NCS
Herald
Cohort
Study
Instrument
#
20
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
Questionnaire
First
Home
Visit
Eligibility:
All
women
who
enrolled
at
delivery
Mode
of
administration:
Interviewer,
home
visit
8/
9/
2005
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
60
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
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

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
QUESTIONNAIRE:

Address
(
update)

1.
I'd
just
like
to
quickly
confirm
the
contact
information
we
have
on
file:
{
FILL
PRELOADED
ADDRESS
AND
PHONE
NUMBER}.
Is
this
still
correct?

1
YES
2
NO

Enter
correct
information,

{
END
OF
ADDRESS
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

2
Household
Composition
(
Full)

The
next
few
questions
are
about
people
living
in
this
household.

1.
Including
yourself,
how
many
adults
ages
18
and
older
are
currently
living
in
this
household?
(
ENTER
NUMBER)

_____

2.
[
IF
Q1>
1]
Not
including
yourself,
who
are
the
other
adults
living
in
this
household?
(
PROMPT:
HOW
ARE
THEY
RELATED
TO
YOU?)
(
CODE
ALL
THAT
APPLY)

1
your
spouse
or
partner
2
your
parent(
s)
3
your
partner's
parent(
s)
4
your
adult
child
/
children
5
other
relation(
s)
of
yourself
6
other
relations
of
your
partner
7
roommate(
s)
8
boarder
or
renter
9
other
(
SPECIFY)
___________________

3.
How
many
children
aged
5
through
17
are
currently
living
in
this
household?
(
ENTER
NUMBER)

_____

4.
How
many
children
under
age
5
are
currently
living
in
this
household?
(
ENTER
NUMBER)

_____

5.
[
IF
Q1>]
Are
you
the
regular
caregiver
for
any
adults
or
children
who
live
in
this
household?

1
YES
2
NO

GO
TO
NEXT
MODULE
6.
How
many
adults
do
you
regularly
care
for?
(
ENTER
NUMBER)

_____

7.
[
IF
Q3+
Q4
>
1]
How
many
children
do
you
regularly
care
for?
(
ENTER
NUMBER)

_____

{
END
OF
HOUSEHOLD
COMPOSITION
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

3
Occupation
(
Full,
revised
for
post­
pregnancy)

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
5.
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.
Please
consider
yourself
employed
if
you
are
on
maternity
leave.
Let's
start
with
your
(
FILL:
current/
most
recent/
next)
job.

6.
When
did
you
start
this
job?

MM/
DD/
YYYY
7.
[
SKIP
AND
PREFILL
WITH
`
1'
IF
CURRENT
JOB]
When
did
you
stop
working
at
this
job?

MM/
DD/
YYYY
1
=
STILL
EMPLOYED
8.
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
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

4
9.
What
kind
of
work
(
FILL:
are/
were)
you
doing?
(
For
example:
farming,
mail
clerk,
computer
specialist.)

_________________________________
ENTER
NAME
OF
OCCUPATION
10.
[
IF
STILL
EMPLOYED]
Are
you
currently
on
paid
or
unpaid
maternity
leave
from
this
job?

1
YES,
PAID
LEAVE
2
YES,
UNPAID
LEAVE
3
BACK
AT
WORK

SKIP
TO
Q12
11.
When
do
you
intend
to
return
to
work?
Would
you
say 

1
Within
one
month
2
Between
1
and
3
months
3
Between
4
and
6
months
4
More
than
6
months
12.
[
IF
BACK
AT
WORK,
ASK]
Who
takes
care
of
your
child
when
you
are
at
work?
[
IF
NOT
BACK
AT
WORK,
ASK]
What
plans
do
you
have
for
the
care
of
your
child
when
you
go
back
to
work?

1
EMPLOYER­
SPONSORED
DAYCARE
2
OTHER
DAYCARE
3
CARE
PROVIDED
BY
FAMILY
MEMBER
4
CARE
PROVIDED
BY
FRIEND
5
OTHER
(
SPECIFY)
_______________________

13.
How
many
hours
a
week
(
FILL:
do/
did)
you
usually
work
at
this
job?

____
HOURS
14.
(
FILL:
Do/
Did)
you
do
shift
work
for
this
job?

1
YES
2
NO

SKIP
TO
Q16
15.
(
FILL:
Does/
Did)
this
include
the
night
shift?

1
YES
2
NO
16.
Do
you
currently
have
another
job?

1
YES
[
REPEAT
Q6­
Q15
FOR
UP
TO
3
JOBS]
2
NO

GO
TO
NEXT
MODULE
{
END
OF
OCCUPATION
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

5
Chemical
Exposures
Module
Now
I'm
going
to
ask
you
about
chemicals
you
may
have
used
at
work,
at
home,
or
for
any
hobbies.

1.
Have
you
been
exposed
to
[
HAND
SHOW
CARD
TO
R
FOR
EACH
EXPOSURE
FROM
TABLE
BELOW]
in
the
last
12
months?

If
Yes,
ASK:

2.
Are
you
currently
exposed
to
[
INSERT
EXPOSURE]
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?

1.
Exposed
in
last
12
months
Yes=
01
No
=
02
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
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

6
Home
Environment/
Conditions
(
Full)

The
next
series
of
questions
are
related
to
your
home
environment,
including
your
water
sources,
heating,
and
air
conditioning.

1.
How
long
have
you
lived
at
this
address:
{
FILL
PRELOAD
ADDRESS}?

______
YEARS
_______
MONTHS
2.
Which
water
source
is
used
more
than
half
the
time
for
cooking?

1
Tap
water
2
Bottled
water,
or
3
Water
from
some
other
source?
(
SPECIFY)
__________________

3.
Which
water
source
is
used
more
than
half
the
time
for
drinking?

1
Tap
water
2
Bottled
water,
or
3
Water
from
some
other
source?
(
SPECIFY)
__________________

4.
Do
you
use
any
of
the
following
to
treat
your
water
at
home?
(
CODE
ALL
THAT
APPLY)

1
A
water
softener?
2
Charcoal
filters?
3
Reverse
osmosis?
4
Distillation?
5
Something
else?
(
SPECIFY)_______________________

Heat
and
Air
Conditioning
1.
Which
fuels
are
used
for
heating
this
residence?
(
CODE
ALL
THAT
APPLY)

1
Gas:
from
underground
pipes
serving
the
neighborhood
2
Gas:
bottled,
tank,
or
LP
3
Electricity
4
Fuel
oil,
kerosene,
etc
5
Coal
or
coke
6
Wood
7
Solar
energy
8
Propane
9
Other
fuel
(
SPECIFY)
____________________

2.
Does
this
residence
have
a
central
heating
system
with
ducts
that
blow
air
into
most
rooms?

1
YES
2
NO
3.
During
which
month
do
you
usually
start
using
heating
devices?

_____
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

7
4.
During
which
month
do
you
usually
stop
using
heating
devices?

