NCS
Herald
Cohort
Study
Instrument
#
23
Female
Questionnaire
Six
Month
Home
Visit
Eligibility:
All
women
who
gave
birth
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
6
Month
(
Instrument
#
23)

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
Last
interview
date
Student
status
Employment
status
Flag
for
house
pets
reported
Smoking
status
Chemicals
Medications
QUESTIONNAIRE:
Female
6
Month
(
Instrument
#
23)

2
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
[
ADMINISTER
INSTRUMENT
#
29,
NEW
HOME
LOCATION]

{
END
OF
ADDRESS
MODULE}
Female
6
Month
(
Instrument
#
23)

3
Pregnancy
Status
(
Update)

Now
I'd
like
to
ask
you
about
your
pregnancy
status
and
plans.

1.
Are
you
currently
pregnant?

1
YES
2
NO

SKIP
TO
Q3
3
DON'T
KNOW

SKIP
TO
Q3
2.
What
is
your
due
date?

MM/
DD/
YYYY
DON'T
KNOW

What
was
the
first
day
of
your
last
menstrual
period?
MM/
DD/
YYYY
[
SKIP
TO
END]

3.
Which
of
the
following
statements
best
describes
your
current
feelings
about
becoming
pregnant?

1
I
am
trying
to
get
pregnant
now
2
I
don't
wish
to
get
pregnant
now,
but
I
would
like
to
get
pregnant
within
the
next
three
months
3
I
would
like
to
get
pregnant
sometime
in
the
future,
but
not
in
the
next
three
months
4
I
do
not
wish
to
get
pregnant
again
4.
Are
you
currently
sexually
active?

1
YES
2
NO

GO
TO
NEXT
MODULE
5.
Do
you
currently
use
any
form
of
birth
control?
By
birth
control,
I
mean
anything
that
you
might
have
done
to
prevent
pregnancy.

1
YES
2
NO

GO
TO
NEXT
MODULE
6.
What
form(
s)
of
birth
control
do
you
use?
(
CODE
ALL
THAT
APPLY)

1
Birth
control
pills
2
IUD
3
Depo­
Provera/
Norplant
4
Condoms
5
Rhythm
Method
6
Diaphragm
7
Some
other
method
(
SPECIFY)
___________

{
END
OF
PREGNANCY
STATUS
MODULE}
Female
6
Month
(
Instrument
#
23)

4
Occupation
(
Update,
revised
for
post­
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
currently
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

GO
TO
Q5
[
PROGRAMMING
NOTES]
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
new
jobs
since
[
FILL
DATE]?

1
YES
2
NO

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

7.
On
what
date
did
you
start
this
job?
Female
6
Month
(
Instrument
#
23)

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
Q6­
Q13
FOR
UP
TO
3
JOBS]
2
NO

GO
TO
Q15
15.
Are
you
currently
on
paid
or
unpaid
maternity
leave
from
any
job?

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

SKIP
TO
Q17
16.
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
Female
6
Month
(
Instrument
#
23)

6
17.
[
IF
BACK
AT
WORK,
ASK]
What
type
of
early
childhood
education
program
or
other
child
care
does
your
child
participate
in
while
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?
[
IF
R
DOES
NOT
WORK,
ASK]
Do
you
have
any
usual
arrangements
for
the
care
of
your
child?

1
EMPLOYER­
SPONSORED
EARLY
CHILDHOOD
EDUCATION
PROGRAMS
OR
CHILD
CARE
2
OTHER
EARLY
CHILDHOLD
EDUCATION
PROGRAMS
OR
CHILD
CARE
3
CARE
PROVIDED
BY
FAMILY
MEMBER
4
CARE
PROVIDED
BY
FRIEND
5
OTHER
(
SPECIFY)__________

18.
How
many
hours
per
week
does
your
child
spend
in
[
INSERT
ANSWER
FROM
Q5]?
____
hours
{
END
OF
OCCUPATION
MODULE}
Female
6
Month
(
Instrument
#
23)

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,
SKIP
TO
END
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
6
Month
(
Instrument
#
23)

8
Home
Environment/
Conditions
(
Update)
[
If
Instrument
#
29
has
been
administered
Go
To
Next
Module]

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
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....
Female
6
Month
(
Instrument
#
23)

9
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

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

1
You,
2
A
professional,
or
3
Someone
else?

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
Female
6
Month
(
Instrument
#
23)

10
1.
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
2.
Have
you
seen
any
mold
or
mildew
on
walls
or
other
surfaces
other
than
food,
inside
your
home?

