**PRAMS Phase Three Questionnaire**

**Topical Reference**

**TABLE OF CONTENTS**

I. About this
document\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
p.4

1\. Abuse

> A.
> Physical\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> p.5
>
> B.
> Sexual\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> p.7
>
> C.
> Verbal\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> p.8
>
> D.
> Other\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> p.8

2\.
Breast-Feeding\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
p.9

3\. Contraception

> A.
> Pre-Pregnancy\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> p.12
>
> B.
> Conception\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> p.12
>
> C.
> Postpartum\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> p.13

4\.
Douching\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
p.16

5\. Drug Use

> A.
> Alcohol\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> p.17
>
> B.
> Tobacco\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> p.18
>
> C.
> Other\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> p.20

6\. Health
Insurance\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
p.21

7\.
HIV\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
p.26

8\. House and Household Characteristics

> A. Composition of
> Residents\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> p.27
>
> B. Number of
> Rooms\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> p.28
>
> C. Telephone
> Coverage\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> p.28

9\.
Incentive\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
p.30

10\.
Income\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
p.31

11\. Infant Health

> A. General Baby
> Care\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> p.39
>
> B. Sick Baby
> Care\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> p.39
>
> C. Well Baby
> Care\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> p.41

12\. Infant
Status\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
p.44

13\. Injury
Prevention\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
p.45

14\. Intendedness of
Pregnancy\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
p.48

15\. Knowledge of Pregnancy
Status\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
p.50

16\. Lead
Exposure\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
p.51

17\. Length of Stay

> A.
> Infant\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> p.52
>
> B.
> Maternal\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> p.52

18\. Mental
Health\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
p.54

19\. Morbidity

> A.
> Infant\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> p.56
>
> B.
> Maternal\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> p.56

20\. Oral
Health\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
p.60

21\. Parent and Infant Characteristics

> A. Infant
> Demographics\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> p.61
>
> B. Maternal
> Demographics\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> p.61
>
> C. Paternal
> Demographics\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> p.62
>
> D. Parental Relationship
> Status\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> p.63

22\. Physical Activity and
Work\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
p.65

23\. Pre-Conception
Readiness\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
p.68

24\. Prenatal Care

> A.
> Barriers\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> p.69
>
> B.
> Content\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> p.69
>
> C.
> Location\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> p.73
>
> D.
> Satisfaction\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> p.74
>
> E. Visits and Timing of
> Visits\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> p.75

25\. Questionnaire
Details\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
p.77

26\. Reproductive History

> A. Age at Menarche and Conception of First
> Birth\...\...\...\...\...\..... p.78
>
> B. Previous Pregnancy
> Outcome\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> p.78

27\. School
Status\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
p.80

28\. Second-Hand Smoke
Exposure\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
p.81

29\. Sleeping
Behaviors\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
p.82

30\. Social
Services\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
p.83

31\. Social
Stress\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
p.89

32\. Social
Support\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
p.90

33\. Vitamin Use and Folic
Acid\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
p.93

34\. Appendix A: State-by-State List of
Topics\...\...\...\...\...\...\...\...\...\...\...\...\... p.95

35\. Appendix B: List of Standard Questions and States Using

> The Standard
> Questions\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> p.115

**I. ABOUT THIS DOCUMENT**

The purpose of this document is to provide a topical reference to the
Pregnancy Risk Assessment Monitoring System (PRAMS) Phase Three
questionnaire. All core, standard, and state-developed questions
utilized in this version of the questionnaire are represented in this
document. Many questions could have been placed under several different
topics. In each case, an effort was made to select the *one* topic which
best captures the question=s intent and content. Where appropriate,
references are made in a *ASee also\...@* style to those questions which
pertain indirectly to a given topic but were placed in a different
section.

Each topic or sub-topic is broken down into three categories: Core,
Standard, and State-Developed. Core questions are listed sequentially
within a topic, with the question number cited. Likewise, standard
questions are listed sequentially within a topic, with the number of the
*standard* question cited, the states using the question listed, the
number of the standard question as it appears in the state=s
questionnaire cited, and any modifications made to the question by a
particular state listed. State-developed questions are organized
alphabetically by state within a topic, with the state and question
number both cited. In the case where there are no questions pertaining
to a topic within one of the three categories (core, standard, and
state-developed), that category is omitted. All questions are shown in
English and are in the form used in the self-administered
questionnaires. All questions included in this document have a
complement in the interviewer-administered (telephone) format. Questions
in the telephone format can be found elsewhere. Several PRAMS states
also use a Spanish translation for the self-administered and
interviewer-administered formats. These questions are found elsewhere,
and states that use a Spanish translation are marked by an asterisk in
Appendix A.

Appendix A contains a state-by-state listing of topics covered in the
*non-core* section of the questionnaire. For each state, topics are
listed alphabetically with a reference to the question number as it
appears on the questionnaire. The questions are appropriately identified
as either standard or state-developed.

Appendix B contains a list of the standard questions, along with the
states using each question. The questions are ordered numerically.

Finally, this is a dynamic document. As states are added to PRAMS and
questionnaires are developed, sections of this document will necessarily
expand. Subsequently, to properly maintain the document, it is suggested
that the document, as well as the footer be updated with each revision.
(Instructions on updating a footer can be found using the on-line
**Help**.)

**1. ABUSE**

**A. PHYSICAL**

**Core**

**Q 31** During the ***12 months before you got pregnant*** with your
new baby, did any of these people physically abuse you? **Check all that
apply**.

> \[ \] My husband or partner
>
> \[ \] A family or household member ***other than*** my husband or
> partner
>
> \[ \] A friend
>
> \[ \] Someone else \-\-\-\--\> Please tell us: \_\_\_\_\_\_\_\_\_\_
>
> \[ \] No one physically abused me during the 12 months before I got
> pregnant

**Q 32 *During your most recent pregnancy***, did any of these people
physically abuse you? **Check all that apply**.

> \[ \] My husband or partner
>
> \[ \] A family or household member ***other than*** my husband or
> partner
>
> \[ \] A friend
>
> \[ \] Someone else \-\-\-\--\> Please tell us: \_\_\_\_\_\_\_\_\_\_
>
> \[ \] No one physically abused me during my pregnancy

**Q 33** ***During your most recent pregnancy***, would you say that you
were physically abused ***more*** often, ***less*** often, or ***about
the same*** compared to the ***12 months before*** you got pregnant?
**Check only one**.

> \[ \] I was physically abused ***more often*** during my pregnancy
>
> \[ \] I was physically abused ***less often*** during my pregnancy
>
> \[ \] I was physically abused ***about the same*** during my pregnancy
>
> \[ \] No one physically abused me during the ***12 months before*** I
> got pregnant

**State-Developed**

**AK Q 54**

> During your most recent pregnancy, did your prenatal care provider
> ever ask you whether you had been hurt or threatened by your partner?
>
> \[ \] No
>
> \[ \] Yes
>
> \[ \] I don=t remember

**NC Q 65**

Since you had your new baby, did any of these people physically abuse
you? Physical

abuse means pushing, hitting, slapping, kicking, or any other way of
physically hurting

someone. **Check all that apply.**

\[ \] My husband or partner

\[ \] A family or household member ***other than*** my husband or
partner

\[ \] A friend

\[ \] Someone else \-\-\-\--\> Please tell us: \_\_\_\_\_\_\_\_\_\_

\[ \] No one physically abused me after I had my baby \_\_\_\_\_\> Go to
Question 67

**NC Q 66**

Since you had your new baby, did any of these things happen to you as a
result of

physical abuse by anyone? **For each thing, circle Y (Yes) if it
happened to you or N**

**(No) if it did not.**

**No Yes**

a\. I had a sprain, bruise, or small cut N Y

b\. I felt pain that hurt the next day N Y

c\. I had a broken bone, severe cut, or a burn N Y

d\. I had a head injury, internal injury, or a permanent injury N Y

e\. I had a wound from a weapon N Y

f\. I went to a doctor because of being hurt N Y

g\. I needed to see a doctor because of being hurt, but did not N Y

**NY Q 67b**

> During the 12 months before your delivery did any of these things
> happen to you? **For each thing, circle Y(Yes) if it happened to you,
> or N(No) if it did not.**
>
> No Yes
>
> b\. Your husband or partner threatened to physically hurt you N Y

**UT Q 63**

When you were physically abused during the 12 months before or during
your most

recent pregnancy, who did you receive help from? **For each one, circle
Y (Yes) if it**

**applies to you, or circle N (No) if it does not.**

> **No** **Yes**
>
> a\. Family member N Y
>
> b\. Friend N Y
>
> c\. My doctor N Y
>
> d\. Emergency room or urgent care medical facility N Y
>
> e\. Other health care provider N Y
>
> f\. Counselor, therapist, or social worker N Y
>
> g\. Religious advisor N Y
>
> h\. Law enforcement N Y
>
> i\. Statewide Domestic Violence Information Line (1-800-897-LINK) N Y
>
> j\. Other \-\-\--\> Please tell us: N Y

k\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> l\. I didn=t get any help N Y

**UT Q 64**

If you did not receive help, please tell us what kept you from receiving
help. **For each**

**thing, circle Y (Yes) if it applies to you or N (No) if it does not.**

> **No** **Yes**
>
> a\. I did not know where to get help N Y
>
> b\. I did not have the money to pay for services N Y
>
> c\. I was afraid the person who physically hurt me would find out N Y
>
> d\. It was my fault that I was physically hurt N Y
>
> e\. I thought the abuse would stop N Y
>
> f\. I did not have someone to tend my children N Y
>
> g\. I was afraid someone would take my children away from me N Y
>
> h\. I did not have a way to get there N Y
>
> i\. I did not want any help N Y
>
> j\. Other \-\-\--\> Please tell us: N Y

k\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***See also: Core Q 16m in section 24B, Prenatal Care, Content***

> ***Core Q 30j in section 31, Social Stress***

**B. SEXUAL**

**State-Developed**

**AK Q 55**

> During your most recent pregnancy or since your new baby was born, has
> anyone close to you forced you to have sexual activities when you did
> not want to? **For each time period, circle Y(Yes) if it has happened
> to you or N(No) if it has not**.
>
> **No** **Yes**
>
> a\. During your most recent pregnancy N Y
>
> b\. Since your new baby was born N Y

**C. VERBAL**

**State-Developed**

**NY Q 67a**

> During the 12 months before your delivery did any of these things
> happen to you? **For each thing, circle Y(Yes) if it happened to you,
> or N(No) if it did not.**
>
> **No** **Yes**
>
> a\. Your husband or partner verbally abused you N Y

**D. OTHER**

**State-Developed**

**FL Q 72**

> Does your husband or partner make it hard for you to leave the house
> by yourself or to see your friends?
>
> \[ \] No
>
> \[ \] Yes
>
> \[ \] I don=t have a husband or partner now

***See also: State-Developed MI Q 61e in section 30, Social Services***

> ***State-Developed MI Q 62e in section 30, Social Services***
>
> ***State-Developed NM Q 63h in section 30, Social Services***

**2. BREAST-FEEDING**

**Core**

**Q 42** For how many weeks did you breast-feed your new baby?

> \_\_\_\_\_ Weeks
>
> \[ \] I didn=t breast-feed my baby \-\-\-\--\>**Go to Question 44**
>
> \[ \] I breast-fed less than 1 week\-\-\-\--\>**Go to Question 44**
>
> \[ \] I=m still breast-feeding

**Q 43** How many weeks old was your baby the first time you fed him or
her anything besides breastmilk? **Include formula, baby food, juice,
cow=s milk or anything else**.