_____

5.
During
the
months
that
you
use
heating
devices,
do
you
use
portable
kerosene
heaters
in
this
residence?

1
YES
2
NO

SKIP
TO
Q7
6.
How
often
do
you
use
your
kerosene
heater
during
the
heating
season?

1
Less
than
one
day
a
month
2
One
to
three
days
per
month
3
One
or
two
days
a
week
4
3­
5
days
a
week
5
More
than
5
days
a
week
7.
During
the
heating
season,
is
a
portable
or
nonvented
gas
(
non­
kerosene)
heater
used
in
this
residence?

1
YES
2
NO

SKIP
TO
Q9
8.
How
often
do
you
use
a
portable
or
nonvented
gas
heater
during
the
heating
season?

1
Less
than
one
day
a
month
2
One
to
three
days
per
month
3
One
or
two
days
a
week
4
3­
5
days
a
week
5
More
than
5
days
a
week
9.
During
the
heating
season,
is
a
wood­
or
coal­
burning
stove
or
a
wood­
burning
fireplace
used
in
this
residence?

1
YES
2
NO

SKIP
TO
Q11
10.
How
often
do
you
use
a
wood­
or
coal­
burning
stove
or
a
wood­
burning
fireplace
during
the
heating
season?

1
Less
than
one
day
a
month
2
One
to
three
days
per
month
3
One
or
two
days
a
week
4
3­
5
days
a
week
5
More
than
5
days
a
week
11.
Is
air
conditioning
(
refrigeration)
used
to
cool
this
residence?

1
YES
2
NO

SKIP
TO
NEXT
SECTION
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

8
12.
Which
of
the
following
types
of
air
conditioning
units
do
you
use?
(
CODE
ALL
THAT
APPLY)

1
Central
unit/
units?
2
Window
or
wall
unit/
units?
3
Portable
unit/
units?

13.
During
which
month
do
you
usually
start
using
air
conditioning
to
cool
this
residence?

_____

14.
During
which
month
do
you
usually
stop
using
air
conditioning?

_____

Cooking
1.
Do
you
use
a
gas
stove
for
cooking?

1
YES
2
NO
2.
Do
you
use
a
gas
stove
for
any
other
purpose
than
cooking,
for
example,
drying
clothes
or
heating
a
room?

1
YES
2
NO
Pesticides
and
Lawn
Care
Now
I'm
going
to
ask
you
about
the
use
of
pesticides
and
lawn
treatments
in
and
around
your
home.

1.
In
the
past
6
months,
were
any
chemicals
used
inside
this
residence
for
the
control
of
termites,
insects,
rodents,
or
other
pests?

1
YES
2
NO

SKIP
TO
Q6
2.
In
the
past
6
months,
what
rooms
in
your
home
were
treated
with
products
for
the
control
of
termites,
insects,
rodents,
or
other
pests?
(
CODE
ALL
THAT
APPLY)

1
Living
room
2
Family
room
3
Dining
room
4
Kitchen
5
Bathroom(
s)
6
Bedroom(
s)
7
Other
rooms
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

9
3.
In
the
past
6
months,
how
many
times....

a.
did
a
professional
exterminator
apply
these
products
inside
this
residence?
_______

b.
did
you
apply
these
products
inside
this
residence?
_______

4.
In
what
month
were
they
last
used
inside
this
residence?

_____

5.
What
were
the
names
of
the
products
last
used
inside
this
residence?

_________________
_________________
_________________

6.
In
the
past
6
months,
were
any
chemicals
used
outside
this
residence
for
the
control
of
termites,
insects,
rodents,
or
other
pests?

1
YES
2
NO

SKIP
TO
Q10
7.
In
the
past
6
months,
how
many
times....

a.
did
a
professional
exterminator
apply
these
products
outside
this
residence?
_______

b.
did
you
apply
these
products
outside
this
residence?
_______

8.
In
what
month
were
they
last
used
outside
this
residence?

_____

9.
What
were
the
names
of
the
products
last
used
outside
this
residence?

_________________
_________________
_________________

10.
In
the
past
6
months,
have
you
had
any
regular
lawn
or
yard
treatments?

1
YES
2
NO

SKIP
TO
NEXT
SECTION
11.
Who
usually
applies
these
treatments?

1
You,
2
A
professional,
or
3
Someone
else?
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

10
The
next
few
questions
are
about
the
general
condition
of
your
home.

Renovations
and
Paint
1.
In
the
last
6
months,
which
of
the
following
renovations
have
been
performed
in
this
home?
(
CODE
ALL
THAT
APPLY)

1
Adding
a
room?
2
Putting
up
or
taking
down
a
wall?
3
Replacing
windows?
4
Refinishing
floors?
5
Exterior
painting?
6
Interior
painting
2.
Over
the
last
6
months,
how
would
you
rate
the
typical
condition
of
the
painted
surfaces
 
the
walls,
trim,
etc.
 
inside
this
residence?
Would
you
say 

1
Excellent,
2
Very
good,
3
Fair,
or
4
Poor?

Water
Damage
/
Mold
3.
Water
damage
includes
water
stains
on
the
ceiling
or
walls,
rotting
wood,
and
flaking
sheetrock
or
plaster.
This
damage
may
be
from
broken
pipes,
a
leaky
roof
or
floods.
Have
you
seen
any
water
damage
in
your
home?

