver?

1
HOSPITAL
(
SPECIFY)
_______________________________
2
OTHER
(
SPECIFY)
_______________________________
3
DON'T
KNOW
4
REFUSED
{
END
OF
PREGNANCY
STATUS
MODULE}
Female
Pregnancy
3
(
instrument
#
17)

3
Breastfeeding
Intent
1.
Which
of
the
following
statements
describes
your
current
feelings
about
breastfeeding
your
new
baby?

1
I
know
I
will
breastfeed
2
I
think
I
might
breastfeed
[
Provide
Public
Health
brochure
about
benefits
of
breastfeeding]
3
I
know
I
will
not
breastfeed
[
Provide
Public
Health
brochure
about
benefits
of
breastfeeding]
4
I
don't
know
right
now
[
Provide
Public
Health
brochure
about
benefits
of
breastfeeding]

2.
Has
anyone
suggested
that
you
not
breastfeed
your
new
baby?

1
YES
2
NO

GO
TO
NEXT
MODULE
3.
Who
suggested
that
you
not
breastfeed
your
new
baby?
(
CODE
ALL
THAT
APPLY)

1
HUSBAND
OR
PARTNER
2
MOTHER,
FATHER,
OR
IN­
LAWS
3
OTHER
FAMILY
MEMBERS
OR
RELATIVES
4
FRIENDS
5
DOCTOR,
NURSE,
OR
OTHER
HEALTH
CARE
WORKER
6
OTHER
(
SPECIFY)
______________
Female
Pregnancy
3
(
instrument
#
17)

4
Occupation
(
Update
Revised
for
Pregnancy)

1.
In
your
last
interview
on
[
FILL
DATE],
you
reported
that
you
were
(
FILL
:
not
a/
a
full­
time/
a
parttime
student.
Is
this
still
correct?

1
YES

SKIP
TO
Q4
2
NO
2.
Are
you
now
a
student
full
or
part­
time?

1
YES,
FULL­
TIME
2
YES,
PART­
TIME
3
NO,
NOT
A
STUDENT

SKIP
TO
Q4
3.
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)_________________

4.
In
your
last
interview
on
[
FILL
DATE],
you
reported
that
you
were
(
FILL
EMPLOYMENT).
Is
this
still
correct?

1
YES
2
NO

SKIP
TO
Q5
Q4=
YES,
STILL
WORKING

SKIP
TO
Q6
Q4=
YES,
STILL
LOOKING
FOR
WORK

GO
TO
NEXT
MODULE
Q4=
YES,
STILL
NOT
WORKING

GO
TO
NEXT
MODULE
5.
Are
you
currently 

[
ONLY
DISPLAY
THE
OPTIONS
NOT
SELECTED
IN
PREVIOUS
INTERVIEW]
1
Working
at
a
job
or
business,

SKIP
TO
PARAGRAPH
BEFORE
Q7
2
Looking
for
work,
or

GO
TO
NEXT
MODULE
3
Not
working
at
a
job
or
business?

GO
TO
NEXT
MODULE
6.
Did
you
start
work
at
any
jobs
since
your
last
interview
on
[
FILL
DATE]?

1
YES
2
NO

SKIP
TO
Q15
Please
tell
me
about
the
jobs
you've
had
since
your
last
interview,
starting
with
the
(
FILL:
current/
most
recent)
one.

7.
On
what
date
did
you
start
this
job?
Female
Pregnancy
3
(
instrument
#
17)

5
MM/
DD/
YYYY
8.
On
what
date
did
you
stop
working
at
this
job?

MM/
DD/
YYYY
1
=
STILL
EMPLOYED
9.
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
10.
What
kind
of
work
(
FILL:
are/
were)
you
doing?
(
For
example:
farming,
mail
clerk,
computer
specialist.)

_________________________________
ENTER
NAME
OF
OCCUPATION
11.
How
many
hours
a
week
(
FILL:
do/
did)
you
usually
work
at
this
job?

____
HOURS
12.
(
FILL:
Do/
Did)
you
do
shift
work
for
this
job?

1
YES
2
NO

SKIP
TO
Q14
13.
(
FILL:
Does/
Did)
this
include
the
night
shift?