1
YES
2
NO

GO
TO
NEXT
MODULE
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
6
Month
(
Instrument
#
23)

11
Medical
History
 
Child
6
month
(
update)

The
next
questions
are
about
your
baby's
general
health.

1.
Has
your
baby
had
any
of
the
following
illnesses
or
problems
since
our
last
interview
on
{
FILL
DATE}?
(
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
Food
allergy
11
Eczema
(
atopic
dermatitis)
12
Weight
loss
or
poor
weight
gain
13
Seizure
2.
[
ASK
IF
Q1=
13]
Was
your
baby's
seizure
related
to
a
high
fever?

1
YES
2
NO
3.
Since
your
last
interview,
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
Q5
4.
How
many
nights
was
your
baby
in
the
hospital
for
the
most
recent
problem?
(
WRITE
0
IF
BABY
DID
NOT
STAY
OVERNIGHT)

___________
NIGHTS
5.
Has
your
baby
been
diagnosed
with
any
severe,
long­
term
medical
problems
or
birth
defects
since
{
FILL
DATE}?

1
YES
2
NO

SKIP
TO
Q6
5a.
What
medical
problems?

__________________________________
Female
6
Month
(
Instrument
#
23)

12
6.
How
would
you
describe
{
FILL
NAME}'
s
health
now?

1
Excellent
2
Good
3
Fair
4
Poor
7.
Has
your
child
seen
the
doctor
for
at
least
one
well
visit
since
your
last
interview?

1
YES
2
NO
{
END
OF
CHILD
HEALTH
MODULE}
Female
6
Month
(
Instrument
#
23)

13
Developmental/
Sleep
(
6
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
Follow
you
with
his/
her
eyes?
0
1
2
3
Smile
when
you
smile
at
him/
her?
0
1
2
3
Try
to
get
a
toy
that
is
out
of
reach?
0
1
2
3
Feed
him/
herself
a
cracker
or
cereal?
0
1
2
3
Wave
goodbye?
0
1
2
3
Reaches
for
toys
or
food
held
to
him/
her?
0
1
2
3
Grab
an
object
like
a
block
or
rattle
from
you?
0
1
2
3
Move
a
toy
or
block
from
one
hand
to
the
other?
0
1
2
3
Pick
up
a
small
object
like
a
Cheerio
or
raisin?
0
1
2
3
Hold
two
toys
or
blocks
at
a
time,
one
in
each
hand?
0
1
2
3
Startle
or
react
to
a
sound?
0
1
2
3
Turns
towards
a
sound?
0
1
2
3
Turns
toward
someone
when
they're
speaking?
0
1
2
3
Makes
sounds
as
though
he/
she
is
trying
to
speak?
0
1
2
3
Says
mama
or
dada?
0
1
2
3
Can
keep
head
steady
when
sitting
or
held
up?
0
1
2
3
Rolls
over
from
stomach
to
back?
0
1
2
3
Rolls
from
back
to
stomach?
0
1
2
3
Sit
up
by
him/
herself?
0
1
2
3
Stand
while
holding
onto
something?
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?

1
Rarely
2
Some
of
the
time
3
Almost
always
4
Always
Female
6
Month
(
Instrument
#
23)

14
5.
Do
you
think
your
baby's
crying
is
a
problem?

1
YES
2
NO
6.
You
may
notice
your
baby's
personality
developing
a
bit
more
now
that
{
he/
she}
is
six
months
old.
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
g.
Happy?
1
2
7.
How
often
do
you
do
following
activities
with
your
baby?

Never
Occasionally
Almost
Everyday
Every
day
Play
with
toys?
0
1
2
3
Watch
TV?
0
1
2
3
Read
or
look
at
books?
0
1
2
3
Go
for
walks?
0
1
2
3
Attend
baby
activity
classes
such
as
Mommy
and
me,
Baby
Gymboree,
swimming
classes?
0
1
2
3
Now
I'll
ask
you
about
your
baby's
sleeping.

8.
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
9.
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
10.
Does
your
baby
usually
sleep
in
your
room
or
in
a
different
room
at
night?