1
YES
2
NO
4.
Have
you
seen
any
mold
or
mildew
on
walls
or
other
surfaces
other
than
food,
inside
your
home?

1
YES
2
NO

SKIP
TO
NEXT
SECTION
3.
In
which
rooms
have
you
seen
the
mold
or
mildew?
(
CODE
ALL
THAT
APPLY)

1
Kitchen
2
Living
room
3
Hall/
landing
4
Your
bedroom
5
Other
bedrooms
6
Bathroom/
toilet
{
END
OF
HOME
ENVIRONMENT
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

11
Pets
and
Pests
(
Full,
revised
for
post­
pregnancy)

Now
I'm
going
to
ask
you
a
few
questions
about
pets
in
the
household.

1.
Do
you
have
house
pets
such
as
dogs,
cats,
gerbils,
hamsters,
rabbits,
guinea
pigs
or
birds?

1
YES
2
NO

SKIP
TO
Q8
2.
How
many
of
the
following
pets
do
you
have?
[
READ
EACH
TYPE
OF
PET.
IF
1
OR
MORE,
ASK:

3..
[
FILL:
Is
this
pet
/
How
many
of
these
pets
are]
kept
indoors?

Total
Number
Number
kept
indoors
1.
dogs
2.
cats
3.
gerbils,
hamsters
and
guinea
pigs
4.
rabbits
5.
birds
6.
Other
pets
(
specify)
____________

4.
Are
any
of
your
pets
kept
in
the
same
room
where
your
baby
sleeps
most
of
the
time?

1
YES
2
NO
5.
Do
any
of
your
pets
sleep
on
the
same
bedding
as
your
baby?

1
YES
2
NO
6.
Are
any
chemicals
used
on
the
pets
to
control
fleas
and
ticks?
(
e.
g.
treated
collars,
dips,
powders,
drops,
etc.)

1
YES
2
NO

SKIP
TO
Q8
7.
What
is
the
name
of
the
products
last
used
on
your
pets
to
control
fleas
or
ticks?

IF
RESPONDENT
DOES
NOT
KNOW,
ASK
TO
SEE
THE
CONTAINERS
_____________________
_____________________

8.
In
the
last
6
months,
have
you
seen
signs
of
mice,
rats,
or
other
rodents
in
your
home
(
not
including
p
ets)?

1
YES
2
NO
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

12
9.
In
the
last
6
months,
have
you
seen
cockroaches
in
your
home?

1
YES
2
NO
{
END
OF
PETS
AND
PESTS
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

13
Medical
History
 
Child
1
month
The
next
questions
are
about
your
baby's
birth
and
general
health.

1.
Did
you
have
twins
or
more
than
one
baby?

1
YES
2
NO

FILL
1A
WITH
`
1'
AND
SKIP
TO
Q2
1a.
How
many
babies
did
you
have?

______

I'd
like
to
get
some
information
about
{
FILL:
your
baby
/
each
of
your
babies}.
[
CAPI
INSTRUCTION:
LOOP
THROUGH
Q2
 
Q14
FOR
NUMBER
ENTERED
IN
1A]

2.
What
is
your
{
FILL:
first/
next}
baby's
name?

___________________

3.
Is
{
FILL
NAME}
a
boy
or
a
girl?

1
MALE
2
FEMALE
4.
What
did
{
FILL
NAME}
weigh
when
{
he/
she}
was
born?

_____
lb
______
oz
5.
What
was
{
his/
her}
length?

______
inches
6.
After
your
baby
was
born,
was
{
he/
she}
put
in
an
intensive
care
unit?

1
YES
2
NO
­
7
DON'T
KNOW
7.
After
your
baby
was
born,
how
long
did
{
he/
she}
stay
in
the
hospital?

1
Less
than
24
hours
(
less
than
1
day)
2
24
to
48
hours
(
1
to
2
days)
3
3
days
4
4
days
5
5
days
6
6
days
or
more
7
My
baby
was
not
born
in
a
hospital
8
My
baby
is
still
in
the
hospital
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

14
8.
Has
your
baby
had
jaundice
at
any
time
since
{
he/
she}
was
born?

1
YES
2
NO

SKIP
TO
Q10
9.
How
was
the
jaundice
treated?
(
CODE
ALL
THAT
APPLY)

1
Fed
formula
in
addition
to
breastfeeding
for
a
while
2
Stopped
breastfeeding
for
a
while
3
Baby
was
placed
under
a
lamp
(
phototherapy)
4
Baby
was
placed
in
the
sun
5
Baby
received
an
exchange
transfusion
6
Baby
received
some
other
treatment
7
No
treatment
was
given
10.
Not
counting
the
time
when
your
baby
was
born,,
has
{
he/
she}
been
hospitalized
for
any
reason
or
has
your
baby
been
taken
to
a
hospital
for
any
outpatient
procedure
or
surgery?

1
YES
2
NO

SKIP
TO
Q12
11.
How
many
nights
was
your
baby
in
the
hospital
for
the
most
recent
problem?
(
WRITE
0
IF
BABY
DID
NOT
STAY
OVERNIGHT)

___________
NIGHTS
12.
Has
your
baby
had
any
of
the
following
illnesses
or
problems
since
{
he/
she}
was
born?
(
CODE
ALL
THAT
APPLY)

1
Fever
2
Diarrhea
3
Vomiting
4
Ear
infection
5
Colic
6
Fussy
or
irritable
7
Runny
nose
or
cold
8
Cough
or
wheeze
9
Respiratory
Syncytial
Virus
(
RSV)
10
Weight
loss
or
poor
weight
gain
13.
Does
your
baby
have
any
severe,
long­
term
medical
problems
that
you
are
aware
of?

1
YES
2
NO

SKIP
TO
Q14
13a.
What
medical
problems?

__________________________________
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

15
14.
How
would
you
describe
{
FILL
NAME}'
s
health
now?

1
Excellent
2
Good
3
Fair
4
Poor
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

16
Developmental/
Sleep
(
1
month)

Now
I'd
like
to
ask
you
about
your
child's
behavior
and
characteristics.