1
YES
2
NO
14.
Did
you
have
any
other
jobs
since
[
FILL
DATE]?

1
YES
[
REPEAT
Q7­
Q13
FOR
UP
TO
3
JOBS]
2
NO

GO
TO
Q15
15.
Did
you
stop
working
at
any
job,
even
temporarily,
because
of
your
pregnancy?

1
YES
2
NO

GO
TO
NEXT
MODULE
16.
Which
job
was
that?
[
DISPLAY
LIST
OF
ALL
JOBS
HELD]

17.
Did
you
stop
working
for
any
of
these
reasons?
(
CODE
ALL
THAT
APPLY)

1
doctor
recommended
it
2
didn't
feel
well
enough
3
decided
not
to
work
Female
Pregnancy
3
(
instrument
#
17)

6
4
other
medical
reason
5
family
encouraged
you
to
quit
6
non­
family
encouraged
you
to
quit
7
some
other
reason
(
SPECIFY)
______________

[
ASK
Q18­
Q22
ONLY
IF
CURRENTLY
EMPLOYED]
18.
Does
your
current
employer
provide
maternity
leave?

1
YES
2
NO
19.
Do
you
plan
to
work
until
your
delivery
date?

1
YES
2
NO
20.
Do
you
plan
to
return
to
work
after
you
have
had
your
baby?

1
YES
2
NO

GO
TO
NEXT
MODULE
21.
How
long
after
you
have
had
your
baby
do
you
plan
to
return
to
work?

1
Within
one
month
2
Between
1
and
3
months
3
Between
4
and
6
months
4
More
than
6
months
22.
Do
you
plan
to
return
to
work
on
a
full­
or
part­
time
basis?

1
FULL­
TIME
2
PART­
TIME
{
END
OF
OCCUPATION
MODULE}
Female
Pregnancy
3
(
instrument
#
17)

7
Chemical
Exposures
(
Update)

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

1.
Last
time
you
said
you
were
{
FILL:
not
exposed
to
any
of
these
chemicals
/
exposed
to
[
DISPLAY
LIST
OF
EXPOSURES
REPORTED
IN
PREVIOUS
VISIT]}.
Is
this
still
correct?
(
HAND
SHOW
CARD
TO
RESPONDENT
AND
READ
THE
LETTER
CORRESPONDING
TO
EACH
PREVIOUS
EXPOSURE)

1
YES

IF
NO
PREVIOUS
EXPOSURES,
GO
TO
NEXT
MODULE
2
NO
2.
[
IF
Q1=
1,
ASK:]
Are
you
currently
also
exposed
to
any
of
the
following
chemicals?
[
IF
Q1=
2,
ASK:]
Which
of
the
following
chemicals
are
you
currently
exposed
to?

[
IF
Q1=
1,
DISPLAY
ONLY
THOSE
EXPOSURES
NOT
PREVIOUSLY
REPORTED.
IF
Q1=
2,
DISPLAY
ALL
EXPOSURES]

YES
NO

SKIP
TO
NEXT
EXPOSURE
3.
How
often
are
you
exposed
to
[
INSERT
EXPOSURE]
?
Would
you
say.
.
.

4.
Did
the
exposure
occur
while
you
were
at
work?

2.
Currently
Exposed
Yes
=
01
No
=
02
3.
Frequency
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
4.
At
work
Yes
=
01
No
=
02
A.
Fuels,
solvents,
dry
cleaning
fluids,
degreasers,
or
adhesives
B.
Lead,
including
paints
with
lead
in
them
C.
Fumes
or
gases
(
e.
g.,
nitrous
oxide,
ethylene
oxide,
anesthetic
gases)
D.
Radiation
(
e.
g.,
fluoroscopy,
radioisotopes,
highintensity
microwaves,
x­
rays)
E.
Mercury
F.
Metal
fumes
or
particles
G.
Pesticides
that
you've
mixed
or
applied
H.
Paints,
strippers,
or
varnishes
I.
Hair
and
nail
products
(
e.
g,
hair
dye,
bleach,
hair
relaxer,
nail
polish
and
remover)
J.
Cleaning
products
(
e.
g.,
oven
cleaner,
disinfectant,
carpet
cleaner,
bleach)
K.
Carbon
black
from
copying
machines
L.
Coal
or
coal
products
from
hot
asphalt,
tar,
or
roofing
material
{
END
OF
CHEMICAL
EXPOSURES
MODULE}
Female
Pregnancy
3
(
instrument
#
17)