1
IN
YOUR
ROOM
2
IN
A
DIFFERENT
ROOM
Female
6
Month
(
Instrument
#
23)

15
11.
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
6
Month
(
Instrument
#
23)

16
Child
Diet
6
Months
The
next
questions
are
about
feeding
your
baby.

1.
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................................................................................................
_______
Cow's
milk...........................................................................................
_______
Other
milk:
soy
milk,
rice
milk,
goat
milk
.............................................
_______
Other
dairy
foods:
Yogurt,
cheese,
ice
cream,
pudding,
etc.
...................
_______
Other
soy
foods:
tofu,
frozen
soy
desserts,
etc.......................................
_______
100%
fruit
or
100%
vegetable
juice.......................................................
_______

Sweet
drinks
(
juice
drinks,
soft
drinks,
soda,
pop,
Kool­
Aid,
Sunny­
D,
etc.)
..............................................................................................
_______

Baby
cereal...........................................................................................
_______
Other
cereals
and
starches:
breakfast
cereals,
teething
biscuits,
crackers,
breads,
pasta,
rice,
etc..........................................................
_______

Fruit
.....................................................................................................
_______
Vegetables
............................................................................................
_______
Meat,
chicken,
combination
dinners
......................................................
_______

Fish
or
shellfish
....................................................................................
_______
Peanut
butter,
other
peanut
foods,
or
nuts
..............................................
_______
Eggs
.....................................................................................................
_______
Sweet
foods:
candy,
cookies,
cake,
etc...................................................
_______

2.
When
eating
does
your
baby 

Yes
No
Eat/
drink
quickly
1
2
Eat/
drink
slowly
1
2
Seem
to
be
fussy
or
choosy
about
food/
breast
milk/
formula
1
2
Seem
satisfied
when
finished
1
2
Seem
hungry
when
finished
1
2
[
SKIP
TO
Q8
IF
`
0'
ENTERED
FOR
FORMULA
IN
Q1]

3.
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
Female
6
Month
(
Instrument
#
23)

17
4.
In
the
past
7
days,
on
the
average,
how
many
ounces
of
formula
did
your
baby
drink
at
each
feeding?

_______
oz
5.
How
often
is
your
baby
encouraged
to
finish
a
bottle
if
he
or
she
stops
drinking
before
the
formula
is
all
gone?

1
Always
2
Most
of
the
time
3
Sometimes
4
Rarely
5
Never
6.
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
7.
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
4
Powder
 
from
single
serving
packs
[
SKIP
TO
Q14
IF
`
0'
FOR
BREASTMILK
IN
Q1]

8.
Does
your
baby
usually
feed
from
both
breasts
at
each
feeding?

1
YES
2
NO
3
BABY
IS
FED
ONLY
PUMPED
MILK

SKIP
TO
Q10
9.
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
Female
6
Month
(
Instrument
#
23)

18
10.
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
11.
How
many
times
in
the
past
7
days
has
your
baby
been
given
expressed
or
pumped
breast
milk
to
drink?

______
TIMES
[
IF
`
0',
SKIP
TO
Q14]

12.
How
often
does
your
baby
drink
all
of
his
or
her
cup
or
bottle
of
expressed
milk?

1
Always
2
Most
of
the
time
3
Sometimes
4
Rarely
5
Never
13.
How
often
is
your
baby
encouraged
to
finish
a
cup
or
bottle
if
he
or
she
stops
drinking
before
the
expressed
breast
milk
is
all
gone?

1
Always
2
Most
of
the
time
3
Sometimes
4
Rarely
5
Never
[
IF
BABY
IS
NOT
FED
ANY
FOODS
OR
DRINKS
BESIDES
BREAST
MILK
OR
FORMULA,
GO
TO
NEXT
MODULE]

[
SKIP
TO
Q17
IF
`
0'
ENTERED
FOR
COW'S
OR
OTHER
MILK
IN
Q1]

14.
How
often
does
your
baby
drink
all
of
his
or
her
bottle
of
cow's
or
other
(
soy,
rice,
or
goat)
milk?

1
Always
2
Most
of
the
time
3
Sometimes
4
Rarely
5
Never
15.
In
the
past
7
days,
on
the
average,
how
many
ounces
of
cow's
or
other
(
soy,
rice,
or
goat)
milk
did
your
baby
drink
at
each
feeding?