1.
Below
is
a
list
of
things
your
baby
may
already
do
or
may
start
doing
when
{
he/
she}
gets
older.
How
often
does
your
baby 

Rarely
Some
of
the
time
Almost
always
Always
a.
Look
at
your
face
when
you
hold
or
feed
him/
her?
0
1
2
3
b.
Follow
you
with
his/
her
eyes?
0
1
2
3
c.
Smile
when
you
smile
at
him/
her?
0
1
2
3
d.
Smile
by
himself/
herself?
0
1
2
3
e.
Laugh
or
squeal?
0
1
2
3
f.
Lift
his/
her
head
when
lying
on
stomach?
0
1
2
3
g.
Startle
or
react
to
a
sound?
0
1
2
3
2.
Compared
to
other
babies,
do
you
think
your
baby
cries
more,
the
same,
or
less?

1
MORE
2
THE
SAME
3
LESS
3.
Can
you
usually
calm
or
console
your
baby
when
{
he/
she}
cries
1
YES
2
NO
4.
How
often
does
your
baby
have
colic,
or
times
when
{
he/
she}
cries
and
can't
be
calmed
or
consoled?

0
Rarely
1
Some
of
the
time
2
Almost
always
3
Always
5.
Do
you
think
your
baby's
crying
is
a
problem?

1
YES
2
NO
6.
Even
though
your
baby
is
only
4
weeks
old,
{
he/
she}
may
show
emotions
or
other
actions.
Overall,
would
you
describe
your
baby
as 

Yes
No
a.
Calm?
1
2
b.
Worried?
1
2
c.
Sociable
or
outgoing?
1
2
d.
Angry?
1
2
e.
Shy
or
quiet?
1
2
f.
Stubborn?
1
2
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

17
g.
Happy?
1
2
Now
I'll
ask
you
about
your
baby's
sleeping.

7.
In
what
position
do
you
most
often
lay
your
baby
down
for
naps?

1
Side
2
Stomach
[
IF
THIS
CHOICE
SELECTED,
GIVE
PARTICIPANT
PUBLIC
HEALTH
BROCHURE
ABOUT
SAFE
SLEEPING
POSITIONS]
3
Back
8.
In
what
position
do
you
most
often
lay
your
baby
down
to
sleep
at
night?

1
Side
2
Stomach
[
IF
THIS
CHOICE
SELECTED,
GIVE
PARTICIPANT
PUBLIC
HEALTH
BROCHURE
ABOUT
SAFE
SLEEPING
POSITIONS]
3
Back
9.
Does
your
baby
usually
sleep
in
your
room
or
in
a
different
room
at
night?

1
IN
YOUR
ROOM
2
IN
A
DIFFERENT
ROOM
10.
What
does
your
baby
usually
sleep
in
at
night?

1
Bassinette
2
Crib
3
Co­
sleeper
(
attaches
to
the
side
of
your
bed)
4
In
bed
or
other
place
with
you
5
In
something
else
{
END
OF
DEVELOPMENTAL
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

18
Infant
Safety
(
Full)

1.
I'm
going
to
read
you
some
statements
about
safety.
Do
any
of
these
statements
apply
to
you?

a.
My
infant
was
brought
home
from
the
hospital
in
an
infant
car
seat
Y
N
b.
My
home
has
a
working
smoke
alarm
Y
N
c.
There
are
loaded
guns,
rifles,
or
other
firearms
in
my
home
Y
N
[
IF
Q1a=
N,
Q1b=
N,
or
Q1c=
Y,
HAND
OUT
APPROPRIATE
PUBLIC
HEALTH
BROCHURES]

2.
Did
you
worry
that
wearing
your
seat
belt
during
pregnancy
would
hurt
your
new
baby?

1
YES
2
NO
3.
When
your
new
baby
rides
in
a
car,
truck,
or
van,
how
often
does
he
or
she
ride
in
an
infant
car
seat?

1
Always
2
Often
3
Sometimes
4
Rarely
5
Never

GO
TO
NEXT
MODULE
[
Give
participant
public
health
brochure
about
benefits
of
infant
safety
car
seats]

4.
When
your
new
baby
rides
in
an
infant
car
seat,
is
he
or
she
usually
in
the
front
or
back
seat
of
the
car,
truck,
or
van?

1
Front
seat
[
GIVE
PUBLIC
HEALTH
BROCHURE]
2
Back
seat
5.
When
your
new
baby
rides
in
an
infant
car
seat,
is
he
or
she
usually
facing
forward
or
facing
the
rear
of
the
car,
truck,
or
van?

1
Facing
forward
[
GIVE
PUBLIC
HEALTH
BROCHURE]
2
Facing
the
rear
6.
Does
the
car,
truck,
or
van
that
your
new
baby
usually
rides
in
have
an
airbag
on
the
passenger
side?

1
YES
2
NO
{
END
OF
INFANT
SAFETY
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

19
Child
Diet
1
Month
The
next
questions
are
about
feeding
your
baby.

1.
About
how
long
after
your
delivery
did
you
breastfeed
or
try
to
breastfeed
your
baby
for
the
very
first
time?

1
NEVER
BREASTFED
2
LESS
THAN
1
HOUR
3
1
 
6
HOURS
4
7­
12
HOURS
5
13­
24
HOURS
6
1
­
2
DAYS
7
MORE
THAN
2
DAYS
2.
How
long
did
it
take
for
your
milk
to
come
in?

1
1
DAY
OR
LESS
2
2
DAYS
3
3
DAYS
4
4
DAYS
5
MORE
THAN
4
DAYS
3.
While
you
were
in
the
hospital
or
birth
center,
was
your
baby
fed
water,
formula,
or
sugar
water
at
any
time?
(
CODE
ALL
THAT
APPLY)

1
WATER
2
FORMULA
3
SUGAR
WATER
4.
When
you
left
the
hospital
or
birth
center,
how
were
you
feeding
your
baby?

1
Breastfeeding
only
2
Formula
feeding
only,
or
3
Both
breast
and
formula
feeding
5.
During
the
first
few
days
after
your
baby
was
born,
did
you
feed
him
or
her
1
Whenever
he
or
she
cried
or
seemed
hungry
2
On
a
schedule
or
routine
3
Sometimes
on
a
schedule
AND
sometimes
when
he
or
she
cried
or
seemed
hungry
6.
In
the
past
7
days,
how
often
was
your
baby
fed
each
item
listed
below?
Include
feedings
by
everyone
who
feeds
the
baby
and
include
snacks
and
night­
time
feedings.