8
Personal
Medical
History
(
update,
revised
for
pregnancy)

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

1.
Since
your
last
interview
on
[
FILL
DATE],
have
you
developed
any
of
the
following
health
problems?
(
CODE
ALL
THAT
APPLY)

[
CAPI:
ONLY
DISPLAY
ITEMS
=
NO
FOR
LAST
INTERVIEW]
1
High
blood
sugar
(
diabetes)
that
started
before
this
pregnancy
2
High
blood
sugar
(
diabetes)
that
started
during
this
pregnancy
3
Vaginal
bleeding
or
spotting
4
Kidney
or
bladder
(
urinary
tract)
infection
5
Severe
nausea,
vomiting,
or
dehydration
6
High
blood
pressure
or
hypertension
that
started
before
this
pregnancy
7
High
blood
pressure
or
hypertension
that
started
during
this
pregnancy
(
including
pregnancy­
induced
hypertension
[
PIH],
preeclampsia,
or
toxemia)
8
High
cholesterol
9
Anemia
(
poor
blood,
low
iron)
10
Heart
problems
11
Cervix
had
to
be
sewn
shut
(
incompetent
cervix)
12
Asthma
IF
Q1
=
12,
ASK
Q2­
4
ELSE,
SKIP
TO
Q5
2.
Did
a
doctor
or
other
medical
provider
ever
tell
you
that
you
had
asthma?

1
YES
2
NO

SKIP
TO
Q8
3.
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
4.
Have
you
ever
gone
to
an
emergency
room
or
stayed
overnight
in
a
hospital
for
your
asthma?

1
YES
2
NO
5.
Some
women
experience
several
days
or
weeks
of
nausea
or
feeling
sick
to
their
stomach
when
they
are
pregnant
while
other
women
do
not.
Have
you
had
any
times
when
you
had
a
feeling
of
nausea
during
this
pregnancy?

1
YES
2
NO

SKIP
TO
Q9
6.
Did
your
nausea
cause
you
to:
[
read
choices
and
circle
all
that
apply]

1.
eat
less
food
than
you
usually
did
before
you
were
pregnant
2.
not
be
able
to
do
your
normal
daily
activities
Female
Pregnancy
3
(
instrument
#
17)

9
3.
not
be
able
to
take
your
prenatal
vitamin
0.
none
of
the
above
7.
Have
you
vomited
during
this
pregnancy
because
of
nausea
related
to
being
pregnant?

1
YES
2
NO

SKIP
TO
Q9
8.
Have
you
vomited
more
than
4
times
in
a
week
for
at
least
one
week
during
this
pregnancy?

1
YES
2
NO
9.
Since
your
last
interview
on
[
FILL
DATE],
have
you
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.
Since
[
FILL
DATE],
have
you
been
hospitalized
for
any
reason?

1
YES
2
NO

GO
TO
NEXT
MODULE
10a.
Why
were
you
hospitalized?
(
ENTER
VERBATIM)

_______________________

{
END
OF
PERSONAL
MEDICAL
HISTORY
MODULE}
Female
Pregnancy
3
(
instrument
#
17)

10
Prenatal
Care
(
Full)

Now
I'm
going
to
ask
you
about
prenatal
care
you
have
received
during
your
pregnancy.

1.
Since
you
became
pregnant,
how
many
times
have
you
been
to
a
doctor
or
other
health
care
provider
for
regular
prenatal
care
visits?
Please
do
not
include
hospitalizations
or
visits
that
were
not
specifically
intended
for
prenatal
care.

1
NONE

GO
TO
NEXT
MODULE
[
HAND
OUT
PUBLIC
HEALTH
BROCHURE
ON
PRENATAL
CARE]
2
1
to
4
3
5
to
9
4
10
to
14
5
15
or
more
2.
Where
did
you
go
most
of
the
time
for
your
prenatal
visits?
Do
not
include
visits
for
WIC.

1
Hospital
clinic
2
Health
department
clinic
3
Private
doctor's
office
or
HMO
clinic
4
Other
(
SPECIFY)
__________

3.
During
any
of
your
prenatal
care
visits,
did
a
doctor,
nurse,
or
other
health
care
worker
talk
with
you
about
how
much
weight
you
should
gain
during
your
pregnancy?