_______
oz
16.
How
often
is
your
baby
encouraged
to
finish
a
bottle
if
he
or
she
stops
drinking
before
the
cow's
or
other
(
soy,
rice,
or
goat)
milk
is
all
gone?
Female
6
Month
(
Instrument
#
23)

19
1
Always
2
Most
of
the
time
3
Sometimes
4
Rarely
5
Never
[
IF
BABY
IS
NOT
FED
ANY
FOODS
OR
DRINKS
BESIDES
BREAST
MILK,
COW'S
MILK
OR
FORMULA,
SKIP
TO
END]

17.
For
each
food
category
listed
below,
was
most
of
the
food
fed
to
the
baby
over
the
past
7
days
commercial
baby
food?
Commercial
baby
foods
are
those
sold
especially
for
babies.
Foods
that
are
not
commercial
baby
foods
include
fresh
fruit,
fruit
juices
other
than
those
especially
sold
for
babies,
foods
you
prepare
especially
for
the
baby,
and
table
food.

YES
NO
Fruit
and
vegetable
juice
1
2
Fruit
1
2
Vegetables
1
2
Meat,
chicken,
combination
dinners,
etc
1
2
Female
6
Month
(
Instrument
#
23)

20
18.
Is
any
of
the
food
you
feed
to
your
baby
organic,
or
pesticide­
free?

1
YES
2
NO
19.
Which
of
the
following
supplements
was
your
baby
given
at
least
three
days
a
week
during
the
past
2
weeks?
If
your
baby
was
given
a
supplement
containing
more
than
one
of
the
items
listed,
mark
each
of
the
separate
items.
(
CODE
ALL
THAT
APPLY)

1
Fluoride
2
Iron
3
Vitamin
D
4
Other
vitamins
{
END
OF
6
MONTH
CHILD
DIET
MODULE}
Female
6
Month
(
Instrument
#
23)

21
Personal
Medical
History
(
Update,
revised
for
post­
pregnancy)

The
next
few
questions
are
about
changes
to
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
pressure
or
hypertension
2
High
blood
sugar
or
diabetes
3
High
cholesterol
4
Anemia
(
poor
blood,
low
iron)
5
Heart
problems
6
Hayfever
or
allergy
7
Skin
allergy
or
eczema
8
Asthma
IF
Q1
=
8,
ASK
Q2­
4
ELSE,
SKIP
TO
Q5
2.
Did
a
doctor
or
other
medical
provider
tell
you
that
you
have
asthma?

1
YES
2
NO

SKIP
TO
Q5
3.
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.
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

GO
TO
NEXT
MODULE
5a.
What
were
those
illnesses?
(
ENTER
VERBATIM)

_______________________

6.
Since
[
FILL
DATE],
have
you
been
hospitalized
for
any
reason?

1
YES
2
NO

GO
TO
NEXT
MODULE
Female
6
Month
(
Instrument
#
23)

22
6a.
Why
were
you
hospitalized?
(
ENTER
VERBATIM)

__________________________

{
END
OF
PERSONAL
MEDICAL
HISTORY
MODULE}
Female
6
Month
(
Instrument
#
23)

23
Activity
(
Full)

Now
I
am
going
to
ask
you
some
questions
about
physical
activities
you
might
do
at
work,
at
home,
for
recreation,
and
about
activities
involving
child
or
adult
care.
I
want
you
to
tell
me
about
activities
you
did
in
the
past
month
that
caused
at
least
some
increase
in
breathing
and
heart
rate.