FEEDINGS
PER
DAY
Breast
milk
...................................................................
_______
Formula
........................................................................
_______
Water............................................................................
_______
Sugar
water...................................................................
_______
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

20
Other
milk
(
soy,
rice,
goat
milk)
...................................
_______
Other
(
SPECIFY)
_______________________________
_______

7.
Which
of
the
following
was
your
baby
given
in
vitamin
or
mineral
drops
at
least
3
days
a
week
during
the
past
2
weeks?
(
CODE
ALL
THAT
APPLY)

1
Fluoride
2
Iron
3
Vitamin
D
4
Other
vitamins
8.
Has
your
baby
ever
been
fed
formula?
1
YES
2
NO

SKIP
TO
Q14
9.
How
old
was
your
baby
when
{
he/
she}
was
first
fed
formula?

1
1
day
old
or
less
2
2­
6
days
old
3
7­
13
days
old
4
14­
20
days
old
5
More
than
20
days
old
10.
How
often
does
your
baby
drink
all
of
his
or
her
bottle
of
formula?

1
Always
2
Most
of
the
time
3
Sometimes
4
Rarely
5
Never
11.
In
the
past
7
days,
on
the
average,
how
many
ounces
of
formula
did
your
baby
drink
at
each
feeding?

_______
oz
12.
Which
brand
of
infant
formula
was
fed
to
your
baby
in
the
past
7
days?
Please
tell
me
the
group
number
for
each
infant
formula
your
baby
was
fed.
(
INTERVIEWER:
USE
SHOW
CARD)

1
Group
1
2
Group
2
3
Group
3
4
Group
4
5
Group
5
6
Group
6
13.
What
type
of
infant
formula
is
it?
(
CODE
ALL
THAT
APPLY)

1
Ready
to
feed
2
Liquid
concentrate
3
Powder
 
from
can
that
makes
more
than
one
bottle
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

21
4
Powder
 
from
single
serving
packs
[
GO
TO
NEXT
MODULE
IF
`
0'
FOR
BREASTMILK
IN
Q6]

14.
Does
your
baby
usually
feed
from
both
breasts
at
each
feeding?

1
YES
2
NO
3
BABY
IS
FED
ONLY
PUMPED
MILK

SKIP
TO
Q15
15.
Does
your
baby
usually
let
go
of
the
breast
him
or
herself
when
finished
feeding?

1
YES,
BOTH
BREASTS
2
YES,
FIRST
BREAST
ONLY
3
YES,
SECOND
BREAST
ONLY
4
NO
16.
In
an
average
24­
hour
period,
what
is
the
LONGEST
time
for
you,
the
mother,
between
breastfeedings
or
expressing
milk,
that
is,
from
the
start
of
one
breastfeeding
or
expressing
session
to
the
start
of
the
next?
Please
think
of
time
between
feedings
during
both
night
and
day
to
find
the
longest
time.
(
WRITE
IN
THE
NUMBER
OF
HOURS
AND
MINUTES)

______
HOURS
________
MINUTES
17.
How
many
times
in
the
past
7
days
has
your
baby
been
given
expressed
or
pumped
breast
milk
to
drink?

______
TIMES
[
IF
`
0',
GO
TO
NEXT
MODULE]

18.
Since
you
have
been
breastfeeding,
have
you
changed
the
amount
you
eat
of
the
following
foods?
[
USE
SHOWCARDS]

Stopped
Eating
Eat
Less
Eat
about
the
same
Eat
More
Did
not
eat
before
Milk
or
other
dairy
foods
1
2
3
4
0
Soy
milk
or
other
soy
foods
1
2
3
4
0
Eggs
1
2
3
4
0
Fish,
including
canned
tuna
1
2
3
4
0
Shellfish
1
2
3
4
0
Onions
or
garlic
1
2
3
4
0
Broccoli,
cauliflower,
or
cabbage
1
2
3
4
0
Citrus
fruit
such
as
oranges
and
grapefruit
1
2
3
4
0
Nuts,
peanuts,
or
peanut
butter
1
2
3
4
0
Alcoholic
drinks,
including
beer
1
2
3
4
0
Vitamin
or
mineral
supplement
1
2
3
4
0
Any
herbal
or
botanical
supplement
1
2
3
4
0
{
END
OF
1
MONTH
CHILD
DIET
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

22
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

23
Personal
Medical
History
(
Full,
revised
for
post­
pregnancy)

Now
I'd
like
to
ask
you
about
your
delivery.

1.
Which
type
of
health
professional
was
your
birth
attendant?
(
CODE
ALL
THAT
APPLY)

1
An
obstetrician
2
A
family
doctor,
general
practitioner,
or
other
physician
3
A
midwife
or
nurse
midwife
4
Another
type
of
health
care
provider
5
No
health
professional
was
present
2.
Other
than
medical
staff,
who
was
with
you
during
your
labor?
(
CODE
ALL
THAT
APPLY)

1
The
baby's
father
2
Relatives
or
friends
3
A
professional
labor
support
person,
such
as
a
doula
4
No
other
person
3.
How
was
your
baby
delivered?

1
Vaginally
and
not
induced
2
Vaginally
and
induced
3
A
planned
cesarean
4
An
unplanned
or
emergency
cesarean
4.
How
long
did
you
stay
in
the
hospital
after
delivering
your
baby?

1
Less
than
24
hours
(
less
than
1
day)
2
24
to
48
hours
(
1
to
2
days)
3
3
days
4
4
days
5
5
days
6
6
days
or
more
7
Did
not
deliver
in
hospital
Now
I'd
like
to
ask
you
some
questions
about
your
general
health.

5.
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)
__________________

6.
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
Q8
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

24
7.
Did
a
doctor
or
other
medical
provider
ever
say
that
this
was
hayfever
or
allergy?

