NCS
Herald
Cohort
Study
Instrument
#
28
Female
Questionnaire
18
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
18
Month
(
instrument
#
28)

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
18
Month
(
instrument
#
28)

2
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
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
18
Month
(
instrument
#
28)

3
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

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
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?

MM/
DD/
YYYY
Female
18
Month
(
instrument
#
28)

4
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.
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
18
Month
(
instrument
#
28)

5
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
Female
18
Month
(
instrument
#
28)

6
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
18
Month
(
instrument
#
28)

7
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
18
Month
(
instrument
#
28)

8
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
18
Month
(
instrument
#
28)

9
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
18
Month
(
instrument
#
28)

10
Medical
History
 
Child
18
month
The
next
questions
are
about
your
child's
general
health.

1.
Has
your
child
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
Runny
nose
or
cold
6
Cough
or
wheeze
7
Respiratory
Syncytial
Virus
(
RSV)
8
Food
allergy
9
Eczema
(
atopic
dermatitis)
10
Asthma
11
Weight
loss
or
poor
weight
gain
12
Vision
problems
13
Seizure
2.
[
ASK
IF
Q1=
13]
Was
your
child's
seizure
related
to
a
high
fever?

1
YES
2
NO
[
SKIP
TO
Q7
IF
Q1
NOT
=
8]

3.
Has
your
child
been
diagnosed
as
having
an
allergy
to
any
food?

1
YES
2
NO

SKIP
TO
Q7
4.
What
method
was
used
to
test
for
food
allergy?
(
CODE
ALL
THAT
APPLY)

1
A
skin
test
2
A
blood
test
3
Food
elimination
(
withdrawal
of
the
specific
food
to
see
if
symptoms
disappeared)
4
Food
challenge
(
introduction
of
a
specific
food
to
see
if
symptoms
reappeared)
5
Based
on
your
description
of
symptoms
6
Other
(
specify)_____________________

5.
How
old
was
your
child
the
first
time
he
or
she
was
diagnosed
has
having
a
food
allergy?

__________
MONTHS
AND
_________
WEEKS
6.
Which
of
the
following
treatments
has
your
baby
had
for
problems
with
food?
(
CODE
ALL
THAT
APPLY)

1
Non­
prescription
medicine
2
Prescription
medicine
3
Treatment
in
a
doctor's
office
or
emergency
room
4
Admitted
to
a
hospital
Female
18
Month
(
instrument
#
28)

11
7.
Since
your
last
interview
on
{
FILL
DATE},
has
your
child
had
wheezing
or
whistling
in
the
chest?

1
YES
2
NO

SKIP
TO
Q9
8.
How
many
attacks
of
wheezing
has
your
child
had
since
{
FILL
DATE}?

1
NONE
2
1
TO
3
3
4
TO
12
4
MORE
THAN
12
9.
Since
your
last
interview,
has
your
child
had
a
dry
cough
at
night,
apart
from
a
cough
associated
with
a
cold
or
chest
infection?

1
YES
2
NO

SKIP
TO
Q12
10.
Has
your
child
had
a
problem
with
sneezing
or
a
runny
or
blocked
nose
when
{
he/
she}
DID
NOT
have
a
cold
or
flu?

1
YES
2
NO
11.
Since
your
last
interview
on
{
FILL
DATE},
has
this
nose
problem
been
accompanied
by
itchy­
watery
eyes?

1
YES
2
NO
12.
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
Q14
13.
How
many
nights
was
your
child
in
the
hospital
for
the
most
recent
problem?
(
WRITE
0
IF
BABY
DID
NOT
STAY
OVERNIGHT)

___________
NIGHTS
14.
Has
your
child
been
diagnosed
with
any
severe,
long­
term
medical
problems
since
{
FILL
DATE}?

1
YES
2
NO

GO
TO
NEXT
MODULE
14a.
What
medical
problems?

__________________________________
Female
18
Month
(
instrument
#
28)

12
15.
How
would
you
describe
{
FILL
NAME}'
s
health
now?

1
Excellent
2
Good
3
Fair
4
Poor
16
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
18
Month
(
instrument
#
28)

13
Developmental/
Sleep
(
18
month)

1.
Now
I'm
going
to
ask
you
some
questions
about
[
child]'
s
activities
and
development.
This
list
probably
includes
some
skills
that
[
child]
has
already
learned,
and
some
that
he/
she
can't
do
yet.
For
each
question,
you
can
answer
"
yes"
if
this
is
an
activity
that
[
child]
does
regularly;
"
sometimes"
if
it's
an
activity
that
[
child]
is
learning
how
to
do;
and
"
not
yet"
if
it's
something
that
he/
she
hasn't
yet
learned.
If
you're
not
sure,
then
we'll
try
it
out
and
see
if
[
child]
can
do
it.
You
can
follow
along
by
looking
at
this
paper;
some
of
the
questions
have
pictures
showing
the
activity.