1
YES
2
NO
4.
Did
you
receive
information
on
breastfeeding
during
any
of
your
prenatal
care
visits?

1
YES
2
NO
5.
During
any
of
your
prenatal
care
visits,
did
a
doctor,
nurse,
or
other
health
care
worker
ask
if
you
were
smoking
cigarettes?

1
YES
2
NO
6.
[
During
any
of
your
prenatal
care
visits,]
did
a
doctor,
nurse,
or
other
health
care
worker
ask
if
you
were
drinking
alcoholic
beverages
(
beer,
wine,
wine
cooler,
or
liquor)?

1
YES
2
NO
7.
During
any
of
your
prenatal
care
visits,
did
a
doctor,
nurse,
or
other
health
care
worker
ask
you
 
Yes
No
a.
How
much
alcohol
you
were
drinking
..................................................................
Y
N
b.
If
someone
was
hurting
you
emotionally
or
physically..........................................
Y
N
c.
If
you
were
using
illegal
drugs
(
marijuana
or
hash,
cocaine,
crack,
etc.)................
Y
N
d.
If
you
wanted
to
be
tested
for
HIV
(
the
virus
that
causes
AIDS)
...........................
Y
N
Female
Pregnancy
3
(
instrument
#
17)

11
e.
If
you
planned
to
use
birth
control
after
your
baby
was
born
.................................
Y
N
8.
During
any
of
your
prenatal
care
visits,
did
a
doctor,
nurse,
or
other
health
care
worker
talk
with
you
about
the
bacteria
Group
B
Strep
(
Beta
Strep)?

1
YES
2
NO
9.
During
any
of
your
prenatal
care
visits,
did
a
doctor,
nurse,
or
other
health
care
worker
talk
with
you
about
any
of
the
things
listed
below?
Please
count
only
discussions,
not
reading
materials
or
videos.

Yes
No
a.
Washing
hands
after
contact
with
soil,
sand,
litter,
or
any
other
material
that
may
be
contaminated
with
cat
feces......................................................................
Y
N
b.
How
eating
fish
containing
high
levels
of
mercury
could
affect
your
baby?
..........
Y
N
c.
taking
a
multivitamin
or
a
prenatal
vitamin
during
your
pregnancy?
These
are
pills
that
contain
many
different
vitamins
and
minerals
.........................
Y
N
10.
At
any
time
during
your
most
recent
pregnancy,
did
your
regular
prenatal
care
provider
ask
you
to
see
a
specialist
doctor
for
help
with
any
health
problem(
s)?

1
YES
2
NO
{
END
OF
PRENATAL
CARE
MODULE}
Female
Pregnancy
3
(
instrument
#
17)

12
Medications
(
Update)

I'll
be
asking
you
about
prescription
and
non­
prescription
medications
you
are
currently
taking.
If
you
do
not
remember
the
specific
names
of
your
medications,
I
can
wait
for
you
to
gather
them.

1.
Are
you
currently
taking
any
new
prescription
medications
that
you
were
not
taking
when
we
last
interviewed
you
on
[
FILL
DATE]?

1
YES
2
NO

SKIP
TO
Q3
2.
Please
tell
me
what
prescription
medications
you
are
taking.
Are
you
currently
taking
any 

Medication
Type
IF
YES:
What
is
the
name
of
the
[
INSERT
MED
TYPE]
you
are
taking?
a.
Antibiotics?
1
YES
2
NO
b.
Allergy
medications,
antihistamines,
or
decongestants?
1
YES
2
NO
c.
Pain
Killers?
1
YES
2
NO
d.
Medications
for
depression?
1
YES
2
NO
e.
Medications
for
asthma?
1
YES
2
NO
f.
Other
prescription
medications?
1
YES
2
NO
3.
Do
you
currently
take
any
non­
prescription,
or
over­
the­
counter,
medications
on
a
regular
basis?