1
YES
2
NO
8.
Did
a
doctor
or
other
medical
provider
ever
tell
you
that
you
had
a
skin
allergy
or
eczema?

1
YES
2
NO
9.
Did
a
doctor
or
other
medical
provider
ever
tell
you
that
you
had
asthma?

1
YES
2
NO

SKIP
TO
Q12
10.
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
11.
Have
you
ever
gone
to
an
emergency
room
or
stayed
overnight
in
a
hospital
for
your
asthma?

1
YES
2
NO
12.
Do
you
currently
have
any
of
the
following
health
problems?
(
CODE
ALL
THAT
APPLY)

1
High
blood
sugar
(
diabetes)
2
High
blood
pressure
or
hypertension
3
High
cholesterol
4
Anemia
(
poor
blood,
low
iron)
5
Heart
problems
13.
Did
you
have
any
of
the
following
health
problems
during
your
pregnancy?
(
CODE
ALL
THAT
APPLY)

1
High
blood
sugar
(
diabetes)
that
started
during
this
pregnancy
2
Vaginal
bleeding
or
spotting
3
Kidney
or
bladder
(
urinary
tract)
infection
4
Severe
nausea,
vomiting,
or
dehydration
5
High
blood
pressure
or
hypertension
that
started
during
this
pregnancy
(
including
pregnancy­
induced
hypertension
[
PIH],
preeclampsia,
or
toxemia)

14.
Have
you
ever
been
diagnosed
with
any
other
serious
illnesses
that
I
haven't
asked
about?

1
YES
2
NO

SKIP
TO
Q15
14a.
What
were
those
illnesses?
(
ENTER
VERBATIM)
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

25
_______________________

15.
During
the
past
6
months,
have
you
been
hospitalized
overnight
for
any
reason
(
other
than
for
delivering
your
baby)?

1
YES
2
NO

SKIP
TO
Q16
15a.
Why
were
you
hospitalized?
(
ENTER
VERBATIM)

_______________________

16.
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?

Now
I
would
like
to
confirm
the
name
of
the
place
where
you
gave
birth,
and
also
the
healthcare
providers
you
used
/
are
planning
to
use.

17.
Where
did
you
deliver
your
baby?
(
Specify
name
of
facility)
___________________________

19.
What
is
the
name
of
your
OB/
GYN
doctor?

(
Specify
name
of
OB/
GYN)
_______________________________

20.
What
is
the
name
of
your
pediatrician?
(
Specify
name
of
pediatrician)
_____________________
888
DO
NOT
HAVE
ONE
999
DON'T
KNOW
{
END
OF
PERSONAL
AND
FAMILY
MEDICAL
HISTORY
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

26
Dental
Health
(
Full)

1.
Have
you
ever
been
to
the
dentist
for
a
routine
cleaning?

1
YES
2
NO

SKIP
TO
Q3
2.
When
was
your
last
routine
cleaning?

MM/
YYYY
3.
Do
you
currently
have
any
of
the
following
dental
problems?

[
READ
EACH
CATEGORY]

IF
YES,
ASK:
When
was
the
last
time
you
saw
a
dentist
for
this
condition?

a.
Plaque
YES
NO
MM/
YYYY
0
=
NEVER
b.
Bleeding
gums
or
other
gum
disease
YES
NO
MM/
YYYY
0
=
NEVER
c.
Tooth
decay
YES
NO
MM/
YYYY
0
=
NEVER
d.
Tooth
ache
YES
NO
MM/
YYYY
0
=
NEVER
e.
Dentist­
diagnosed
gingivitis
YES
NO
MM/
YYYY
0
=
NEVER
f.
Dentist­
diagnosed
periodontitis
YES
NO
MM/
YYYY
0
=
NEVER
g.
Missing
or
broken
teeth?
YES
NO
MM/
YYYY
0
=
NEVER
g.
Any
other
dental
problems?
(
SPECIFY)
YES
NO
MM/
YYYY
0
=
NEVER
{
END
OF
DENTAL
HEALTH
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

27
Medications
(
Full)

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
prescription
medications?

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
2
NO

SKIP
TO
END
4.
Please
tell
me
which
non­
prescription
medications
you
currently
take
on
a
regular
basis.
Do
you
take 

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
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

28
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
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

29
Supplements,
Vitamins,
Etc.
(
Full)

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,
or
Centrum?

1
YES
2
NO

SKIP
TO
Q5
2.
How
often
do
you
take
any
multivitamins?

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.
How
long
have
you
been
taking
multivitamins?

1
Less
than
3
months
2
3
months
to
1
year
3
More
than
1
year
5.
Are
you
currently
taking
any
vitamins,
minerals,
or
supplements
other
than
your
multivitamins?

1
YES
2
NO

GO
TO
NEXT
MODULE
6.
Which
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
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

30
17.
SELENIUM
18.
ZINC
7.
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
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

31
Neighborhood
(
Full)

Now
I'd
like
to
ask
you
about
the
neighborhood
you
live
in.

1.
In
your
opinion,
is
your
neighborhood 

1
A
very
good
place
to
live
2
A
fairly
good
place
to
live
3
Not
a
very
good
place
to
live,
or
4
Not
at
all
a
good
place
to
live?

2.
How
often
do
people
in
your
neighborhood 

Never
Rarely
Sometimes
Often
Always
DK
a.
Visit
your
home?
0
1
2
3
4
­
1
b.
Argue
with
you?
0
1
2
3
4
­
1
c.
Look
after
your
children?
0
1
2
3
4
­
1
d.
Keep
to
themselves?
0
1
2
3
4
­
1
e.
Attend
religious
services?
0
1
2
3
4
­
1
3.
Is
your
neighborhood 

Not
at
all
Sometimes
Usually
a.
Lively?
0
1
2
b.
Polluted/
dirty?
0
1
2
c.
Friendly?
0
1
2
d.
Noisy?
0
1
2
e.
Clean?
0
1
2
f.
Attractive?
0
1
2
4.
Have
you
ever
asked
a
neighbor 
(
CODE
ALL
THAT
APPLY)

1.
To
help
with
minor
household
tasks
or
repairs?
2.
To
give
you
a
ride
somewhere?
3.
To
help
take
care
of
you
or
a
family
member
when
you
are
sick?
4.
To
borrow
money?
5.
To
borrow
other
items
such
as
food
or
tools?