> \_\_\_\_\_ Weeks
>
> \[ \] My baby was less than 1 week old
>
> \[ \] I haven=t fed my baby anything besides breastmilk

**Standard**

**Q 1** What were your reasons for *not* breast-feeding? **Check all
that apply**.

> \[ \] I didn=t want to breast-feed
>
> \[ \] I had to go to work or school
>
> \[ \] I think it=s better for my baby to be bottle-fed
>
> \[ \] It takes too much time to breast-feed
>
> \[ \] I was taking medicine
>
> \[ \] My baby was not with me
>
> \[ \] Other \-\-\-\--\> Please tell us: \_\_\_\_\_\_\_\_\_\_

**Used by: AR Q 68, IL Q 63, LA Q 63, ME Q 61, MI Q 55, NY Q 61, OH Q
62**

**Q 2** Do you breast-feed your new baby *now*?

> \[ \] No
>
> \[ \] Yes \-\-\-\--\>**Go to Question** \_\_\_\_\_

**Used by: AK Q 65a, ME Q 62, MI Q 56, UT Q 58**

**Q 3** What were your reasons for stopping breast-feeding? **Check all
that apply**.

> \[ \] I didn=t want to keep breast-feeding
>
> \[ \] I had to go to work or school
>
> \[ \] I tried but my baby didn=t breast-feed very well
>
> \[ \] I didn=t have enough milk
>
> \[ \] I felt it was the right time to stop
>
> \[ \] My baby was not with me
>
> \[ \] I was taking medicine
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**Used by: AK Q 65b, ME Q 63, MI Q 57, UT Q 59**

**Q 4** This question asks about things that may have happened at the
hospital where your new baby was born. **For each thing, circle Y(Yes)
if it happened or circle N(No) if it did not happen**.

> **No Yes**
>
> a\. Hospital staff gave me information about breast-feeding N Y
>
> b\. My baby stayed in the same room with me at the hospital N Y
>
> c\. I breast-fed my baby at the hospital N Y
>
> d\. Hospital staff helped me learn how to breast-feed N Y
>
> e\. My baby was fed ***only*** breast milk at the hospital N Y
>
> f\. Hospital staff told me to breast-feed whenever my baby wanted N Y
>
> g\. The hospital gave me a gift pack with formula N Y
>
> h\. The hospital gave me a telephone number to call for help
>
> about breast-feeding N Y

**Used by: AL Q 63, FL Q 64, IL Q 64, LA Q 64, NY Q 62, OH Q 63, WV Q
60**

**Q 5** During your most recent pregnancy, what did you think about
breast-feeding your new baby? **Check one answer**.

> \[ \] I knew I would breast-feed
>
> \[ \] I thought I might breast-feed
>
> \[ \] I knew I would ***not*** breast-feed
>
> \[ \] I didn=t know what to do about breast-feeding

**Not currently in use**

**State-Developed**

**AL Q 62**

> When you went for WIC visits for your new baby, did you receive
> information about breast-feeding?
>
> \[ \] No
>
> \[ \] Yes

***See also: Core Q 16 in section 24B, Prenatal Care, Content***

> ***Standard Q 18 in section 30, Social Services; GA modification***
>
> ***State-Developed MI Q 61o in section 30, Social Services***
>
> ***State-Developed MI Q 62o in section 30, Social Services***
>
> ***State-Developed NM Q 63a in section 30, Social Services***

**3. CONTRACEPTION**

**A. PRE-PREGNANCY**

**State-Developed**

**SC Q 61**

> During the ***3 months before*** you got pregnant were you or your
> husband or partner using any birth control methods? **Check all that
> apply**.
>
> \[ \] Pill
>
> \[ \] Condoms (rubbers)
>
> \[ \] Foam, jelly, cream, or suppositories
>
> \[ \] Diaphragm, cap, or sponge
>
> \[ \] Norplant (little tubes placed under the skin)
>
> \[ \] Shots (Depo-Provera)
>
> \[ \] Rhythm method/Natural family planning
>
> \[ \] I was not planning to have sex (abstinence)
>
> \[ \] Other \-\-\-\--\> Please tell us:\_\_\_\_\_\_\_\_\_\_
>
> \[ \] I was not using birth control

**B. CONCEPTION**

**Core**

**Q 8** When you got pregnant with your new baby, were you or your
husband or partner using any kind of birth control? **Birth control
means the pill, condoms, diaphragm, foam, rhythm, Norplant, shots
(Depo-Provera) or ANY other way to keep from getting pregnant**.

> \[ \] No
>
> \[ \] Yes \-\-\-\--\>**Go to Question 10**

**Q 9** Why were you or your husband or partner not using any birth
control? **Check all that apply**.

> \[ \] I wanted to get pregnant
>
> \[ \] I didn=t think I could get pregnant
>
> \[ \] I had been having side effects from the birth control I used
>
> \[ \] I didn=t want to use birth control
>
> \[ \] I didn=t think I was going to have sex
>
> \[ \] My husband or partner didn=t want to use birth control
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**C. POSTPARTUM**

**Standard**

**Q 6** Are you or your husband or partner using any kind of birth
control ***now***? **Birth control means having your tubes tied,
vasectomy, the pill, condoms, diaphragm, foam, rhythm, Norplant, shots
(Depo-Provera) or ANY other way to keep from getting pregnant**.

> \[ \] No
>
> \[ \] Yes

**Used by: AK Q 56, AL Q 57, AR Q 61, FL Q 59, GA Q 58, IL Q 58, IN Q
59, LA Q 58,**

**ME Q 56, NC Q 58, NM Q 60, NY Q 55, OH Q 60, SC Q 62, UT Q 55, WA Q**

**62, WV Q 57**

**Modifications:**

> **AK** - Includes AIUD@ in sentence ABirth control means \...@
>
> **FL** - Modifies ABirth control means \...@ sentence to read as
> follows: ABirth control means the pill, IUD, condoms, diaphragm, the
> shot, and other ways to keep from getting pregnant.@
>
> **SC** - Includes Aabstinence@ in sentence ABirth control means \...@
>
> **UT -** ABirth control means \...@ sentence appears above the
> question.

**Q 7** What kind of birth control are you or your husband or partner
using now? **Check all that apply**.

> \[ \] Tubes tied (sterilization)
>
> \[ \] Vasectomy (sterilization)
>
> \[ \] Pill
>
> \[ \] Condoms
>
> \[ \] Foam, jelly, cream
>
> \[ \] Norplant
>
> \[ \] Shots (Depo-Provera)
>
> \[ \] Withdrawal
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**Used by: AL Q 58, AR Q 62, FL Q 60, GA Q 59, LA Q 59, NC Q 59, NM Q
61, SC Q 63, UT Q 56, WV Q 58**

**Modifications:**

> **FL** - Adds option AIUD@
>
> **SC** - Modifies option ACondoms@ to read ACondoms (rubbers)@
>
> Modifies option AFoam, jelly, cream@ to read AFoam, jelly, cream, or
> suppositories@
>
> Modifies option ANorplant@ to read ANorplant (little tubes placed
> under the skin)@
>
> Does not use option AWithdrawal@
>
> Adds option ADiaphragm, cap, or sponge@

Adds option ARhythm method/ Natural family planning@

Adds option AI am not planning to have sex (abstinence)@

> **UT -** Adds option AAbstinence@

**Q 8** What are your reasons for not using any birth control now?
**Check all that apply**.

> \[ \] I am not having sex
>
> \[ \] I want to get pregnant
>
> \[ \] I don=t want to use birth control
>
> \[ \] My husband or partner doesn=t want to use birth control
>
> \[ \] I don=t think I can get pregnant
>
> \[ \] I can=t pay for birth control
>
> \[ \] I am pregnant now
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**Used by: AK Q 57, AL Q 59, AR Q 63, FL Q 61, IL Q 59, IN Q 60, LA Q
60, ME Q 57, NM Q 62, NY Q 56, OH Q 61, UT Q 57, WA Q 63**

**Modifications:**

> **FL** - Adds option AIt=s against my religion@
>
> **NM** - Adds option AI haven=t started my period yet@

**Q 9** After your new baby was born, did a doctor, nurse or other
health worker talk with you about using birth control?

> \[ \] No
>
> \[ \] Yes

**Used by: IL Q 60, OH Q 59, WA Q 61**

**State-Developed**

**SC Q 64**

> **At this time**, where do you usually get the birth control methods
> you are using? **Check all that apply**.
>
> \[ \] Health Department clinic
>
> \[ \] Private doctor=s office
>
> \[ \] Hospital clinic
>
> \[ \] Drug or grocery store
>
> \[ \] Other clinic (Community health center, military facility,
> Planned Parenthood)
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_
>
> \[ \] I do not go anywhere to get the method I now use
>
> \[ \] I do not have a place to get a method

***See also: Core Q 16f in section 24B, Prenatal Care, Content***

> ***State-Developed NM Q 64 in section 19B, Morbidity, Maternal***

**4. DOUCHING**

**State-Developed**

**GA Q 61**

> Did you douche at any time during your most recent pregnancy?
>
> \[ \] No \-\-\-\--\>**Go to Question 63**
>
> \[ \] Yes
>
> \[ \] I don=t know or don=t remember

**GA Q 62**

> About how often did you douche during your most recent pregnancy?
>
> \[ \] Several times a week
>
> \[ \] Once a week
>
> \[ \] Several times a month
>
> \[ \] Once a month or less
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**5. DRUG USE**

**A. ALCOHOL**

**Core**

**Q 25a** During the ***3 months before*** you got pregnant, how many
alcoholic drinks did you have in an average week? (A drink is: One glass
of wine, one wine cooler, one can or bottle of beer, one shot of liquor,
one mixed drink.)

> \[ \] I didn=t drink then
>
> \[ \] Less than 1 drink a week
>
> \[ \] 1 to 3 drinks a week
>
> \[ \] 4 to 6 drinks a week
>
> \[ \] 7 to 13 drinks a week
>
> \[ \] 14 drinks or more a week
>
> \[ \] I don=t know

**Q 25b** During the ***3 months before*** you got pregnant, how many
times did you drink 5 or more alcoholic drinks at one sitting?

> \_\_\_\_\_ Times
>
> \[ \] I didn=t drink then
>
> \[ \] I don=t know

**Q 26a** During the ***last 3 months*** of your pregnancy, how many
alcoholic drinks did you have in an average week?

\[ \] I didn=t drink then

> \[ \] Less than 1 drink a week
>
> \[ \] 1 to 3 drinks a week
>
> \[ \] 4 to 6 drinks a week
>
> \[ \] 7 to 13 drinks a week
>
> \[ \] 14 drinks or more a week
>
> \[ \] I don=t know

**Q 26b** During the ***last 3 months*** of your pregnancy, how many
times did you drink 5 or more alcoholic drinks at one sitting?

> \_\_\_\_\_ Times
>
> \[ \] I didn=t drink then
>
> \[ \] I don=t know

**State-Developed**

**AK Q 62**

> Since your baby was born, how many alcoholic drinks do you have in an
> average week? (A drink is: One glass of wine, one wine cooler, one can
> or bottle of beer, one shot of liquor, one mixed drink.)
>
> \[ \] I don=t drink
>
> \[ \] Less than 1 drink a week
>
> \[ \] 1 to 3 drinks a week
>
> \[ \] 4 to 6 drinks a week
>
> \[ \] 7 to 13 drinks a week
>
> \[ \] 14 or more drinks a week
>
> \[ \] I don=t know

**AK Q 63**

> Since your new baby was born, how many times have you had 5 or more
> alcoholic drinks at one sitting?
>
> \[ \] \_\_\_\_\_ Times
>
> \[ \] I don=t drink
>
> \[ \] I don=t know

***See also: Core Q 16d in section 24B, Prenatal Care, Content***

> ***Standard Q 15 in section 24B, Prenatal Care, Content***
>
> ***State-Developed IN Q 53a in section 23, Pre-Conception Readiness***
>
> ***State-Developed OK Q 53b in section 23, Pre-Conception Readiness***

**B. TOBACCO**

**Core**

**Q 21** Have you smoked at least 100 cigarettes in your entire life?

> \[ \] No \-\-\-\--\>**Go to Question 25**
>
> \[ \] Yes

**Q 22** In the ***3 months before*** you got pregnant, how many
cigarettes or packs of cigarettes did you smoke on an average day? A
pack has 20 cigarettes.

> \_\_\_\_\_ Cigarettes or \_\_\_\_\_ Packs
>
> \[ \] Less than 1 cigarette a day
>
> \[ \] I didn=t smoke
>
> \[ \] I don=t know

**Q 23** In the ***last 3 months*** of your pregnancy, how many
cigarettes or packs of cigarettes did you smoke on an average day?