1
YES

IF
PREVIOUS
OTC
MEDS
REPORTED,
GO
TO
Q4.
IF
NOT,
GO
TO
Q5
2
NO

GO
TO
NEXT
MODULE
4.
[
CAPI
INSTRUCTION:
DISPLAY
PREVIOUS
OTC
MEDS
FROM
TABLE
BELOW
AND
FREQUENCY
REPORTED]
Last
time,
you
said
you
took
{
FILL
MED
NAME}
{
FILL
FREQUENCY}.
Has
this
changed?

4a.
Are
you
currently
taking
any
of
these
other
non­
prescription
medications
in
a
regular
basis?
[
CAPI
INSTRUCTION:
DISPLAY
OTC
MEDS
NOT
REPORTED
DURING
LAST
INTERVIEW]

5.
Please
tell
me
which
non­
prescription
medications
you
currently
take
on
a
regular
basis.
Do
you
take 
Female
Pregnancy
3
(
instrument
#
17)

13
Medication
Type
IF
YES:
How
often
do
you
usually
take
this
medication?
a.
Tylenol
(
Acetominophen)?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
b.
Advil
or
Motrin
(
Ibuprofen)?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
c.
Cough
or
cold
medicine?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
d.
Allergy
medications,
antihistamines,
or
decongestants?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
e.
Aspirin?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
f.
Other
nonprescription
medications?
(
SPECIFY)
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
{
END
OF
MEDICATIONS
MODULE}
Female
Pregnancy
3
(
instrument
#
17)

14
Supplements,
Vitamins,
Etc.
(
update)

Now
I
will
ask
you
similar
questions
about
vitamins
and
supplements
you
are
taking.

1.
Are
you
currently
taking
any
multivitamins
such
as
One­
a­
Day,
Centrum,
or
prenatal
vitamins?

1
YES
2
NO

SKIP
TO
Q4
2.
How
often
do
you
take
any
multivitamins
or
prenatal
vitamins?

1
Every
day
2
4
 
6
days
per
week
3
1
 
3
days
per
week
4
1
 
3
days
per
month
3.
Do
your
multivitamins
usually
contain
minerals
such
as
iron,
zinc,
etc.?

1
YES
2
NO
4.
Are
you
currently
taking
any
vitamins,
minerals,
or
supplements
other
than
your
multivitamins?

1
YES
2
NO

GO
TO
NEXT
MODULE
5.
Do
you
take
any
of
the
following
supplements
that
are
not
part
of
a
multivitamin?
(
INTERVIEWER:
HAND
SHOW
CARD
TO
RESPONDENT.
CODE
ALL
THAT
APPLY)

1.
BETA­
CAROTENE
2.
VITAMIN
A
3.
VITAMIN
B­
6
OR
B­
COMPLEX
4.
VITAMIN
C
5.
VITAMIN
E
6.
CALCIUM
OR
CALCIUM­
CONTAINING
ANTACIDS
7.
VITAMIN
D,
INCLUDING
VITAMIN
D
TAKEN
AS
PART
OF
A
CALCIUM
SUPPLEMENT
8.
BREWER'S
YEAST
9.
COD
LIVER
OIL
10.
COENZYME
Q
11.
FISH
OIL
(
OMEGA
3
FATTY
ACIDS)
12.
FOLIC
ACID/
FOLATE
13.
GLUCOSAMINE
14.
HYDROXYTRYPTOPHAN
(
HTP)
15.
IRON
16.
NIACIN
17.
SELENIUM
18.
ZINC
Female
Pregnancy
3
(
instrument
#
17)

15
6.
Please
tell
me
if
you
take
any
of
the
following
herbal
or
botanical
supplements
more
than
once
per
week.
Include
only
supplements
and
teas,
not
use
of
the
herb
in
food.
(
INTERVIEWER:
HAND
SHOW
CARD
TO
RESPONDENT.
CODE
ALL
THAT
APPLY)

1.
ALOE
VERA
2.
BILBERRY
3.
CAYENNE
4.
CRANBERRY
5.
DONG
KUAI
(
TANGKWEI)
6.
ECHINACEA
7.
EVENING
PRIMROSE
OIL
8.
FEVERFEW
9.
GARLIC
10.
GINGER
11.
GINKGO
BILOBA
12.
GINSENG
(
AMERICAN
OR
ASIAN)
13.
GOLDENSEAL
14.
GRAPESEED
EXTRACT
15.
KAVA
16.
MILK
THISTLE
17.
SIBERIAN
GINSENG
18.
ST.
JOHN'S
WORT
19.
VALERIAN
20.
OTHER
SPECIFY_____________________

{
END
OF
VITAMINS/
SUPPLEMENTS
MODULE}
Female
Pregnancy
3
(
instrument
#
17)

16
Alcohol
(
update)

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.
Since
your
last
interview
on
[
FILL
DATE],
have
you
had
any
alcoholic
drinks?