5.
Do
you
feel
that
your
neighborhood
is 

1
Very
safe
2
Somewhat
safe
3
Somewhat
unsafe,
or
4
Very
unsafe?

6.
In
your
opinion,
does
your
neighborhood
have
problems
with 
(
CODE
ALL
THAT
APPLY)

a.
Property
crimes
such
as
break­
ins
or
burglaries?
b.
Personal
crimes
such
as
muggings
or
beatings?
c.
Violent
crimes?
d.
Drug
dealing?
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

32
7.
From
where
you
live,
is
it
relatively
easy
for
you
to
get
to 
(
CODE
ALL
THAT
APPLY)

a.
stores
to
get
the
groceries
you
need?
b.
public
parks
or
recreational
facilities?
c.
doctor's
offices
or
clinics?
d.
your
religious
institution?
e.
your
children's
schools?
[
DISPLAY
ONLY
IF
R
HAS
CHILD]
f.
daycare
programs?
[
DISPLAY
ONLY
IF
R
HAS
CHILD]

8.
Are
you
a
member
of
any
religious
faith?

1
YES
2
NO

GO
TO
NEXT
MODULE
9.
How
often
do
you
go
to
a
place
of
worship?

1
At
least
once
a
week
2
At
least
once
a
month
3
At
least
once
a
year
4
Or
not
at
all?

{
END
OF
NEIGHBORHOOD
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

33
Post­
partum
depression
(
Full)

I'm
going
to
ask
you
some
questions
about
how
you
felt
during
your
most
recent
pregnancy.
1.
At
any
time
during
your
most
recent
pregnancy
or
after
delivery,
did
a
doctor,
nurse,
or
other
health
care
worker
talk
with
you
about
"
baby
blues"
or
postpartum
depression?

1
YES
2
NO
2.
Did
you
seek
help
for
depression
from
a
doctor,
nurse,
or
other
health
care
worker?

1
YES
2
NO

SKIP
TO
Q6
3.
At
any
time
during
your
most
recent
pregnancy,
did
you
get
counseling
for
your
depression?

1
YES
2
NO
4.
At
any
time
during
your
most
recent
pregnancy,
did
a
doctor,
nurse,
or
other
health
care
worker
diagnose
you
with
depression?

1
YES
2
NO

SKIP
TO
Q6
5.
At
any
time
during
your
most
recent
pregnancy,
did
you
take
prescription
medicine
for
your
depression?

1
YES
2
NO
6.
How
would
you
describe
the
time
during
your
most
recent
pregnancy?

1
One
of
the
happiest
times
of
my
life
2
A
happy
time
with
few
problems
3
A
moderately
hard
time
4
A
very
hard
time
5
One
of
the
worst
times
of
my
life
Now
I'm
going
to
ask
you
similar
questions
about
how
you
have
felt
since
your
new
baby
was
born.

7.
Since
your
new
baby
was
born,
how
often
have
you
felt
down,
depressed,
or
hopeless?

1
Always
2
Often
3
Sometimes
4
Rarely
5
Never
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

34
8.
Since
your
new
baby
was
born,
how
often
have
you
had
little
interest
or
little
pleasure
in
doing
things?

1
Always
2
Often
3
Sometimes
4
Rarely
5
Never
9.
Since
your
new
baby
was
born,
did
you
seek
help
for
depression
from
a
doctor,
nurse,
or
other
health
care
worker?

1
YES
2
NO

GO
TO
NEXT
MODULE
10.
Have
you
gotten
counseling
for
your
depression?

1
YES
2
NO
11.
Has
a
doctor,
nurse,
or
other
health
care
worker
diagnosed
you
with
depression?

1
YES
2
NO
12.
Since
your
new
baby
was
born,
have
you
taken
prescription
medicine
for
your
depression?

1
YES
2
NO
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

35
Health
Care
Access/
Insurance
(
Full)

The
next
few
questions
are
about
health
care
and
insurance.

1.
Are
you
covered
by
health
insurance
or
some
other
kind
of
health
care
plan?
Include
health
insurance
obtained
through
employment
or
purchased
directly
as
well
as
government
programs
like
Medicare
and
Medicaid
that
provide
medical
care
or
help
pay
medical
bills.

1
YES
2
NO

SKIP
TO
Q3
2.
What
kind
of
health
insurance
or
health
care
coverage
do
you
have?
Include
those
that
pay
for
only
one
type
of
service
(
nursing
home
care,
accidents,
or
dental
care).
Exclude
private
plans
that
only
provide
extra
cash
while
hospitalized.
(
INTERVIEWER:
USE
SHOW
CARD)

1
PRIVATE
HEALTH
INSURANCE
PLAN
FROM
EMPLOYER
OR
WORKPLACE
2
PRIVATE
HEALTH
INSURANCE
PLAN
PURCHASED
DIRECTLY
3
PRIVATE
HEALTH
INSURANCE
PLAN
THROUGH
A
STATE
OR
LOCAL
GOVERNMENT
PROGRAM
OR
COMMUNITY
PROGRAM
4
MEDICARE
5
MEDI­
GAP
6
MEDICAID
({
DISPLAY
STATE
PLAN
NAME})
7
CHIP
(
CHILDREN'S
HEALTH
INSURANCE
PROGRAM)
8
MILITARY
HEALTH
CARE/
VA
9
CHAMPUS/
TRICARE/
CHAMP­
VA
10
INDIAN
HEALTH
SERVICE
11
STATE­
SPONSORED
HEALTH
PLAN
({
DISPLAY
STATE
PLAN
NAME})
12
OTHER
GOVERNMENT
PROGRAM
13
SINGLE
SERVICE
PLAN
(
E.
G.,
DENTAL,
VISION,
PRESCRIPTIONS)