> \_\_\_\_\_ Cigarettes or \_\_\_\_\_ Packs
>
> \[ \] Less than 1 cigarette a day
>
> \[ \] I didn=t smoke
>
> \[ \] I don=t know

**Q 24** How many cigarettes or packs of cigarettes do you smoke on an
average day ***now***?

> \_\_\_\_\_ Cigarettes or \_\_\_\_\_ Packs
>
> \[ \] Less than 1 cigarette a day
>
> \[ \] I don=t smoke
>
> \[ \] I don=t know

**State-Developed**

**AK Q 61**

> During your most recent pregnancy, did you ever use smokeless tobacco
> (chew or snuff)?
>
> \[ \] No
>
> \[ \] Yes

***See also: Core Q 16b in section 24B, Prenatal Care, Content***

> ***Core Q 44 in section 28, Second-Hand Smoke Exposure***
>
> ***Standard Q 14 in section 24B, Prenatal Care, Content***
>
> ***Standard Q 18c in section 30, Social Services***

***Standard Q 18 in section 30, Social Services, NC modification***

> ***State-Developed MI Q 61n in section 30, Social Services***
>
> ***State-Developed MI Q 62n in section 30, Social Services***
>
> ***State-Developed NM Q 63j in section 30, Social Services***
>
> ***State-Developed NY Q 57b in section 30, Social Services***
>
> ***State-Developed OK Q 53a in section 23, Pre-Conception Readiness***

**C. OTHER**

**State-Developed**

**AK Q 58a**

> Did you smoke marijuana or hash at all during the 12 months ***before
> your delivery***?
>
> \[ \] No \-\-\-\--\>**Go to Question 59**
>
> \[ \] Yes

**AK Q 58b**

> How often did you smoke marijuana or hash ***after*** you found out
> that you were pregnant?
>
> \[ \] 1 or more times a week
>
> \[ \] 1 to 3 times a month
>
> \[ \] Less than 1 time a month
>
> \[ \] I did not smoke marijuana or hash ***after*** I found out that I
> was pregnant

**AK Q 59a**

> Did you use cocaine or crack at all during the 12 months ***before
> your delivery***?
>
> \[ \] No \-\-\-\--\>**Go to Question 60**
>
> \[ \] Yes

**AK Q 59b**

> How often did you use cocaine or crack ***after*** you found out that
> you were pregnant?
>
> \[ \] 1 or more times a week
>
> \[ \] 1 to 3 times a month
>
> \[ \] Less than 1 time a month
>
> \[ \] I did not use cocaine or crack ***after*** I found out that I
> was pregnant.

***See also: Core Q 16g-h in section 24B, Prenatal Care, Content***

> ***Core Q 30l in section 31, Social Stress***
>
> ***State-Developed MI Q 61b in section 30, Social Services***
>
> ***State-Developed MI Q 62b in section 30, Social Services***
>
> ***State-Developed NM Q 63i in section 30, Social Services***

**6. HEALTH INSURANCE**

**Core**

**Q 6** ***Just before*** you got pregnant, did you have health
insurance? **Don=t count Medicaid.**

> \[ \] No
>
> \[ \] Yes

**Q 7** ***Just before*** you got pregnant, were you on Medicaid?

> \[ \] No
>
> \[ \] Yes

**Q 15** How was your prenatal care paid for? **Check all that apply**.

> \[ \] Medicaid
>
> \[ \] Personal income (cash, check or credit card)
>
> \[ \] Health Insurance
>
> \[ \] *State option*
>
> \[ \] *State option*
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**Q 40** How was your delivery paid for? **Check all that apply.**

> \[ \] Medicaid
>
> \[ \] Personal income (cash, check or credit card)
>
> \[ \] Health Insurance
>
> \[ \] *State option*
>
> \[ \] *State option*
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**State-Developed**

**CO Q 54**

> During your most recent pregnancy, did you have any type of public or
> private health care plan (including health insurance, Medicaid,
> prepaid plans such as health maintenance organizations (HMOs),
> military health coverage, or other government plans) that paid for
> most of your ***prenatal care***?
>
> \[ \] No \-\-\-\--\>**Go to Question 58**
>
> \[ \] Yes

**CO Q 55**

> Did Medicaid pay for most of your prenatal care during your most
> recent pregnancy?
>
> \[ \] No \-\-\-\--\>**Go to Question 57**
>
> \[ \] Yes

**CO Q 56**

> Was the Medicaid plan that paid for most of your prenatal care a
> health maintenance organization (HMO)?
>
> \[ \] No \-\-\-\--\>**Go to Question 58**
>
> \[ \] Yes \-\-\-\--\>**Go to Question 58**
>
> \[ \] I don=t know \-\-\-\--\>**Go to Question 58**

**CO Q 57**

> Was the plan that paid for most of your prenatal care a health
> maintenance organization (HMO)?
>
> \[ \] No
>
> \[ \] Yes
>
> \[ \] I don=t know

**FL Q 56**

> What is the name of the medical-care plan that paid for the delivery
> of your new baby? **It may help to look at your medical-care card.**
>
> Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \[ \] I did not have a medical-care plan to pay for the delivery
>
> \[ \] I don=t know

**IN Q 61**

> Were you on Medicaid during your most recent pregnancy?
>
> \[ \] Yes
>
> \[ \] No \-\-\-\--\>**Go to Question 63**

**IN Q 62**

> Which of these things happened during your most recent pregnancy?
>
> **For each thing, circle Y (Yes) if it happened to you or N (No) if it
> did not**.
>
> **No Yes**
>
> a\. I had a hard time getting help from the Medicaid staff. N Y
>
> b\. I did not understand how to use my Medicaid card or
>
> what was covered. N Y
>
> c\. I did not get all the Medicaid services I needed. N Y
>
> d\. I had problems finding a doctor who would accept me as a
>
> Medicaid patient. N Y
>
> e\. I was assigned to a doctor that I did not choose. N Y
>
> f\. I had problems with Medicaid=s transportation service. N Y
>
> g\. My doctor or nurse treated me differently from other patients. N Y
>
> h\. I did not have any problems with Medicaid. N Y

**OK Q 58**

> How much money did you pay ***before*** a doctor or nurse would see
> you for your first prenatal care visit? **Do not count your pregnancy
> test**.
>
> \[ \] I did not pay anything before a doctor or nurse would see me
>
> \[ \] I had to pay \-\-\-\--\>How much? \$\_\_\_\_\_\_\_\_\_\_

**OK Q 59**

> How much of your own money did you pay for your prenatal care and
> delivery? **Count any copayment. Do not count your pregnancy test.**
>
> \[ \] None
>
> \[ \] \$199 or less
>
> \[ \] \$200 - \$499
>
> \[ \] \$500 - \$999
>
> \[ \] \$1,000 or more

**OK Q 60**

> What is the name of the main health insurance plan you used to pay for
> your prenatal care? **(For example, BlueLincs, PruCare, Foundation,
> Heartland, Soonercare, Medicaid, Indian Health Service/Tribal,
> Military.)**
>
> Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \[ \] I did not have a health insurance plan to pay for prenatal care

**SC Q 54**

> Did you have health insurance, Medicaid, or HMO (Health Maintenance
> Organization) coverage during your most recent pregnancy or delivery?
>
> \[ \] No \-\-\-\--\>**Go to Question 56**
>
> \[ \] Yes

**SC Q 55**

> Are any of the following true about your health insurance, Medicaid,
> or HMO coverage during pregnancy or delivery? **For each thing listed
> below, circle Y (Yes) if it is true for you or circle N (No) if it is
> not.**
>
> **No Yes**
>
> a\. I still owe money for my medical bills N Y
>
> b\. I still owe money for my baby=s medical bills N Y
>
> c\. I could only go to certain doctors or clinics N Y
>
> d\. I could only go to certain hospitals N Y
>
> e\. I had to call my insurance company for approval to
>
> see a doctor or have a test done N Y
>
> f\. I belonged to an HMO (Health Maintenance Organization) N Y

**SC Q 56**

> Did you apply for Medicaid during your most recent pregnancy?
>
> \[ \] No \-\-\-\--\>**Go to Question 58**
>
> \[ \] Yes

**SC Q 57**

> Which of these things happened when you applied for Medicaid during
> your most recent pregnancy? **For each thing, circle Y(Yes) if it
> happened or N(No) if it did not happen.**
>
> **No Yes**
>
> a\. I got information about Medicaid managed care
>
> programs (PEP or HMO) N Y
>
> b\. It took longer than 4 weeks to get my Medicaid card N Y
>
> c\. I had to go over to the Department of Social Services N Y
>
> d\. I had a hard time finding the information they needed N Y
>
> e\. I had a hard time getting help from the Medicaid staff N Y
>
> f\. I had to make many trips to the Medicaid office N Y
>
> g\. I had too many papers to fill out N Y
>
> h\. I had problems getting a Medicaid card for my baby N Y

**SC Q 58**

> How much of your own money did you have to pay for your prenatal care
> and delivery, including any deductibles and copayments? **Check none
> if you did not pay any money.**
>
> \[ \] None
>
> \[ \] \$99 or less
>
> \[ \] \$100 to \$499
>
> \[ \] \$500 to \$999
>
> \[ \] \$1,000 to \$1,999
>
> \[ \] \$2,000 to \$2,999
>
> \[ \] \$3,000 or more

***See also: Core Q 12 in section 24A, Prenatal Care, Barriers***

> ***State-Developed ME Q 53 in section 24A, Prenatal Care, Barriers***
>
> ***State-Developed ME Q 54 in section 24A, Prenatal Care, Barriers***
>
> ***State-Developed ME Q 66 in section 11C, Infant Health, Well Baby
> Care***

**7. HIV**

**Standard**

**Q 47** At any time during your most recent pregnancy ***or***
delivery, did you have a blood test for HIV (the virus that causes
AIDS)?

> \[ \] No
>
> \[ \] Yes
>
> \[ \] I don=t know

**Used by: AR Q 59, CO Q 58, FL Q 57, GA Q 71, IL Q 56, IN Q 56, NC Q
56, NY Q 54, OH Q 55, OK Q 63, WV Q 54**

**State-Developed**

**AL Q 55**

> During any of your prenatal care visits, did a doctor, nurse or other
> health care worker talk to you about how HIV (the virus that causes
> AIDS) could affect your baby?
>
> \[ \] No
>
> \[ \] Yes

***See also: Core Q 16k-l in section 24 B, Prenatal Care, Content***

**8. HOUSE AND HOUSEHOLD CHARACTERISTICS**

**A. COMPOSITION OF RESIDENTS**

**Core**

**Q 49** How many people live in your house, apartment, or trailer?
**Count yourself**.

> How many?
>
> Babies, children, or teens aged 17 or younger \_\_\_\_\_\_\_\_\_\_
>
> Adults aged 18 or older \_\_\_\_\_\_\_\_\_\_

**Standard**

**Q 34** When you got pregnant, who lived in the same house with you?
**Check all that apply.**

> \[ \] My husband or partner
>
> \[ \] Children aged 5 years and under \-\-\-\--\>How many? \_\_\_\_\_
>
> \[ \] Children aged 6 years and over \-\-\-\--\>How many? \_\_\_\_\_
>
> \[ \] My mother
>
> \[ \] My father
>
> \[ \] My husband=s or partner=s parent(s)
>
> \[ \] Friend or roommate
>
> \[ \] Other relative
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_
>
> \[ \] I lived alone

**Used by: LA Q 57, WA Q 54**

**Modifications:**

> **WA** - Changes the phrase AWhen you got pregnant\...@ to AWhen you
> found out that you were pregnant\...@
>
> Does not use the following options: AMy mother@, AMy father@, AMy
> husband=s or partner=s parent(s)@, AFriend or roommate@, AOther
> relative@, AOther, Please tell us@. Adds option AOther adults@. Adds
> option AHow many \[other adults\]?@

**Q 35** Who lives in the same house with you ***now***? **Check all
that apply.**

> \[ \] My husband or partner
>
> \[ \] Children aged 5 years and under \-\-\-\--\>How many? \_\_\_\_\_
>
> \[ \] Children aged 6 years and over \-\-\-\--\>How many? \_\_\_\_\_
>
> \[ \] My mother
>
> \[ \] My father
>
> \[ \] My husband=s or partner=s parent(s)
>
> \[ \] Friend or roommate
>
> \[ \] Other relative
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

\[ \] I live alone

**Not currently in use**

**Q 36** Do you have a husband or partner who lives with you ***now***?

> \[ \] No
>
> \[ \] Yes

**Not currently in use**

**B. NUMBER OF ROOMS**

**Core**

**Q 48** Which rooms are in the house, apartment, or trailer where you
live? **Check all that you have.**

> \[ \] Bedrooms \-\-\-\--\>How many? \_\_\_\_\_
>
> \[ \] Living room
>
> \[ \] Separate dining room
>
> \[ \] Kitchen
>
> \[ \] Bathroom(s)
>
> \[ \] Recreation room, den or family room
>
> \[ \] Finished basement