1.
In
the
past
month,
did
you 
2.
IF
YES:
On
average
over
the
past
month,
how
many
times
did
you
do
these
activities?
Would
you
say 
3.
Thinking
about
your
breathing
and
heart
rate,
how
hard
did
this
usually
feel
to
you?
Did
it
feel 
(
HAND
SHOW
CARD
TO
RESPONDENT)
A.
[
SKIP
IF
NOT
CURRENTLY
EMPLOYED]
participate
in
any
work
activities,
such
as
walking,
lifting,
or
carrying
objects
or
people,
that
caused
at
least
some
increase
in
breathing
and
heart
rate?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
B.
participate
in
any
non­
work,
recreational
activity
or
exercise,
such
as
walking
for
exercise,
swimming,
or
dancing,
that
caused
at
least
some
increase
in
breathing
and
heart
rate?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
C.
participate
in
any
outdoor
household
activities,
such
as
gardening,
mowing,
or
raking,
[
that
caused
at
least
some
increase
in
breathing
and
heart
rate]?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
D.
participate
in
any
indoor
household
activities,
such
as
scrubbing
floors,
mopping,
laundry,
or
vacuuming,
[
that
caused
at
least
some
increase
in
breathing
and
heart
rate]?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
E.
participate
in
any
child
or
adult
care
activities
that
caused
at
least
some
increase
in
breathing
and
heart
rate?
These
would
be
activities
such
as
playing
with
children,
pushing
a
stroller
or
wheelchair,
carrying,
or
lifting
a
child
or
adult.
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
F.
walk
for
transportation,
such
as
to
work
or
to
the
store,
and
that
walking
caused
at
least
some
increase
in
breathing
and
heart
rate?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
G.
bike
for
transportation,
such
as
to
work
or
to
the
store,
and
that
biking
caused
at
least
some
increase
in
breathing
and
heart
rate?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
FH
=
Fairly
hard
(
at
least
some
increase
in
breathing
and
heart
rate),
SH
=
Somewhat
hard
(
moderate
increase
in
breathing
and
heart
rate),
or
H
=
Hard
or
very
hard
(
large
increase
in
breathing
and
heart
rate)?
Female
6
Month
(
Instrument
#
23)

24
Now
think
about
the
activities
you
did
in
the
past
week 

4.
[
SKIP
IF
NOT
CURRENTLY
EMPLOYED]
In
the
past
week,
would
you
say
your
work
activities
were
usually 

1
Not
hard
=
did
not
feel
any
increase
in
breathing
or
heart
rate
2
Fairly
light
=
at
least
some
increase
in
breathing
and
heart
rate
3
Somewhat
hard
=
moderate
increase
in
breathing
and
heart
rate
4
Hard
or
very
hard
=
large
increase
in
breathing
and
heart
rate
5.
Think
about
how
active
you
were
during
your
non­
working
and
recreational
hours
in
the
past
week.
Would
you
say
your
activities
were
usually 

1
not
hard
=
you
did
not
feel
any
increase
in
breathing
or
heart
rate
2
fairly
light
=
you
had
at
least
some
increase
in
breathing
and
heart
rate
3
somewhat
hard
=
you
had
a
moderate
increase
in
breathing
and
heart
rate
4
hard
or
very
hard
=
you
had
a
large
increase
in
breathing
and
heart
rate
Now
I
will
ask
you
to
think
about
your
typical
daily
activities
during
the
past
month.

6.
Please
tell
me
which
of
these
four
sentences
best
describes
your
usual
daily
activities
over
the
past
month?
(
INTERVIEWER
PROBE:
Daily
activities
may
include
your
work,
housework,
errands,
and
anything
else
you
normally
do
throughout
a
typical
day.)

1
You
sit
during
the
day
and
do
not
walk
about
very
much
2
You
stand
or
walk
about
quite
a
lot
during
the
day,
but
do
not
have
to
carry
or
lift
things
very
often
3
You
lift
or
carry
light
loads,
or
have
to
climb
stairs
or
hills
often
4
You
do
heavy
work
or
carry
heavy
loads
7.
Over
the
past
month,
on
a
typical
day
how
much
time
altogether
did
you
spend
sitting
and
watching
TV
or
videos
or
using
a
computer
outside
of
work?
Would
you
say
.
.
.

0
Less
than
1
hour
1
1
hour
2
2
hours
3
3
hours
4
4
hours
5
5
hours
or
more
6
You
do
not
watch
TV
or
videos
or
use
a
computer
outside
of
work
8.
How
does
the
amount
of
activity
that
you
reported
for
the
past
month
compare
with
your
physical
activity
before
you
got
pregnant?
Over
the
past
month,
were
you
.
.
.