3.
Are
you
currently
on
WIC
(
The
Special
Supplemental
Nutrition
Program
for
Women,
Infants,
and
Children)?

1
YES
2
NO
4.
What
kind
of
place
do
you
usually
go
to
most
often
when
you
are
sick
or
need
advice
about
your
health?

1
A
clinic
or
health
center,
2
A
doctor's
office
or
HMO,
3
A
hospital
emergency
room,
4
A
hospital
outpatient
department,
or
5
Some
other
place?
Specify:
__________________
6
DON'T
GO
TO
ONE
PARTICULAR
PLACE
MOST
OFTEN
2.
About
how
long
has
it
been
since
you
last
saw
or
talked
to
a
doctor
or
other
health
care
professional
about
your
own
health?
Include
doctors
seen
while
a
patient
in
a
hospital.
Would
you
say 

0
Never,
1
6
months
or
less,
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

36
2
More
than
6
months,
but
not
more
than
1
year
ago,
3
More
than
1
year,
but
not
more
than
2
years
ago,
4
More
than
2
years,
but
not
more
than
5
years
ago,
or
5
More
than
5
years
ago?

{
END
OF
HEALTH
CARE
ACCESS/
INSURANCE
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

37
Reproductive
History
(
Full,
revised
for
pregnancy)

Now,
I
have
some
questions
about
your
reproductive
health
and
menstrual
history.
Please
remember
that
your
responses
will
be
kept
strictly
confidential.

Menstrual
History
1.
How
old
were
you
when
you
had
your
first
menstrual
period?

______
YEARS
OLD
2.
During
the
12
months
before
you
were
pregnant,
what
was
the
average
number
of
days
between
the
first
day
of
bleeding
of
one
period
to
the
first
day
of
bleeding
of
your
next
period?

_____
DAYS
99
=
TOO
IRREGULAR
TO
KNOW
3.
During
the
12
months
before
you
were
pregnant
{
FILL
IF
Q2=
99:
and
not
counting
any
previous
pregnancy},
did
you
ever
go
more
than
2
months
without
having
a
period?

1
YES
2
NO
Pregnancy
History
4.
Not
counting
this
pregnancy,
how
many
times
have
you
ever
been
pregnant?
(
INT
PROBE:
No
matter
what
happened
with
the
pregnancy)

_____
[
IF
0,
SKIP
TO
NEXT
SECTION]

4a.
Did
any
of
these
pregnancies
result
in
a
live
birth?

1
YES
2
NO

GO
TO
NEXT
MODULE
5.
Did
any
of
your
babies
have
any
birth
defects
at
birth?

1
YES
2
NO
6.
Have
you
ever
had
a
baby
that
weighed
5
pounds,
8
ounces
(
2.5
kilos)
or
less
at
birth?

1
YES
2
NO
7.
Have
you
ever
had
baby
that
was
born
more
than
3
weeks
before
your
due
date?

1
YES
2
NO
{
END
OF
REPRO
HISTORY
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

38
Demographics
(
Income)

Household
income
is
often
used
in
scientific
studies
to
compare
groups
of
people
who
are
similar.
We
do
some
analysis
of
the
data
using
these
groups.
Please
remember
that
all
the
data
you
provide
is
held
in
strict
confidence.

1.
Do
you
or
your
household
receive
income
from ?
(
INTERVIEWER:
USE
SHOW
CARD.
CODE
ALL
THAT
APPLY)

1.
Wages
and
salaries?
2.
Self­
employment,
including
business
and
farm
income?
3.
Family
or
friends?
4.
Aid
such
as
Temporary
Assistance
for
Needy
Families
(
TANF),
welfare,
WIC,
public
assistance,
general
assistance,
food
stamps,
or
Supplemental
Security
Income?
5.
[
Do
you
or
your
household
receive
income
from]
Interest­
bearing
checking
accounts,
savings
accounts,
IRAs
or
certificates
of
deposit,
money
market
funds,
treasury
notes,
bonds,
or
other
investments
that
earned
interest?
6.
Dividends
received
from
stocks
or
mutual
funds,
or
net
rental
income
from
property,
royalties,
estates
or
trusts?
7.
Unemployment
benefits?
8.
Child
support
or
alimony?
9.
Social
security,
Railroad
Retirement,
workers'
compensation,
disability,
veteran
benefits,
or
pensions?
10.
Any
other
source?
(
SPECIFY)____________________

2.
Including
all
sources
of
income
just
mentioned,
approximately
what
is
the
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?

3.
How
many
adults
depend
on
this
income?

______

4.
How
many
children
depend
on
this
income?

______

5.
Do
you
own
this
house/
apartment,
or
is
it
being
rented
or
occupied
through
some
other
arrangement?

1
OWN
OR
BEING
BOUGHT
2
RENT
3
OTHER
ARRANGEMENT
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

39
6.
Do
you
{
FILL:
or
your
spouse/
partner}
have
any
money
in
savings
or
checking
accounts
or
other
investment
accounts?
(
INTERVIEWER:
IF
NECESSARY
READ:
Please
think
ONLY
about
these
types
of
savings
for
this
question.)

1
YES
2
NO
7.
Do
you
{
FILL:
or
your
spouse/
partner}
have
any
money
in
individual
retirement
accounts
such
as
IRAs
or
Keoghs?
(
INTERVIEWER:
IF
NECESSARY
READ:
Please
think
only
about
these
types
of
savings
for
this
question,
and
DO
NOT
REPORT
any
savings
already
reported.)

1
YES
2
NO
{
END
OF
DEMOGRAPHICS/
INCOME
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

40
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

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

1
YES
2
NO

GO
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
SPEFICY:_________________

{
END
OF
ALCOHOL
MODULE}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

41
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
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

42
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?

7.
[
IF
PARTNER
EXISTS
ASK:]
Does
your
husband/
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}
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

43
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)

____________________________

9.
Finally,
do
you
have
any
recommendations
as
to
what
we
could
do
differently
in
the
overall
study
or
in
these
interviews?
(
ENTER
VERBATIM)
Female
(
enrolled
at
delivery,
2nd
or
3rd
trimester)
First
Home
Visit
(
instrument
#
20)

44
____________________________

{
END
OF
ACCEPTABILITY
MODULE}