**C. TELEPHONE COVERAGE**

**Standard**

**Q 32** Do you have a telephone in your home that has been working (in
service) for the past month?

> \[ \] No \-\-\-\--\>**Go to Question**\_\_\_\_\_
>
> \[ \] Yes

**Not currently in use**

**Q 33** Is your telephone number listed in the most recent telephone
book under your last name and current address?

> \[ \] Yes
>
> \[ \] Telephone unlisted
>
> \[ \] Telephone listed under another name or address

**Not currently in use**

**9. INCENTIVE**

**State-Developed**

**GA Q 72**

> Would you like for us to send you a coupon for a certified copy of
> your baby=s birth certificate?
>
> \[ \] No
>
> \[ \] Yes

**ME Q 73**

> Would you like us to send you a free certified copy of your baby=s
> birth certificate (usual cost \$10.00)?
>
> \[ \] No
>
> \[ \] Yes

**10. INCOME**

**Core**

**Q 50** What were the sources of family income during the past 12
months? **Check all that apply.**

> \[ \] Money from a job or business
>
> \[ \] Aid such as AFDC, welfare, public assistance, general
> assistance, Food Stamps or SSI
>
> \[ \] Unemployment benefits
>
> \[ \] Child support or alimony
>
> \[ \] Fees, rental income, commissions, interest, dividends
>
> \[ \] Social security, workers= compensation, veteran benefits, or
> pensions
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**Standard**

**Q 43** How many people, including yourself, depended on this income?

> \_\_\_\_\_ People

**Used by: AK Q 68b, AR Q 70, CO Q 68b, IL Q 66, IN Q 68, ME Q 72, MI Q
64, NM Q 69, OH Q 69, OK Q 69b, UT Q 62, WV Q 70**

**Modifications:**

> **AR** - Includes the phrase, ABefore your delivery, how many \...@
>
> **CO** - Includes the phrase, A\...depended on this income ***when you
> got pregnant***?@
>
> **IN** - Includes the phrase, A**Do not include your new baby.**@
>
> **OK** - Includes the phrase, A\...depended on this income when you
> got pregnant?@

**State-Developed**

**AK Q 68a**

> Please check your total family income for last year. Include ***all***
> money your family received. **Check only one box.**
>
> \[ \] Less than \$5,000
>
> \[ \] \$5,001 to \$10,000
>
> \[ \] \$10,001 to \$15,000
>
> \[ \] \$15,001 to \$20,000
>
> \[ \] \$20,001 to \$25,000
>
> \[ \] \$25,001 to \$\$30,000
>
> \[ \] \$30,001 to \$35,000
>
> \[ \] \$35,001 to \$40,000
>
> \[ \] \$40,001 to \$45,000
>
> \[ \] \$45,001 to \$50,000
>
> \[ \] More than \$50,000

**AR Q 69**

> What was the total income before taxes for the people living in your
> household during the ***12 months before*** your delivery? **Check the
> box that was closest to your household income. All information will be
> kept private. Your answer will not affect any services that you are
> now getting.**
>
> \[ \] \$7,999 or less
>
> \[ \] \$8,000 to \$9,999
>
> \[ \] \$10,000 to \$11,999
>
> \[ \] \$12,000 to \$13,999
>
> \[ \] \$14,000 to \$15,999
>
> \[ \] \$16,000 to \$17,999
>
> \[ \] \$18,000 to \$19,999
>
> \[ \] \$20,000 to \$24,999
>
> \[ \] \$25,000 to \$29,999
>
> \[ \] \$30,000 to \$34,999
>
> \[ \] \$35,000 to \$39,999
>
> \[ \] \$40,000 or more

**CO Q 68a**

> What was your family=s income, before deductions and taxes, ***when
> you got pregnant with your new baby?*** **Include ANY income or money
> you could use. (For example, job, AFDC, child support, etc.) Please
> give us your best guess. All information will be kept private.**
>
> \$\_\_\_\_\_\_\_\_\_\_Monthly or \$\_\_\_\_\_\_\_\_\_\_Yearly

**FL Q 74**

> What was your family=s ***monthly*** income from all sources during
> the 12 months before your new baby was born? **Include your income,
> your husband=s or partner=s income and any other income you used. All
> information you give us will be kept private.**
>
> \[ \] Under \$650
>
> \[ \] \$651 to \$1,300
>
> \[ \] \$1,301 to \$2,100
>
> \[ \] \$2,101 to \$3,300
>
> \[ \] \$3,301 to \$4,200
>
> \[ \] \$4,201 or more

**GA Q 70**

> What was your total family income, ***before taxes***, during the 12
> months before you delivered your most recent baby?
>
> \[ \] Under \$8,000
>
> \[ \] \$8,000 - \$11,999
>
> \[ \] \$12,000 - \$15,999
>
> \[ \] \$16,000 - \$19,999
>
> \[ \] \$20,000 - \$24,999
>
> \[ \] \$25,000 - \$29,999
>
> \[ \] \$30,000 - \$39,999
>
> \[ \] \$40,000 or more

**IL Q 65**

Which category best describes your annual household income from all
sources? **Include**

**your income and the income of others living with you.**

> \[ \] Less than \$10,000
>
> \[ \] \$10,000 to less than \$15,000
>
> \[ \] \$15,000 to less than \$20,000
>
> \[ \] \$20,000 to less than \$25,000
>
> \[ \] \$25,000 to less than \$35,000
>
> \[ \] \$35,000 or more

**IN Q 67**

> In the 12 months before your delivery, what was your total household
> income ***before taxes***? **Include your income and the incomes of
> others living with you.**
>
> \[ \] \$0 to \$5,000
>
> \[ \] \$5,001 to \$10,000
>
> \[ \] \$10,001 to \$15,000
>
> \[ \] \$15,001 to \$20,000
>
> \[ \] \$20,001 to \$25,000
>
> \[ \] \$25,001 to \$30,000
>
> \[ \] \$30,001 to \$35,000
>
> \[ \] \$35,001 or more

**LA Q 67**

What was the total income before taxes for the people living in your
household during

the **12 months before** your delivery? **Check the box that was closest
to your income.**

\[ \] \$ 7,999 or less

\[ \] \$ 8,000 to \$ 9,999

\[ \] \$10,000 to \$11,999

\[ \] \$12,000 to \$13,999

\[ \] \$14,000 to \$15,999

\[ \] \$16,000 to \$17,999

\[ \] \$18,000 to \$19,999

\[ \] \$20,000 to \$24,999

\[ \] \$25,000 to \$29,999

\[ \] \$30,000 to \$34,999

\[ \] \$35,000 to \$39,999

\[ \] \$40,000 or more

**ME Q 71**

> In the twelve months before your delivery, what was your total
> ***household*** income? **Include income from all sources, before
> taxes.**
>
> \[ \] Under \$8,000
>
> \[ \] \$8,000 - \$11,999
>
> \[ \] \$12,000 - \$15,999
>
> \[ \] \$16,000 - \$19,999
>
> \[ \] \$20,000 - \$24,999
>
> \[ \] \$25,000 - \$29,999
>
> \[ \] \$30,000 - \$39,999
>
> \[ \] \$40,000 or more

**MI Q 63**

> What was the total annual family income before taxes during the 12
> months before your delivery? **Include your income and the income of
> others living with you. Check the box below that gives the best
> estimate.**
>
> \[ \] \$0 to \$5,000
>
> \[ \] \$5,001 to \$10,000
>
> \[ \] \$10,001 to \$15,000
>
> \[ \] \$15,001 to \$20,000
>
> \[ \] \$20,001 to \$30,000
>
> \[ \] \$30,001 to \$40,000
>
> \[ \] \$40,001 or more

**NC Q 70**

In the 12 months before your most recent delivery, what was your total
family income

before taxes? Include your income, your husband=s or partner=s income,
and any other

income that you may have had. Your answer will not affect your
eligibility for any

services you are now getting.

\[ \] \$7,999 or less

\[ \] \$8,000 to \$9,999

\[ \] \$10,000 to \$11,999

\[ \] \$12,000 to \$13,999

\[ \] \$14,000 to \$15,999

\[ \] \$16,000 to \$17,999

\[ \] \$18,000 to \$19,999

\[ \] \$20,000 to \$24,999

\[ \] \$25,000 to \$29,999

\[ \] \$30,000 to \$39,999

\[ \] \$40,000 to \$49,999

\[ \] \$50,000 or more

**NM Q 68**

> During the 12 months before you delivered, what was your *monthly
> income for your household* before taxes? **Check the box that was
> closest to this income.**
>
> \[ \] Less than \$390 per month
>
> \[ \] \$390 - \$700 per month
>
> \[ \] \$701 - \$1,000 per month
>
> \[ \] \$1,001 - \$1,360 per month
>
> \[ \] \$1,361 - \$1,600 per month
>
> \[ \] \$1,601 - \$1,950 per month
>
> \[ \] \$1,951 or more per month

**NY Q 68**

> In the 12 months before your most recent delivery, what was your total
> family income *before taxes*? **Include your income, your husband=s or
> partner=s income, and any other income you may have had. All
> information you give us will be kept private.**
>
> \[ \] \$7,999 or less
>
> \[ \] \$8,000 - \$11,999
>
> \[ \] \$12,000 - \$15,999
>
> \[ \] \$16,000 - \$19,999
>
> \[ \] \$20,000 - \$24,999
>
> \[ \] \$25,000 - \$29,999
>
> \[ \] \$30,000 - \$39,999
>
> \[ \] \$40,000 or more

**OH Q 68**

Which category best describes your annual household income from all
sources? **Include**

**your income and the income of others living with you.**

\[ \] Less than \$10,000

\[ \] \$10,000 to less than \$15,000

\[ \] \$15,000 to less than \$20,000

\[ \] \$20,000 to less than \$25,000

\[ \] \$25,000 to less than \$35,000

\[ \] \$35,000 or more

**OK Q 69a**

> What was your family=s income, before deductions and taxes, ***when
> you got pregnant with your new baby?*** **Include ANY income or money
> you could use. (For example, job, AFDC, child support, etc.) Please
> give us your best guess. All information will be kept private.**
>
> \$\_\_\_\_\_\_\_\_\_\_ Monthly or \$\_\_\_\_\_\_\_\_\_\_ Yearly

**SC Q 65**

What was the total income before taxes for the people living in your
household during

the ***12 months before*** your delivery? **Check the box that was
closest to your income.**

> \[ \] \$7,999 or less
>
> \[ \] \$8,000 to \$9,999
>
> \[ \] \$10,000 to \$11,999
>
> \[ \] \$12,000 to \$\$13,999
>
> \[ \] \$14,000 to \$15,999
>
> \[ \] \$16,000 to \$17,999
>
> \[ \] \$18,000 to \$19,999
>
> \[ \] \$20,000 to \$24,999
>
> \[ \] \$25,000 to \$29,999
>
> \[ \] \$30,000 to \$34,999
>
> \[ \] \$35,000 to \$39,999
>
> \[ \] \$40,000 or more

**UT Q 61**

What was your total household income during the 12 months before you
delivered your

most recent baby?

\[ \] Less than \$10,000

\[ \] \$10,000 to less than \$15,000

\[ \] \$15,000 to less than \$20,000

\[ \] \$20,000 to less than \$25,000

\[ \] \$25,000 to less than \$35,000

\[ \] \$35,000 to less than \$50,000

\[ \] \$50,000 to less than \$75,000

\[ \] \$75,000 or more

**WA Q 55**

> When you found out that you were pregnant, what was your family=s
> total ***monthly*** income before taxes? **Count wages, child support,
> unemployment or welfare checks, and monthly support from relatives or
> friends.**
>
> \[ \] Under \$500
>
> \[ \] \$500 - \$999
>
> \[ \] \$1,000 - \$1,199
>
> \[ \] \$1,200 - \$1,399
>
> \[ \] \$1,400 - \$1,799
>
> \[ \] \$1,800 - \$2,199
>
> \[ \] \$2,200 - \$2,599
>
> \[ \] \$2,600 - \$2,999
>
> \[ \] \$3,000 or more

**WV Q 69**

> Check which of the following categories best describes your annual
> household income from all sources. **Please include yourself and
> everyone who lives with you.**
>
> \[ \] Less than \$17,000
>
> \[ \] \$17,001 - \$19,000
>
> \[ \] \$19,001 - \$25,500
>
> \[ \] Over \$25,500