1
YES
2
NO

GO
TO
NEXT
MODULE
2.
Since
your
last
interview
on
[
FILL
DATE],
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?

3.
Since
your
last
interview
on
[
FILL
DATE],
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?

{
END
OF
ALCOHOL
MODULE}
Female
Pregnancy
3
(
instrument
#
17)

17
Tobacco
(
update)

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

1.
Since
your
last
interview
on
[
FILL
DATE],
have
you
used
snuff,
dip,
or
chewing
tobacco,
even
once?

1
YES
2
NO
2.
Since
your
last
interview,
have
you
smoked
a
cigar
or
tobacco
pipe,
even
once?

1
YES
2
NO

SKIP
TO
Q3
2a.
How
often
have
you
smoked
cigars
or
tobacco
pipes
since
your
last
interview?

_____
NUMBER
OF
TIMES
ENTER
UNIT
1
DAY
2
WEEK
3
MONTH
[
IF
SMOKER
FROM
PREVIOUS
INTERVIEW,
ASK
Q3­
Q4
]
[
IF
NON­
SMOKER
IN
PREVIOUS
INTERVIEW,
SKIP
TO
Q5
]
3.
Do
you
still
smoke
cigarettes?

1
YES

SKIP
TO
Q6
2
NO
4.
When
did
you
stop
smoking?

MM/
YYYY

SKIP
TO
Q7
5.
In
your
last
interview
you
reported
that
you
were
not
smoking
cigarettes.
Are
you
currently
smoking
cigarettes
now?

1
YES
2
NO

SKIP
TO
Q7
6.
How
many
cigarettes
do
you
smoke
on
an
average
day
now?
Would
you
say 

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?

7.
In
your
last
interview
on
[
FILL
DATE],
you
reported
that
there
were
[
FILL
#]
cigarette
smokers
who
lived
in
your
home
not
including
yourself.
Is
this
still
correct?
Female
Pregnancy
3
(
instrument
#
17)

18
1
YES

SKIP
TO
Q9
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
{
END
OF
TOBACCO
MODULE}
Female
Pregnancy
3
(
instrument
#
17)

19
Acceptability
(
To
be
administered
at
the
end
of
the
clinic
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
2
NO
2.
How
much
time
did
it
take
for
you
to
arrive
here
today?

_______
MINUTES
3.
How
did
you
arrive
at
the
clinic
today?

1
Your
own
vehicle
2
Public
transportation
3
Taxi
4
Some
other
ride
arrangement
4.
Did
you
have
to
take
time
off
from
work
to
come
to
the
clinic
today?

1
YES
2
NO
5.
Did
you
need
to
find
childcare
to
come
here
today?

1
YES
2
NO
6.
How
long
did
you
wait
to
be
seen
today?

_______
MINUTES
7.
How
do
you
feel
about
your
participation
in
this
study
so
far?
(
CODE
ALL
THAT
APPLY)

1
THE
STUDY
IS
INTERESTING
2
IT
TAKES
TOO
MUCH
TIME
3
TOO
MUCH
INFORMATION
BEING
COLLECTED
4
TOO
MANY
DATA
COLLECTION
POINTS
5
CURIOUS
TO
GET
INFORMATION
ABOUT
MY
BABY'S
HEALTH
6
DOING
IT
FOR
THE
MONEY
7
OTHER
(
SPECIFY)
______________________

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

____________________________
Female
Pregnancy
3
(
instrument
#
17)

20
9.
Is
there
anything
you
especially
dislike
about
participating
in
this
study?
(
ENTER
VERBATIM)

____________________________

10.
What
could
we
do
in
the
future
to
keep
women
like
you
involved
in
the
study?
(
ENTER
VERBATIM)

_____________________________

{
END
OF
ACCEPTABILITY
MODULE}