YES
SOMETIMES
NOT
YET
Communication
Questions
When
your
baby
wants
something,
does
she
tell
you
by
pointing
to
it?
1
2
0
Does
your
child
point
to,
pat,
or
try
to
pick
up
pictures
in
a
book?
1
2
0
When
you
ask,
"
Where
is
the
ball
(
hat,
shoe,
etc.)?"
does
your
baby
look
at
the
object?
Make
sure
the
object
is
present.
Check
"
yes"
if
he
knows
one
object.
1
2
0
When
you
ask
her
to,
does
your
child
go
into
another
room
to
find
a
familiar
toy
or
object?
You
might
ask,
"
Where
is
your
ball?"
or
say,
"
Bring
me
your
coat,"
or
"
Go
get
your
blanket."
1
2
0
Does
your
child
imitate
a
two­
word
sentence?
For
example,
when
you
say
a
two­
word
phrase
such
as
"
Mama
eat,"
"
Daddy
play,"
"
Go
home,
"
or
"
What's
this?"
does
your
child
say
both
words
back
to
you?
(
Check
"
yes"
even
if
her
words
are
difficult
to
understand.)
1
2
0
Does
your
child
say
eight
or
more
words
in
addition
to
"
Mama"
and
"
Dada"?
1
2
0
Does
your
child
say
two
or
three
words
that
represent
different
ideas
together,
such
as
"
See
dog,"
"
Mommy
come
home,"
or
"
Kitty
gone"?
(
Don't
count
word
combinations
that
express
one
idea,
such
as
"
Byebye
"
All
gone,"
"
All
right,"
and
"
What's
that?")
Please
give
an
example
of
your
child's
word
combinations:
1
2
0
Gross
Motor
Questions
Does
your
child
climb
onto
furniture?
1
2
0
Does
your
child
bend
over
or
squat
to
pick
up
an
object
from
the
floor
and
then
stand
up
again
without
any
support?
1
2
0
Does
your
child
move
around
by
walking,
rather
than
by
crawling
on
his
hands
and
knees?
1
2
0
Does
your
child
walk
well
and
seldom
fall?
1
2
0
Does
your
child
climb
on
an
object
such
as
a
chair
to
reach
something
she
wants?
1
2
0
Does
your
child
walk
down
stairs
if
you
hold
onto
one
of
her
hands?
1
2
0
When
you
show
him
how
to
kick
a
large
ball,
does
your
child
try
to
kick
the
ball
by
moving
his
leg
forward
or
by
walking
into
it?
(
If
your
child
already
kicks
a
ball,
check
"
yes"
for
this
item.)
1
2
0
Fine
Motor
Questions
Does
your
baby
throw
a
small
ball
with
a
forward
arm
motion?
(
If
he
simply
drops
the
ball,
check
`
not
yet'
for
this
item.)
1
2
0
Does
your
baby
help
turn
the
pages
of
a
book?
(
You
may
lift
a
page
for
her
to
grasp.)
1
2
0
Female
18
Month
(
instrument
#
28)

14
Does
your
child
stack
a
small
block
or
toy
on
top
of
another
one?
1
2
0
Does
your
child
stack
three
small
blocks
or
toys
on
top
of
each
other
by
herself?
1
2
0
Does
your
child
make
a
mark
on
the
paper
with
the
tip
of
a
crayon
(
or
pencil
or
pen)
when
trying
to
draw?
1
2
0
Does
your
child
turn
the
pages
of
a
book
by
himself?
He
may
turn
more
than
one
page
at
a
time.
1
2
0
Does
your
child
get
a
spoon
into
her
mouth
right
side
up
so
that
the
food
usually
doesn't
spill?
1
2
0
Problem
Solving
Questions
Does
your
child
drop
several
(
six
or
more)
small
toys
into
a
container,
such
as
a
box
or
bowl?
(
You
may
show
him
how
to
do
it.)
1
2
0
After
you
have
shown
her
how,
does
your
child
try
to
get
a
toy
that
is
slightly
out
of
reach
by
using
a
spoon,
stick,
or
similar
tool?
1
2
0
Without
first
showing
him
how,
does
your
child
scribble
back
and
forth
when
you
give
him
a
crayon
(
or
pencil
or
pen)?
1
2
0
After
a
crumb
or
Cheerio
is
dropped
into
a
bottle,
does
your
child
turn
the
bottle
upside
down
to
dump
it
out
again?
(
You
may
show
her
how.)
1
2
0
After
he
watches
you
draw
a
line
from
the
top
of
the
paper
to
the
bottom
with
a
crayon
(
or
pencil
or
pen),
does
your
child
copy
you
by
drawing
a
single
line
on
the
paper
in
any
direction?
(
Scribbling
back
and
forth
does
not
count
as
"
yes".)
1
2
0
After
a
crumb
or
Cheerio
is
dropped
into
a
small,
clear
bottle,
does
your
child
turn
the
bottle
upside
down
to
dump
out
the
crumb
or
Cheerio?
(
Do
not
show
her
how.)
1
2
0
Personal­
Social
Questions
Does
your
baby
play
with
a
doll
or
stuffed
toy
by
hugging
it?
1
2
0
While
looking
at
himself
in
the
mirror,
does
your
child
offer
a
toy
to
his
own
image?
1
2
0
Does
your
child
get
your
attention
or
try
to
show
you
something
by
pulling
on
your
hand
or
clothes?
1
2
0
Does
your
child
come
to
you
when
she
needs
help,
such
as
with
winding
up
a
toy?
1
2
0
Does
your
child
drink
from
a
cup
or
glass,
setting
it
down
again
with
little
spilling?
1
2
0
Does
your
child
copy
activities
you
do,
such
as
wipe
up
a
spill,
sweep,
shave,
or
comb
hair?
1
2
0
2.
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
Female
18
Month
(
instrument
#
28)