**11. INFANT HEALTH**

**A. GENERAL BABY CARE**

**State-Developed**

**OK Q 68**

> Did any of these things keep your baby from getting health care?
> **Health care includes shots, check-ups, and visits when your baby was
> sick. Check all that apply.**
>
> \[ \] I didn=t have enough money
>
> \[ \] My insurance did not cover it
>
> \[ \] I couldn=t get to the doctor=s office or clinic during their
> office hours
>
> \[ \] The doctor=s office or clinic was too far away
>
> \[ \] I had no way to get my baby to the doctor=s office or clinic
>
> \[ \] I didn=t think my baby needed to go for health care
>
> \[ \] I did not have a regular health care provider
>
> \[ \] I couldn=t find a doctor or a nurse who would take my baby as a
> patient
>
> \[ \] The attitude of the doctor, nurse, or the office staff
>
> \[ \] I couldn=t take off from work or school
>
> \[ \] Nothing has kept my baby from getting health care

**B. SICK BABY CARE**

**Standard**

**Q 40** How many times has your new baby gone for care when he or she
was sick?

> \_\_\_\_\_ Times
>
> \[ \] None \-\-\-\--\>**Go to Question** \_\_\_\_\_
>
> \[ \] My baby has not been sick \-\-\-\--\>**Go to Question**
> \_\_\_\_\_

**Used by: ME Q 67, MI Q 58, WV Q 66**

**Q 41** Where have you taken your new baby when he or she was sick and
needed care? **Check all that apply.**

> \[ \] Hospital clinic
>
> \[ \] Health department clinic
>
> \[ \] Hospital emergency room
>
> \[ \] Private doctor=s office
>
> \[ \] *State-Specific option*
>
> \[ \] *State-Specific option*
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**Used by: ME Q 68, MI Q 59**

**Modifications:**

> **ME** - Selects as *State Options*: APrivate doctor=s office@, and
> ARural health center@
>
> **MI** - Selects as *State Options*: APrivate doctor=s office@, and
> ACommunity or rural health center@

**Q 42** Has your baby gone for care as many times as you wanted when he
or she was sick?

> \[ \] No
>
> \[ \] Yes

**Used by: ME Q 69, MI Q 60, WV Q 67**

**State-Developed**

**FL Q 68**

> Was there a time when your new baby needed to see a doctor, but you
> could not afford it?
>
> \[ \] No
>
> \[ \] Yes

**ME Q 70**

> Did any of these things keep your baby from getting care when he or
> she was sick? **Check all that apply.**
>
> \[ \] I didn=t have enough money or insurance to pay for it
>
> \[ \] I had no way to get my baby to the clinic or office
>
> \[ \] I didn=t have anyone to take care of my other children
>
> \[ \] I couldn=t get an appointment
>
> \[ \] I couldn=t get an appointment because I still owe money on my
> bill
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**SC Q 66**

> Where will you take your new baby when he or she gets sick? **Check
> all that apply.**
>
> \[ \] Health Department
>
> \[ \] Community health center
>
> \[ \] Hospital clinic
>
> \[ \] Private doctor=s office or private clinic
>
> \[ \] Military facility
>
> \[ \] Hospital emergency room
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**WV Q 68**

> Did any of these things keep your baby from having care when he or she
> was sick? **Check all that apply.**
>
> \[ \] I didn=t have enough money or insurance to pay for it
>
> \[ \] I couldn=t get an appointment
>
> \[ \] I had no way to get my baby to the clinic or doctor=s office
>
> \[ \] I didn=t have anyone to take care of my other children
>
> \[ \] Other \-\-\-\--\> Please tell us:\_\_\_\_\_\_\_\_\_\_

***See also: Standard Q 18 in section 30, Social Services; IN
modification***

**C. WELL BABY CARE**

**Core**

**Q 46** How many times has your baby been to a doctor or nurse for
***routine*** well baby care? **Don=t count the times you took your baby
for care when he or she was sick. It may help to use the calendar.**

> \_\_\_\_\_ Times
>
> \[ \] My baby hasn=t been for routine well baby care \-\-\-\--\>**Go
> to Question 48**

**Q 47** When your baby goes for ***routine*** well baby care, where do
you take him or her? **Check all the places that you use.**

> \[ \] Hospital clinic
>
> \[ \] Health department clinic
>
> \[ \] Private doctor=s office
>
> \[ \] *State Option*
>
> \[ \] *State Option*
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**Standard**

**Q 16** Has your baby gone as many times as you wanted for routine well
baby care?

> \[ \] No
>
> \[ \] Yes \-\-\-\--\>**Go to Question**\_\_\_\_\_

**Used by: AR Q 66, FL Q 66, IL Q 61, LA Q 65, ME Q 64, OH Q 64**

**Q 17** Did any of these things keep your baby from having routine well
baby care? **Check all that apply.**

> \[ \] I didn=t have enough money or insurance to pay for it
>
> \[ \] I had no way to get my baby to the clinic or office
>
> \[ \] I didn=t have anyone to take care of my other children
>
> \[ \] I couldn=t get an appointment
>
> \[ \] My baby was too sick to go for routine care
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**Used by: AR Q 67, FL Q 67, IL Q 62, LA Q 66, ME Q 65, OH Q 65**

**State-developed**

**AL Q 64**

> How old was your baby when he or she went for his or her first routine
> well baby care visit?
>
> \_\_\_\_\_ Weeks old
>
> \[ \] Less than 1 week
>
> \[ \] My baby has never had a routine well baby care visit

**ME Q 66**

> How are your baby=s visits for routine well baby care paid for?
> **Check all that apply.**
>
> \[ \] Medicaid
>
> \[ \] Personal income (cash, check, or credit card)
>
> \[ \] Health insurance
>
> \[ \] Military
>
> \[ \] They are not paid for, I still owe money on my bill

**NM Q 67**

> Has your new baby gone to a clinic for his or her first baby shots
> (immunizations)?
>
> \[ \] No
>
> \[ \] Yes

**WA Q 64**

> When did you know where you would take your baby for his or her first
> well baby checkup?
>
> \[ \] During my pregnancy
>
> \[ \] At the time of my delivery
>
> \[ \] After I left the hospital or birthing center
>
> \[ \] I still don=t know

**12. INFANT STATUS**

**Core**

**Q 41** Is your baby alive now?

> \[ \] No \-\-\-\--\>When did your baby die?
> \_\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_
>
> month day year
>
> \[ \] Yes \-\-\-\--\>Is your baby living with you now? \[ \] No
>
> \[ \] Yes

**13. INJURY PREVENTION**

**Standard**

**Q 21** Listed below are some things about safety. **For each thing,
circle Y(Yes) if it applies to you or N(No) if it does not apply to
you.**

> **No Yes**
>
> a\. My infant was brought home from the hospital in an
>
> infant car seat N Y
>
> b\. My baby always rides in an infant car seat N Y
>
> c\. My home has a working smoke alarm N Y
>
> d\. There are loaded guns, rifles, or other firearms in my home N Y

**Used by: AK Q 66, AL Q 65, FL Q 69, GA Q 63, IN Q 66, LA Q 62, NC Q
67, NY Q 63, OH Q 66, WV Q 64**

**Modifications:**

> **AL** - Does not use the option AMy baby always rides in an infant
> car seat@
>
> **AK** - Does not use the option AThere are loaded guns, rifles, or
> other firearms in my home@
>
> **IN** - Does not use the option AMy infant was brought home from the
> hospital in an infant car seat@
>
> Adds the option AThe electrical outlets are child-proof in my home@

**NC** - Adds the options AThere are guns, rifles, or other firearms in
my home@,

AThere are loaded guns, rifles, or other firearms with trigger locks in
my home@,

AThere is a member of my household who smokes inside my home@

**State-Developed**

**AL Q 66**

> How often does your baby ride in an infant car seat? **Check the best
> answer.**
>
> \[ \] Always
>
> \[ \] Almost always
>
> \[ \] Sometimes
>
> \[ \] Never

**CO Q 63**

> Listed below are some things that describe the place where you live.
> **For each thing, circle Y(Yes) if it applies to you, circle N(No) if
> it does not apply to you, or circle DK(Don=t Know) if you don=t
> know.**
>
> **No Yes Don=t Know**
>
> a\. My hot water heater temperature is set at 120F
>
> or lower N Y DK
>
> b\. My home has a working smoke alarm N Y DK

**CO Q 64**

> Listed below are some things that describe the care of your new baby.
> **For each thing, circle A if it always applies to you, circle S if it
> sometimes applies to you, or circle N if it never applies to you.**
>
> **Never Sometimes Always**
>
> a\. My new baby rides in an infant car seat N S A
>
> b\. My new baby rides in an infant car seat
>
> that faces the rear window of the car,
>
> truck, or van N S A
>
> c\. My new baby rides in an infant car seat
>
> in the back seat of the car, truck, or van N S A
>
> d\. My new baby takes a bottle to bed N S A
>
> e\. My new baby sleeps on something soft,
>
> like a fluffy blanket or comforter, soft
>
> pillow, featherbed, or sheepskin N S A
>
> f\. My new baby sleeps in the same bed
>
> with me N S A
>
> g\. I test the temperature of the bath water
>
> when I give my new baby a bath N S A

**WA Q 65**

> Listed below are some statements about safety. **For each thing listed
> below, circle Y(Yes) if it applies to you, N(No) if it does not apply
> to you, or DK(don=t know) if you are unsure.**
>
> **No Yes Don=t Know**
>
> a\. My home has a working smoke alarm that
>
> has been tested in the past year N Y DK
>
> b\. My hot water heater has been turned down
>
> or set to 120 F or below N Y DK
>
> c\. The last time my baby rode in a car he or
>
> she was in a car safety seat N Y DK

**WA Q 66**

> a\. Do you have any guns, rifles, or firearms in your home?
>
> \[ \] No \-\-\-\--\>**Go to Page 15**
>
> \[ \] Yes
>
> \[ \] I don=t know \-\-\-\--\>**Go to Page 15**
>
> b\. Are any of these guns kept loaded?
>
> \[ \] No
>
> \[ \] Yes
>
> \[ \] I don=t know
>
> c\. Are all of these guns stored in locked cabinets and storage areas?
>
> \[ \] No
>
> \[ \] Yes
>
> \[ \] I don=t know
>
> d\. Are there trigger locks on these guns?
>
> \[ \] No
>
> \[ \] Yes
>
> \[ \] I don=t know

***See also: Core Q 16 in section 24B, Prenatal Care, Content***

> ***State-Developed NY Q 53e-f in section 24B, Prenatal Care,
> Content***

**14. INTENDEDNESS OF PREGNANCY**

**Core**

**Q 5** Thinking back to ***just before*** you got pregnant, how did you
feel about becoming pregnant? **Check the best answer.**

> \[ \] I wanted to be pregnant sooner
>
> \[ \] I wanted to be pregnant later
>
> \[ \] I wanted to be pregnant then
>
> \[ \] I didn=t want to be pregnant then or at any time in the future
>
> \[ \] I don=t know

**State-Developed**

**OK Q 55**

> ***Just before*** you became pregnant with your baby, would you say
> you probably wanted to become pregnant at that time or probably not?
> **Check the best answer.**
>
> \[ \] I probably did not want to become pregnant at that time
>
> \[ \] I didn=t mind if I became pregnant at that time
>
> \[ \] I probably wanted to become pregnant at that time
> \-\-\-\--\>**Go to Question 57**

**OK Q 56**

> Did you become pregnant with your new baby ***sooner*** than you
> wanted? **Check the best answer.**
>
> \[ \] No, I did not become pregnant sooner than I wanted
>
> \[ \] Yes, I became pregnant sooner than I wanted \-\-\-\--\>How much
> sooner?
>
> \_\_\_\_\_ Months \_\_\_\_\_Years
>
> \[ \] I did not want to become pregnant then or at any time in the
> future

**OK Q 57**

> Thinking back to ***just before*** you got pregnant with your new
> baby, how did the baby=s father feel about you becoming pregnant?
> **Check the best answer.**
>
> \[ \] He wanted me to be pregnant sooner
>
> \[ \] He wanted me to be pregnant later
>
> \[ \] He wanted me to be pregnant then
>
> \[ \] He didn=t want me to be pregnant then or at any time in the
> future
>
> \[ \] It didn=t matter to him when I became pregnant
>
> \[ \] I don=t know

**WA Q 53**

> Thinking back to just before you got pregnant, how did your husband or
> partner feel about you becoming pregnant?
>
> \[ \] My husband or partner wanted me to be pregnant then
>
> \[ \] My husband or partner wanted me to be pregnant sooner
>
> \[ \] My husband or partner wanted me to be pregnant later
>
> \[ \] My husband or partner didn=t want me to be pregnant then or at
> any time in the future

\[ \] It didn=t matter to my husband or partner when I became pregnant

\[ \] I don=t know

\[ \] I didn=t have a husband or partner

**15. KNOWLEDGE OF PREGNANCY STATUS**

**Core**

**Q 4** How many weeks or months pregnant were you when you were
***sure*** you were pregnant? (For example, you had a pregnancy test or
a doctor or nurse said you were pregnant.)