1
More
active
2
Less
active
3
About
the
same
{
END
OF
ACTIVITY
MODULE}
Female
6
Month
(
Instrument
#
23)

25
Neighborhood
(
Full)
[
If
Instrument
#
29
has
been
administered
Go
To
Next
Module]

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
6
Month
(
Instrument
#
23)

26
7.
From
where
you
live,
is
it
relatively
easy
for
you
to
get
to 
(
CODE
ALL
THAT
APPLY)

1
stores
to
get
the
groceries
you
need?
2
public
parks
or
recreational
facilities?
3
doctor's
offices
or
clinics?
4
your
religious
institution?
5
your
children's
schools?
[
DISPLAY
ONLY
IF
R
HAS
CHILD]
6
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
6
Month
(
Instrument
#
23)

27
Diet
(
Full)

1.
On
average,
how
many
times
per
week
do
you
eat
meals
from
fast­
food
restaurants?

|___|___|
ENTER
NUMBER
ENTER
`
0'
IF
NEVER
ENTER
`
66'
IF
LESS
THAN
WEEKLY
2.
On
average,
how
many
times
per
week
do
you
eat
meals
that
were
prepared
in
a
restaurant,
other
than
fast­
food
restaurants?
Please
include
eat­
in
restaurants,
carry
out
restaurants
and
restaurants
that
deliver
food
to
your
house.
`
MEALS'
MEAN
MORE
THAN
A
BEVERAGE
OR
SNACK
FOOD
LIKE
CANDY
BARS
OR
BAG
OF
CHIPS
|___|___|
ENTER
NUMBER
ENTER
`
0'
IF
NEVER
ENTER
`
66'
IF
LESS
THAN
WEEKLY
3.
What
type
of
salt
do
you
usually
add
to
your
food
at
the
table?

0
I
do
not
add
salt
to
my
food
at
the
table

SKIP
TO
Q5
1
ordinary
salt
[
includes
regular
iodized
salt,
sea
salt
and
seasoning
salts
made
with
regular
salt]
2
lite
salt
3
salt
substitute
4.
How
often
do
you
add
ordinary
salt
to
your
food
at
the
table?

1
Rarely
2
Occasionally
3
Very
often
5.
During
the
past
6
months,
how
often
per
day,
per
week,
per
month
or
per
year
did
you
eat
dark
green
vegetables,
such
as
(
INTERVIEWER,
USE
SHOW
CARD)

|___|___|___|
ENTER
NUMBER
OF
TIMES
(
PER
DAY,
WEEK,
MONTH
OR
YEAR)
ENTER
`
0'
IF
NEVER
ENTER
UNIT
DAY
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
1
WEEK
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
..
2
MONTH
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
3
YEAR
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
4
6.
During
the
past
6
months,
how
often
per
day,
per
week,
per
month
or
per
year
did
you
eat
cooked
dried
beans
or
peas,
such
as
(
INTERVIEWER,
USE
SHOW
CARD)

|___|___|___|
ENTER
NUMBER
OF
TIMES
(
PER
DAY,
WEEK,
MONTH
OR
YEAR)
Female
6
Month
(
Instrument
#
23)

28
ENTER
`
0'
IF
NEVER
ENTER
UNIT
DAY
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
1
WEEK
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
..
2
MONTH
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
3
YEAR
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
4
7.
Do
you
ever
eat
poultry
such
as
chicken
and
turkey?
Please
include
foods
that
are
made
with
poultry
such
as
soups,
sandwiches,
stews
and
salads.
IF
EATEN
RARELY
OR
OCCASIONALLY,
ENTER
`
YES'

1
YES
2
NO

SKIP
TO
Q9
8.
When
you
eat
chicken
or
other
types
of
poultry,
how
often
do
you
eat
the
skin?

0
Never
1
Rarely
or
seldom
2
Sometimes
or
occasionally
3
Often
or
very
often
4
Always
9.
Do
you
ever
eat
meat
such
as
beef,
pork,
lamb
and
veal?
Please
include
foods
that
are
made
with
meat
such
as
soups,
stews,
sandwiches,
lunch
meats,
and
casseroles.
IF
EATEN
RARELY
OR
OCCASIONALLY,
ENTER
`
YES'

1
YES
2
NO

SKIP
TO
Q11
10.
When
you
eat
meat,
how
often
do
you
eat
the
visible
fat?
[
Visible
fat
is
the
fat
tissue
that
you
may
see
around
the
edge
of
a
piece
of
meat.]

0
Never
1
Rarely
or
seldom
2
Sometimes
or
occasionally
3
Often
or
very
often
4
Always
Now
I'm
going
to
ask
a
few
questions
about
milk
products.
Do
not
include
their
use
in
cooking.