15
f.
Stubborn?
1
2
g.
Happy?
1
2
3.
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
Play
outside?
0
1
2
3
4.
How
much
TV
does
your
child
watch
on
an
average
day?

1
Less
than
1
hour
2
1
 
3
hours
3
4
 
6
hours
4
More
than
6
hours
5.
When
your
child
watches
TV,
does
{
he/
she}
usually
watch 

1
Educational
videos
such
as
Baby
Einstein
2
Recreational
videos
3
Children's
television
programming
4
Regular
television
programs
Now
I'll
ask
you
about
your
baby's
sleeping.

6.
In
what
position
do
you
most
often
lay
your
baby
down
for
naps?

1
Side
2
Stomach
3
Back
7.
In
what
position
do
you
most
often
lay
your
baby
down
to
sleep
at
night?

1
Side
2
Stomach
3
Back
8.
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
18
Month
(
instrument
#
28)

16
9.
What
does
your
baby
usually
sleep
in
at
night?

1
Crib
2
Co­
sleeper
(
attaches
to
the
side
of
your
bed)
3
In
bed
or
other
place
with
you
4
In
his/
her
own
bed
{
END
OF
DEVELOPMENTAL
MODULE}
Female
18
Month
(
instrument
#
28)

17
Child
Diet
18
Months
The
next
questions
are
about
feeding
your
child.

1.
In
the
past
7
days,
how
often
was
your
child
fed
each
item
listed
below?
Include
feedings
by
everyone
who
feeds
the
child
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...................................................
_______
Fast
foods
.............................................................................................
_______

2.
When
eating
does
your
child 

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
Female
18
Month
(
instrument
#
28)

18
5
Never
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
18
Month
(
instrument
#
28)

19
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
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
18
Month
(
instrument
#
28)

20
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,
GO
TO
NEXT
MODULE]

17.
For
each
food
category
listed
below,
was
most
of
the
food
fed
to
the
child
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
18
Month
(
instrument
#
28)

21
18.
Is
any
of
the
food
you
feed
to
your
child
organic,
or
pesticide­
free?

1
YES
2
NO
19.
Which
of
the
following
supplements
was
your
child
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
18
MONTH
CHILD
DIET
MODULE}
Female
18
Month
(
instrument
#
28)

22
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
18
Month
(
instrument
#
28)

23
6a.
Why
were
you
hospitalized?
(
ENTER
VERBATIM)

__________________________

{
END
OF
PERSONAL
MEDICAL
HISTORY
MODULE}
Female
18
Month
(
instrument
#
28)

24
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
18
Month
(
instrument
#
28)

25
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
six
months
ago?
Over
the
past
month,
were
you
.
.
.

1
More
active
2
Less
active
3
About
the
same
{
END
OF
ACTIVITY
MODULE}
Female
18
Month
(
instrument
#
28)

26
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
18
Month
(
instrument
#
28)

27
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?
f.
daycare
programs?

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
18
Month
(
instrument
#
28)

28
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)

a.
Wages
and
salaries?
b.
Self­
employment,
including
business
and
farm
income?
c.
Family
or
friends?
d.
Aid
such
as
Temporary
Assistance
for
Needy
Families
(
TANF),
welfare,
WIC,
public
assistance,
general
assistance,
food
stamps,
or
Supplemental
Security
Income?
e.
[
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?
f.
Dividends
received
from
stocks
or
mutual
funds,
or
net
rental
income
from
property,
royalties,
estates
or
trusts?
g.
Unemployment
benefits?
h.
Child
support
or
alimony?
i.
Social
security,
Railroad
Retirement,
workers'
compensation,
disability,
veteran
benefits,
or
pensions?
j.
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
18
Month
(
instrument
#
28)

29
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
18
Month
(
instrument
#
28)

30
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
18
Month
(
instrument
#
28)

31
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
18
Month
(
instrument
#
28)

32
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
child
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
18
Month
(
instrument
#
28)

33
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
18
Month
(
instrument
#
28)

34
____________________________

{
END
OF
ACCEPTABILITY
MODULE}