> \_\_\_\_\_ Weeks or \_\_\_\_\_ Months
>
> \[ \] I don=t remember

**16. LEAD EXPOSURE**

**State-Developed**

**FL Q 73**

> About what year was the place you live in built?
>
> \[ \] 1955 or earlier
>
> \[ \] 1956 - 1978
>
> \[ \] 1979 - present
>
> \[ \] I don=t know

**17. LENGTH OF STAY**

**A. INFANT**

**Core**

**Q 38** When your baby was born, how many nights did he or she stay in
the hospital?

> \_\_\_\_\_ Nights
>
> \[ \] My baby did not stay overnight in the hospital
>
> \[ \] My baby was not born in a hospital

***See also: Core Q 39 in section 19, Morbidity, Infant***

**B. MATERNAL**

**Core**

**Q 36** When did you go into the hospital to have your baby?

> \_\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_
>
> month day year
>
> \[ \] I did not have my baby in a hospital

**Q 37** When you had your baby, how many nights did you stay in the
hospital?

> \_\_\_\_\_ Nights
>
> \[ \] I did not stay overnight in the hospital
>
> \[ \] I did not have my baby in a hospital

**State-Developed**

**OK Q 66**

> ***After*** your new baby was born, how many hours or days did
> ***you*** stay in the hospital?
>
> \_\_\_\_\_Hours or \_\_\_\_\_Days
>
> \[ \] I did not have my baby in a hospital

**WA Q 60**

> How long ***after your baby=s birth*** did you stay in the hospital or
> birthing center?
>
> \[ \] Less than 12 hours
>
> \[ \] 12 - 24 hours
>
> \[ \] 2 days (25 - 48 hours)
>
> \[ \] 3 - 4 days (49 - 96 hours)
>
> \[ \] More than 4 days (more than 96 hours)
>
> \[ \] I did not deliver my baby in a hospital or birthing center

**18. MENTAL HEALTH**

**Standard**

**Q 44** How would you describe the time during your pregnancy? **Check
the best answer.**

> \[ \] One of the happiest times of my life
>
> \[ \] A happy time with few problems
>
> \[ \] A moderately hard time
>
> \[ \] A very hard time
>
> \[ \] One of the worst times of my life

**Used by: CO Q 65, NC Q 68, NY Q 65**

**Q 45** In the months after your delivery, would you say that you
were\-\--

> **Check the best answer.**
>
> \[ \] Not depressed at all
>
> \[ \] A little depressed
>
> \[ \] Moderately depressed
>
> \[ \] Very depressed
>
> \[ \] Very depressed and had to get help

**Used by: CO Q 66, NC Q69, NY Q 66, UT Q 60**

**Q 46** At any time during your pregnancy or after delivery, did a
doctor, nurse, or other health worker talk with you about Ababy blues@
(postpartum depression)?

> \[ \] No
>
> \[ \] Yes

**Used by: CO Q 67**

**State-Developed**

**GA Q 68**

> ***During*** your most recent pregnancy, did you ever feel depressed
> or lose interest in almost all activities every day for at least two
> weeks?
>
> \[ \] No
>
> \[ \] Yes

**GA Q 69**

> ***Since*** you had your new baby, have you ever felt depressed or
> lost interest in almost all activities every day for at least two
> weeks?
>
> \[ \] No
>
> \[ \] Yes

**NM Q 54**

> The next question is about how you felt during the first 3 months of
> your most recent pregnancy. **For each thing, circle Y(Yes) if you
> felt this way or N(No) if you did not.**
>
> **No Yes**
>
> Did you ever feel\-\--
>
> a\. My life was determined by my own actions N Y
>
> b\. I could do just about anything I set my mind to do N Y
>
> c\. Sometimes I was being pushed around in life N Y
>
> d\. Often helpless in dealing with problems of life N Y
>
> e\. Little control over the things that happened to me N Y

***See also: State-Developed WA Q 56a in section 24B, Prenatal Care,
Content***

**19. MORBIDITY**

**A. INFANT**

**Core**

**Q39** When your baby was born, was he or she put in an intensive care
unit?

\[ \] No

\[ \] Yes

\[ \] I don=t know

**State-Developed**

**FL Q 65**

> Since your new baby=s birth, has he or she had to go back and stay at
> least one night in the hospital for any kind of a problem?
>
> \[ \] No
>
> \[ \] Yes

**OK Q 67**

> In the ***first week*** after your baby was born, was he or she
> readmitted to the hospital? **Check the best answer.**
>
> \[ \] My baby died before 1 week of age without leaving the hospital
>
> \[ \] No, my baby was not readmitted in the first week
>
> \[ \] Yes, my baby was readmitted in the first week
>
> \[ \] My baby was still in the hospital 1 week after he or she was
> born

**B. MATERNAL**

**Core**

**Q 27** ***Not counting*** the time you went to the hospital to have
your baby, how many ***other*** times during your pregnancy did you go
into a hospital and stay ***at least one night?***

> \[ \] None \-\-\-\--\>**Go to Question 30**
>
> \[ \] 1 time
>
> \[ \] 2 times
>
> \[ \] 3 times
>
> \[ \] 4 times or more

**Q 28** What problems caused you to stay in the hospital? **Check all
of the problems that you had.**

> \[ \] Labor pains more than 3 weeks before my due date. (Premature
> labor)
>
> \[ \] High blood pressure (preeclampsia or toxemia)
>
> \[ \] Vaginal bleeding or placenta problems
>
> \[ \] Nausea, vomiting or dehydration
>
> \[ \] Kidney or bladder infection
>
> \[ \] High blood sugar (diabetes)
>
> \[ \] Other \-\-\-\--\>Please tell us: \_\_\_\_\_\_\_\_\_\_

**Q 29** How many months pregnant were you the ***first*** time you had
to go into a hospital and stay at least one night?

> \_\_\_\_\_ Months

**Standard**

**Q 37** After you delivered your baby and went home from the hospital,
did you have to go back and stay at least one night for any kind of
problem?

> \[ \] No \-\-\-\--\>**Go to Question** \_\_\_\_\_
>
> \[ \] Yes

**Used by: ME Q 58, NY Q 58, WV Q 61**

**Modifications:**

> **ME** - Does not skip this question if baby not alive or not living
> with mom. ME also does not use Std Q 39 - Baby=s age in weeks at mom=s
> postpartum hospitalization.

**Q 38** Why did you have to go back into the hospital?

> \[ \] Vaginal bleeding
>
> \[ \] Fever or infection
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**Used by: ME Q 59, NY Q 59, WV Q 62**

**Modifications:**

> **ME** - Does not skip this question if baby not alive or not living
> with mom. ME also does not use Std Q 39 - Baby=s age in weeks at mom=s
> postpartum hospitalization.

**Q 39** How many weeks old was your baby the ***first*** time you had
to go back to the hospital after your delivery and stay at least one
night?

> \_\_\_\_\_ Weeks old

**Used by: NY Q 60, WV Q 63**

**Modifications:**

> **NY** - Adds the option ALess than one week old@

**State-Developed**

**NC Q 62**

Did you have any vaginal infections (for example, yeast, vaginosis, or
STDs) during your

most recent pregnancy?

\[ \] No \-\-\-\--\> Go to Question 65

\[ \] Yes

\[ \] I don=t know

**NC Q 63**

What kind of vaginal infection did you have during your most recent
pregnancy? **Check**

**all that apply.**

\[ \] Yeast

\[ \] Vaginosis

\[ \] Chlamydia

\[ \] Gonorrhea

\[ \] Other vaginal infection \-\-\-\--\> Please tell us:
\_\_\_\_\_\_\_\_

\[ \] I don=t know

**NC Q 64**

Did you ask a doctor, nurse, or health care worker for advice or
treatment for your

vaginal infection?

\[ \] No

\[ \] Yes

**NM Q 55**

> During your pregnancy, did a doctor, nurse, or other health care
> worker treat you for any of these problems? **Check all that apply.**
>
> \[ \] Diabetes I had ***before*** this pregnancy
>
> \[ \] Diabetes I had ***during*** this pregnancy
>
> \[ \] High blood pressure
>
> \[ \] An infection in the vagina (birth canal)
>
> \[ \] A bladder or kidney infection
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_
>
> \[ \] I had no problem needing treatment

**NM Q 64**

> Since your delivery, did you see a doctor, nurse, or midwife for
> yourself for any of these reasons? **Check all that apply.**
>
> \[ \] I received a routine check-up (6 weeks postpartum, after
> delivery)
>
> \[ \] I received care for a health problem
>
> \[ \] I received a birth control method
>
> \[ \] I did not see anyone

***See also: Standard Q 37 in section 17B, Length of Stay, Maternal***

> ***State-Developed AL Q 70 in section 22, Physical Activity and Work
> During Pregnancy***
>
> ***State-Developed GA Q 67 in section 22, Physical Activity and Work
> During Pregnancy***

***State-Developed NC Q 54e in section 24B, Prenatal Care, Content***

> ***State-Developed OK Q 66 in section 17, Length of Stay, Maternal***
>
> ***State-Developed WA Q 60 in section 17, Length of Stay, Maternal***

**20. ORAL HEALTH**

**Standard**

**Q 48** This question is about care of your teeth during your most
recent pregnancy. **For each thing, circle Y(Yes) if it is true or N(No)
if it is not true.**

> **No Yes**
>
> a\. I needed to see a dentist for a problem N Y
>
> b\. I went to a dentist or dental clinic N Y
>
> c\. A dental or other health care worker talked with me about
>
> how to care for my teeth and gums N Y

**Used by: IL Q 57, LA Q 55, NM Q 56**

**Modifications:**

> **NM** - Respondents check all that apply rather than choosing Yes/No
> for each statement. NM also adds the option AI did not go for dental
> care@.

***See also: Standard Q 18 in section 30, Social Services; AR
modification***

**21. PARENT AND INFANT CHARACTERISTICS**

**A. INFANT DEMOGRAPHICS**

**Core**

**Q 34** When was your baby due?

> \_\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_
>
> month day year

**Q 35** When was your baby born?

> \_\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_
>
> month day year

**B. MATERNAL DEMOGRAPHICS**

**Core**

**Q 18** ***Just before*** you got pregnant, how much did you weigh?

> \_\_\_\_\_Pounds
>
> \[ \] I don=t know

**Q 19** How tall are you without shoes?

> \_\_\_\_\_Feet \_\_\_\_\_Inches

**Q 52** What is *your* date of birth?

> \_\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_
>
> month day year

**State-Developed**

**IN Q 54, OK Q 62**

> How much weight did you gain during your pregnancy?
>
> \_\_\_\_\_Pounds
>
> \[ \] I lost weight during my pregnancy
>
> \[ \] I don=t know

**NM Q 53**

> How much weight did you ***gain*** during your pregnancy? **Give your
> best guess, even if you are not very sure. Use the measure you know
> best.**
>
> \_\_\_\_\_Pounds or \_\_\_\_\_Kilograms
>
> \[ \] I lost weight
>
> \[ \] I don=t know

**NM Q 57**

> What language(s) do you speak at home on a daily basis? **Check all
> that apply.**
>
> \[ \] English
>
> \[ \] Spanish
>
> \[ \] A Pueblo language
>
> \[ \] Navajo
>
> \[ \] Other \-\-\-\--\>Pleas tell us:\_\_\_\_\_\_\_\_\_\_

**NM Q 58**

> New Mexico has many cultures. Please tell us about your experience
> with cultural beliefs and activities. **For each thing, circle Y(Yes)
> if it is true or N(No) if it is not.**
>
> **No Yes**
>
> a\. I have regular contact with people outside my family who
>
> share my cultural background N Y
>
> b\. I believe it is important for my children to know about and
>
> take part in activities traditional to my culture N Y
>
> c\. I eat foods that are traditional to my culture at least every
>
> week N Y