11.
In
the
past
30
days,
how
often
did
you
have
milk
to
drink
or
on
your
cereal?
Please
include
chocolate
and
other
flavored
milks
as
well
as
hot
cocoa
made
with
milk.
Do
not
count
small
amounts
of
milk
added
to
coffee
or
tea.

0
Never

SKIP
TO
Q13
1
Rarely
 
less
than
once
a
week
2
Sometimes
 
once
a
week
or
more,
but
less
than
once
a
day
3
Often
 
once
a
day
or
more
12.
What
type
of
milk
was
it?
Was
it
usually
.
.
.
Female
6
Month
(
Instrument
#
23)

29
1
Whole
or
regular
2
2%
fat
milk
(
includes
"
low
fat
milk")
3
1%
fat
milk
4
Skim,
nonfat,
or
0.5%
fat
milk
(
includes
liquid
or
reconstituted
from
dry)
5
Evaporated
milk,
whole
milk
6
Evaporated
milk,
skim
milk
7
Buttermilk
8
Goat's
milk
9
Soy
or
imitation
milk
10
Another
type
(
Specify)
__________

The
next
questions
are
about
the
amount
of
food
you
eat.

13.
On
an
average
day,
how
many
helpings
of
the
following
kinds
of
foods
do
you
eat?

a.
Protein
foods,
such
as
meat,
fish,
seafood,
chicken,
turkey,
or
eggs.
Also
include
protein
foods,
such
as
peanut
butter
or
foods
that
are
made
from
dried
beans,
such
as
bean
soup,
baked
beans,
or
refried
beans,
meat
substitutes
and
soy
protein
foods
such
as
tofu
|___|___|
ENTER
NUMBER
OF
HELPINGS
OR
`
0'
IF
NEVER
OR
RARELY
EAT
THESE
FOODS
b.
Milk
or
dairy
foods
that
are
made
from
milk,
such
as
cheese,
cottage
cheese,
ice
cream,
milk
shakes,
or
yogurt
|___|___|
ENTER
NUMBER
OF
HELPINGS
OR
`
0'
IF
NEVER
OR
RARELY
EAT
THESE
FOODS
c.
Fruits
or
fruit
juices
|___|___|
ENTER
NUMBER
OF
HELPINGS
OR
`
0'
IF
NEVER
OR
RARELY
EAT
THESE
FOODS
d.
Vegetables,
including
vegetable
salads
|___|___|
ENTER
NUMBER
OF
HELPINGS
OR
`
0'
IF
NEVER
OR
RARELY
EAT
THESE
FOODS
e.
Breads
and
other
foods
that
are
made
from
grains,
such
as
cereals,
spaghetti,
pasta,
rice,
or
tortillas
|___|___|
ENTER
NUMBER
OF
HELPINGS
OR
`
0'
IF
NEVER
OR
RARELY
EAT
THESE
FOODS
The
next
questions
are
about
meals
provided
by
community
or
government
programs.

14.
In
the
past
6
months,
did
you
go
to
a
community
program
or
volunteer
center
to
eat
prepared
meals?

1
YES
2
NO

GO
TO
NEXT
MODULE
Female
6
Month
(
Instrument
#
23)

30
15.
In
the
past
30
days,
how
many
days
per
week
did
you
go
to
a
community
program
or
volunteer
center
to
eat
prepared
meals?

|___|___|
ENTER
NUMBER
(
OF
DAYS
PER
WEEK)
ENTER
`
0'
IF
YOU
DID
NOT
GO
TO
PROGRAM
IN
PAST
MONTH
{
END
OF
DIET
MODULE}
Female
6
Month
(
Instrument
#
23)

31
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
6
Month
(
Instrument
#
23)

32
Tobacco
(
update,
revised
for
post­
pregnancy)

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?
Female
6
Month
(
Instrument
#
23)

33
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?

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
10.
About
how
many
hours
per
day
is
your
baby
in
the
same
room
with
someone
who
is
smoking
cigarettes,
cigars,
or
tobacco
pipes?

_____
Hours
000
None
999
Less
than
1
hour
a
day
11.
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
6
Month
(
Instrument
#
23)

34
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
6
Month
(
Instrument
#
23)

35
____________________________

{
END
OF
ACCEPTABILITY
MODULE}