**C. PATERNAL DEMOGRAPHICS**

**Standard**

**Q 27** When you got pregnant, how old was your new baby=s father?

> \_\_\_\_\_ Years old
>
> \[ \] I don=t know

**Used by: AR Q 64, GA Q 55, ME Q 55, OK Q 65**

**State-Developed**

**FL Q 62**

> When your new baby was born, how old was you new baby=s father?
>
> \_\_\_\_\_Years old
>
> \[ \] I don=t know

**D. PARENTAL RELATIONSHIP STATUS**

**Standard**

**Q 28** When you got pregnant, did your new baby=s father live with
you?

> \[ \] No
>
> \[ \] Yes

**Not currently in use**

**Q 29** When you got pregnant, what relationship did you have with your
baby=s father?

> \[ \] He was my husband (legally married)
>
> \[ \] He was my partner (not legally married)
>
> \[ \] He was my boyfriend
>
> \[ \] He was a friend
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**Used by: AR Q 65, CO Q 62, GA Q 56**

**State-Developed**

**GA Q 57**

> Did your new baby=s father live with you *at any time* during the past
> twelve months?
>
> \[ \] No
>
> \[ \] Yes

**OK Q 64**

> Were you married when you got pregnant?
>
> \[ \] No
>
> \[ \] Yes

**22. PHYSICAL ACTIVITY AND WORK**

**State-Developed**

**AL Q 68**

> Did you work for pay at least ten hours per week during your
> pregnancy?
>
> \[ \] Yes
>
> \[ \] No \-\-\-\--\>**Go to Question 70**

**AL Q 69**

> What was the last month of your pregnancy that you worked?
>
> \[ \] First, second, or third month
>
> \[ \] Fourth month
>
> \[ \] Fifth month
>
> \[ \] Sixth month
>
> \[ \] Seventh month
>
> \[ \] Eighth month
>
> \[ \] Ninth month

**AL Q 70**

> Did any of these things happen to you during your pregnancy? **For
> each thing, check Y(Yes) if it happened to you or N(No) if it did not
> happen to you.**
>
> **No** **Yes**
>
> a\. My doctor or nurse told me to stop going to work N Y
>
> b\. I had early labor N Y
>
> c\. I had high blood pressure N Y
>
> d\. I had bleeding in early pregnancy N Y
>
> e\. I had tiredness or work-related stress N Y
>
> f\. I had swelling in my ankles, hands, face or elsewhere N Y

**GA Q 64**

> During your most recent pregnancy, did you work for pay for 10 hours
> or more per week?
>
> \[ \] No \-\-\-\--\>**Go to Question 68**
>
> \[ \] Yes

**GA Q 65**

> What was the last month of your pregnancy that you worked for pay for
> 10 hours or more per week? **Check only one answer.**
>
> \[ \] First, second, or third month
>
> \[ \] Fourth month
>
> \[ \] Fifth month
>
> \[ \] Sixth month
>
> \[ \] Seventh month
>
> \[ \] Eighth month
>
> \[ \] Ninth month

**GA Q 66**

> Did a doctor or nurse tell you that you should stop going to work?
>
> \[ \] No \-\-\-\--\>**Go to Question 68**
>
> \[ \] Yes

**GA Q 67**

> Why did a doctor or nurse tell you that you should stop going to work?
> **Check all that apply.**
>
> \[ \] Early or preterm labor
>
> \[ \] High blood pressure
>
> \[ \] Vaginal bleeding
>
> \[ \] Swelling, water retention, or edema
>
> \[ \] Tiredness or work-related stress
>
> \[ \] Twins or multiple births
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**NM Q 59**

> Which of the following things were you doing in the past month?
> **Check all that apply.**
>
> \[ \] Being a homemaker
>
> \[ \] Working full-time or part-time
>
> \[ \] Going to school full-time or part-time
>
> \[ \] Unemployed, looking for a job
>
> \[ \] Unemployed, not looking for a job
>
> \[ \] Seasonal farm or construction work
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**NY Q 64**

> During the ***3 months before*** your baby was born, did you do any of
> these things ***4 or more times per week?***
>
> No Yes
>
> a\. Exercise for at least 20 minutes at a time N Y
>
> b\. Stand for more than 2 hours at a time N Y
>
> c\. Climb 2 flights of stairs or more at a time N Y
>
> d\. Carry 20 pounds or more at a time N Y

**23. PRE-CONCEPTION READINESS**

**State-Developed**

**IN Q 53**

> ***Before*** you became pregnant with this baby, did any of the
> following things happen to you? **For each thing circle Y(Yes) if it
> happened to you or N(No) if it did not happen to you.**
>
> **No Yes**
>
> a\. I had health classes that taught the basics of sex, human
>
> reproduction, sexually transmitted diseases, etc. N Y
>
> b\. I talked to a doctor or nurse about conception and pregnancy N Y
>
> c\. I knew about the effects of drinking alcohol on a developing
>
> fetus during the first weeks of pregnancy N Y
>
> d\. I talked with a doctor about possible genetic disease in my
>
> family or my partner=s family N Y
>
> e\. I had a physical examination during the year before I
>
> became pregnant N Y
>
> f\. I talked with a doctor, nurse, or other health care worker
>
> about spacing the time between my pregnancies N Y
>
> g\. I understood the impact being a parent would have on my life N Y

**OK Q 53**

> ***Before*** you got pregnant with your new baby, did a doctor, nurse,
> or other health care worker talk with you about any of the things
> listed below? **For each thing, circle Y(Yes) if someone talked with
> you about it or N(No) if no one talked with you about it.**
>
> **No Yes**
>
> a\. How smoking could affect a pregnancy N Y
>
> b\. How alcohol use could affect a pregnancy N Y
>
> c\. How your eating habits could affect a pregnancy N Y
>
> d\. How health problems in your family could affect a pregnancy N Y

**NC Q 53**

***Before you knew you were pregnant,*** how frequently did you take
either vitamins

containing folic acid or multivitamins? Check only one.

\[ \] I took them every day

\[ \] I took them, but not every day

\[ \] I did not take them at all

**24. PRENATAL CARE**

**A. BARRIERS**

**Core**

**Q 12** Did any of these things keep you from getting prenatal care as
early as you wanted? **Check all that apply.**

> \[ \] I couldn=t get an appointment earlier in my pregnancy
>
> \[ \] I didn=t have enough money or insurance to pay for my visits
>
> \[ \] I didn=t know that I was pregnant
>
> \[ \] I had no way to get to the clinic or doctor=s office
>
> \[ \] I couldn=t find a doctor or a nurse who would take me as a
> patient
>
> \[ \] I had no one to take care of my children
>
> \[ \] I had too many other things going on
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**State-Developed**

**ME Q 53**

> In addition to anything you may have mentioned earlier, did any of the
> following things keep you from getting prenatal care as early as you
> wanted? **Check all that apply.**
>
> \[ \] I was unsure about where to go for prenatal care
>
> \[ \] I was not eligible for Medicaid and had no other insurance
>
> \[ \] I had Medicaid, but no doctor=s office or clinic would see me

**ME Q 54**

> Did any of the following things keep you from having as many visits
> for prenatal care as you wanted? **Check all that apply.**
>
> \[ \] I had as many visits as I wanted \-\-\-\--\>**Go to Question
> 55**
>
> \[ \] I had no one to take care of my children
>
> \[ \] I had no way to get to the clinic or doctor=s office
>
> \[ \] I didn=t have enough money or insurance to pay for my visits
>
> \[ \] I still owed on an old bill

\[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_\_\_

**B. CONTENT**

**Core**

**Q 16** During any of your prenatal care visits, did a doctor, nurse,
or other health care worker talk with you about any of the things listed
below? **For each thing, please circle Y(Yes) if someone talked with you
about it or circle N(No) if no one talked with you about it.**

> **No Yes**
>
> a\. What you should eat during your pregnancy N Y
>
> b\. How smoking during pregnancy could affect your baby N Y
>
> c\. Breast-feeding your baby N Y
>
> d\. How drinking alcohol during pregnancy could affect
>
> your baby N Y
>
> e\. Using a seat belt during your pregnancy N Y
>
> f\. Birth control methods to use after your pregnancy N Y
>
> g\. The kinds of medicines that were safe to take during your
>
> pregnancy N Y
>
> h\. How using illegal drugs could affect your baby N Y
>
> i\. How your baby grows and develops during pregnancy N Y
>
> j\. What to do if your labor starts early N Y
>
> k\. How to keep from getting HIV (the virus that causes AIDS) N Y
>
> l\. Getting your blood tested for HIV (the virus that causes AIDS) N Y
>
> m\. Physical abuse to women by their husbands or partners N Y

**Standard**

**Q 11** At any time during your prenatal care, did a doctor, nurse, or
other health care worker talk with you about diseases or birth defects
that could run in your family?

> \[ \] No
>
> \[ \] Yes

**Used by: AR Q 54, LA Q 53, NC Q 54a, UT 53a, WA Q 56c**

**Modifications:**

**NC** - Q 54 is a compilation of standard questions 11, 12, 13, and two
state-developed

questions (NC Q 54d,e). The question is modified to read AAt any time
during

your prenatal care, did a doctor, nurse, or other health care worker
talk with you

about any of the following? **For each thing, circle Y (Yes) if someone
talked**

**with you about it or N (No) if no one talked with you about it.**@

> **UT -** Q 53 is a compilation of standard questions 11-15, asked in
> list format.
>
> **WA** - Q 56 is a compilation of one state-developed question and
> standard questions 13, 11, and 12, in that order. The question is
> modified to read AAt any time during your pregnancy did a doctor,
> nurse, or other health care worker talk to you about the following
> things? **For each thing listed below, circle Y(Yes) if it applies to
> you, N(No) if it does not apply to you, or DK(Don=t Know) if you are
> unsure.**@

**Q 12** At any time during your prenatal care, did a doctor, nurse, or
other health care worker talk with you about doing tests to see if your
baby had a birth defect or genetic disease?

> \[ \] No
>
> \[ \] Yes

**Used by: AR Q 55, NC Q 54b, OK Q 61, UT Q 53b, WA Q 56d**

**Modifications:**

**NC** - Q 54 is a compilation of standard questions 11, 12, 13, and two
state-developed

questions (NC Q 54d,e). The question is modified to read AAt any time
during

your prenatal care, did a doctor, nurse, or other health care worker
talk with you

about any of the following? **For each thing, circle Y (Yes) if someone
talked**

**with you about it or N (No) if no one talked with you about it.**@

> **UT -** Q 53 is a compilation of standard questions 11-15, asked in
> list format.
>
> **WA** - Q 56 is a compilation of one state-developed question and
> standard questions 13, 11, and 12, in that order. The question is
> modified to read AAt any time during your pregnancy did a doctor,
> nurse, or other health care worker talk to you about the following
> things? **For each thing listed below, circle Y(Yes) if it applies to
> you, N(No) if it does not apply to you, or DK(Don=t Know) if you are
> unsure.**@

**Q 13** At any time during your prenatal care, did a doctor, nurse, or
other health care worker talk with you about how much weight you should
gain during your pregnancy?

> \[ \] No
>
> \[ \] Yes

**Used by: AL Q 54, AR Q 56, MI Q 53, NC Q 54c, UT Q 53c, WA Q 56b**

**Modifications:**

> **AL-** Modifies the AYes@ response to read AYes\-\-\-\--\>How many
> pounds did he or she recommend that you gain? \_\_\_\_\_Pounds@

**NC** - Q 54 is a compilation of standard questions 11, 12, 13, and two
state-developed

questions (NC Q 54d,e). The question is modified to read AAt any time
during

your prenatal care, did a doctor, nurse, or other health care worker
talk with you

about any of the following? **For each thing, circle Y (Yes) if someone
talked**

**with you about it or N (No) if no one talked with you about it.**@

> **UT -** Q 53 is a compilation of standard questions 11-15, asked in
> list format.
>
> **WA** - Q 56 is a compilation of one state-developed question and
> standard questions 13, 11, and 12, in that order. The question is
> modified to read AAt any time during your pregnancy did a doctor,
> nurse, or other health care worker talk to you about the following
> things? **For each thing listed below, circle Y(Yes) if it applies to
> you, N(No) if it does not apply to you, or DK(Don=t Know) if you are
> unsure.**@

**Q 14** At any time during your prenatal care, did a doctor, nurse, or
other health care worker ask if you were smoking?

> \[ \] No
>
> \[ \] Yes

**Used by: AR Q 57, IL Q 54, LA Q 54, OH Q 53, UT Q 53d**

**Modifications:**

> **UT -** Q 53 is a compilation of standard questions 11-15, asked in
> list format.

**Q 15** At any time during your prenatal care, did a doctor, nurse, or
other health care worker ask if you were drinking alcoholic beverages
(beer, wine, wine cooler, or liquor)?

> \[ \] No
>
> \[ \] Yes

**Used by: AR Q 58, IL Q 55, OH Q 54, UT Q 53e**

**Modifications:**

> **UT -** Q 53 is a compilation of standard questions 11-15, asked in
> list format.

**State-Developed**

**NC Q 54d,e**

NC Q 54 is a compilation of standard questions 11, 12, 13, and two
state-

developed questions. The question is modified to read AAt any time
during your

prenatal care, did a doctor, nurse, or other health care worker talk
with you about

any of the following? **For each thing, circle Y (Yes) if someone talked
with**

**you about it or N (No) if no one talked with you about it.**@

**No Yes**

d\. Placing your baby to sleep on his or her back or side N Y

e\. How vaginal infection (for example, yeast, vaginosis, STDs)

may be related to the baby being born prematurely N Y

**NY Q 53**

> This question is about things that a doctor, nurse, or other health
> worker might have talked with you about when you went for prenatal
> care during your most recent pregnancy. **For each thing, circle
> Y(Yes) if someone talked with you about it or N(No) if they did not.**
>
> **No Yes**
>
> a\. Diseases or birth defects that can run in families N Y
>
> b\. How long to wait before having another baby N Y
>
> c\. Finding a doctor or nurse practitioner to care for your baby N Y
>
> d\. When your baby should go in for a health checkup N Y
>
> e\. Using a car safety seat for your baby N Y
>
> f\. Having a working smoke alarm in your home N Y

**WA Q 56a**

Q 56 is a compilation of standard questions 46, 13, 11, and 12, in that
order. The

question is modified to read AAt any time during your pregnancy did a
doctor,

nurse, or other health care worker talk to you about the following
things? **For each**

**thing listed below, circle Y(Yes) if it applies to you, N(No) if it
does not apply**

**to you, or DK(Don=t Know) if you are unsure.**@

***See also: State-Developed AK Q 54 in section 1A, Abuse, Physical***

> ***State-Developed AL Q 55 in section 7, HIV***
>
> ***State-Developed FL Q 54 in section 30, Social Services***

**C. LOCATION**

**Core**

**Q 14** Where did you go ***most of the time*** for your prenatal
visits? **Don=t include visits for WIC. Check one answer.**

> \[ \] Hospital clinic
>
> \[ \] Health department clinic
>
> \[ \] Private doctor=s office
>
> \[ \] *State Option*
>
> \[ \] *State Option*
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**D. SATISFACTION**

**Core**

**Q 11** Did you get prenatal care as early in your pregnancy as you
wanted?

> \[ \] No
>
> \[ \] Yes \-\-\-\--\>**Go to Question 13**
>
> \[ \] I did not want prenatal care \-\-\-\--\>**Go to Question 13**

**Standard**

**Q 10** We would like to know how you felt about the prenatal care you
got during your most recent pregnancy. If you went to more than one
place for prenatal care, answer for the place where you got ***most***
of your care. **For each thing, circle Y(Yes) if you were satisfied or
N(No) if you were not satisfied.**

> **No Yes**
>
> Were you satisfied with\-\--
>
> a\. The amount of time you had to wait after you arrived for
>
> your visits N Y
>
> b\. The amount of time the doctor or nurse spent with you
>
> during your visits N Y
>
> c\. The advice you got on how to take care of yourself N Y
>
> d\. The understanding and respect that the staff showed toward
>
> you as a person N Y

**Used by: AR Q 53, CO Q 53, IL Q 53, MI Q 54**

**State-Developed**

**FL Q 53**

> How satisfied were you with the prenatal care you got during your most
> recent pregnancy? **If you went to more than one place for prenatal
> care, answer for the place where you got most of your care.**
>
> \[ \] Very satisfied
>
> \[ \] Somewhat satisfied
>
> \[ \] Somewhat dissatisfied
>
> \[ \] Very dissatisfied

**IN Q 55**

> We are interested in ways to improve prenatal care. **For each thing,
> circle Y(Yes) if you think it would be an important way to make
> prenatal care better or N(No) if you think it would not be.**
>
> **No Yes**
>
> a\. To see the same doctor throughout pregnancy N Y
>
> b\. To be told of what to expect during delivery N Y
>
> c\. To be told how to recognize preterm labor N Y
>
> d\. To have more time to ask questions N Y
>
> e\. To have a doctor or nurse of the same racial/ethnic background N Y

**E. VISITS AND TIMING OF VISITS**

**Core**

**Q 10** How many weeks or months pregnant were you when you had your
first visit for prenatal care? **Don=t count a visit that was only for a
pregnancy test or only for WIC (Women, Infants, and Children=s Nutrition
Program).**

> \_\_\_\_\_Weeks or \_\_\_\_\_Months
>
> \[ \] I did not go for prenatal care

**Q 13** During each month of your pregnancy, about how many visits for
prenatal care did you have? **If you don=t know exactly how many, please
give us your best guess. Don=t count visits for WIC. It may help to use
the calendar.**

> [Month of Pregnancy]{.underline} [How many visits?]{.underline}
>
> First month \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Second month \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Third month \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Fourth month \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Fifth month \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Sixth month \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Seventh month \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Eighth month \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Ninth month \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \[ \] I did not go for prenatal care \-\-\-\--\>**Go to Question 17**

***See also: Section 6, Health Insurance, for all questions dealing with
payment for prenatal care***

**25. QUESTIONNAIRE DETAILS**

**Core**

**Q 51** What is today=s date?

> \_\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_
>
> month day year

**26. REPRODUCTIVE HISTORY**

**A. AGE AT MENARCHE AND CONCEPTION OF FIRST BIRTH**

**Standard**

**Q 30** How old were you when you had your first menstrual period?

> \_\_\_\_\_Years old

**Used by: WV Q 55**

**Q 31** How old were you when you got pregnant with your *first* baby?

> \_\_\_\_\_Years old

**Used by: AL Q 56, IN Q 58, LA Q 56, SC Q 53, WV Q 56**

**State-Developed**

**FL Q 58**

> How old were you when you had your first baby?
>
> \_\_\_\_\_Years old

**OK Q 70**

> When your first baby was born\...
>
> a\. How old were you? \_\_\_\_\_Years old
>
> b\. How old was the baby=s father? \_\_\_\_\_Years old

**B. PREVIOUS PREGNANCY OUTCOME**

**Core**

**Q 1** Before your new baby, did you ever have any other babies who
were born alive?

> \[ \] No \-\-\-\--\>**Go to Question 4**
>
> \[ \] Yes

**Q 2** Did the baby just before your new one weigh 5 pounds, 8 ounces
***or less*** at birth?

> \[ \] No
>
> \[ \] Yes

**Q 3** Was the baby just before your new one born ***more*** than 3
weeks before its due date?

> \[ \] No
>
> \[ \] Yes

**27. SCHOOL STATUS**

**State-Developed**

**FL Q 70**

> Are you in school now?
>
> \[ \] No
>
> \[ \] Yes \-\-\-\--\>**Go to Question 72**

**FL Q 71**

> Do you intend to go back to school in the next 6 months?
>
> \[ \] No
>
> \[ \] Yes

**28. SECOND-HAND SMOKE EXPOSURE**

**Core**

**Q 44** About how many hours a day, on average, is your new baby in the
same room with someone who is smoking?

> \_\_\_\_\_Hours
>
> \[ \] My baby is never in the same room with someone who is smoking

**29. SLEEPING BEHAVIORS**

**Core**

**Q 45** How do you put your baby down to sleep ***most*** of the time?
**Check one answer.**

> \[ \] On his or her side
>
> \[ \] On his or her back
>
> \[ \] On his or her stomach

**Standard**

**Q 22** How often does your new baby sleep in the same bed with you?

> \[ \] Always
>
> \[ \] Almost always
>
> \[ \] Sometimes
>
> \[ \] Never

**Used by: AK Q 67, AL Q 67, OH Q 67, WV Q 65**

***See also: State-Developed CO Q 64e-f in section 13, Injury
Prevention***

***State-Developed NC Q54d in section 24B, Prenatal Care, Content***

**30. SOCIAL SERVICES**

**Core**

**Q 17** During your pregnancy, were you on WIC?

> \[ \] No
>
> \[ \] Yes

**Standard**

**Q 18** During your most recent pregnancy, did you get any of these
services? **Circle Y(Yes) if you got the service or N(No) if you did not
get the service.**

> **No Yes**
>
> a\. Childbirth classes N Y
>
> b\. Parenting classes N Y
>
> c\. Classes on how to stop smoking N Y
>
> d\. Visits to your home by a nurse or other health care worker N Y
>
> e\. Food stamps N Y
>
> f\. TANF (Formerly AFDC) N Y

**Used by: AK Q 60, AL Q 60, AR Q 60, GA Q 60, IN Q 65, LA Q 61, NC Q
60, OH Q 56**

**Modifications:**

> **AR** - Adds the option ADental care from a dentist or clinic@
>
> **GA** - Adds the option AInstructions on how to breast-feed@
>
> **IN** - Does not use the option AParenting classes@
>
> Adds the following options: ABreast-feeding classes@, AClasses about
> sick baby care@ and AHelp from an organization such as United Way or
> your church to get baby supplies (diapers, formula, etc.)@

**NC** - Adds the option ATreatment for alcohol or other drugs@

**Q 19** Since you delivered your new baby, have you used any of these
services? **Circle Y(Yes) if you used the service or N(No) if you have
not used the service.**

> *List of services\-\--*

**Not currently in use**

**Q 20** Since your new baby was born, have you used WIC services for
your new baby?

> \[ \] No
>
> \[ \] Yes

**Used by: AK Q 64, AL Q 61, CO Q 61, FL Q 63, ME Q 60, WV Q 59**

**Modifications:**

> **CO** - Doesn=t skip if baby not alive or not with mom

**State-Developed**

**FL Q 54**

> When you went for prenatal care during your most recent pregnancy, did
> a health care worker ask you if you wanted to participate in Healthy
> Start?
>
> \[ \] No
>
> \[ \] Yes
>
> \[ \] I don=t know

**FL Q 55**

> At the place where your new baby was born, did a health care worker
> ask you if you wanted your baby to participate in Healthy Start?
>
> \[ \] No
>
> \[ \] Yes
>
> \[ \] I don=t know

**GA Q 53**

> During your most recent pregnancy, what month of your pregnancy did
> you get on WIC?
>
> \[ \] 1 to 3 months
>
> \[ \] 4 to 6 months
>
> \[ \] 7 to 9 months
>
> \[ \] I was already on WIC when I got pregnant
>
> \[ \] I got on WIC after my baby was born
>
> \[ \] I did not go on WIC

**IN Q 63**

> Are you aware of a family health help line in your community?
>
> \[ \] No
>
> \[ \] Yes

**IN Q 64**

> Are you aware of the Healthy Start program in Lake County?
>
> \[ \] No
>
> \[ \] Yes

**MI Q 61**

> During your most recent pregnancy, did you feel you needed any of the
> following services? **For each thing, circle Y(Yes) if you felt you
> needed the service or N(No) if you did not feel you needed the
> service.**
>
> **No Yes**
>
> Did you need:
>
> a\. Food, money or coupons to buy food, including food stamps,
>
> WIC or Focus Hope N Y
>
> b\. Help with a drug problem N Y
>
> c\. Counseling from a health care worker to help you with your
>
> problems N Y
>
> d\. Extra money to help with paying bills N Y
>
> e\. Help to reduce violence in your home N Y
>
> f\. Help to reduce violence in your community N Y
>
> g\. Help with a ride to the clinic or doctor=s office N Y
>
> h\. Help with housing problems N Y
>
> i\. Help with reading or understanding important information
>
> (for example, directions from your doctor or health provider,
>
> or instructions on medicines) N Y
>
> j\. Childbirth education N Y
>
> k\. Information on how to be a good parent N Y
>
> l\. Help to reduce stress N Y
>
> m\. Help with family problems N Y
>
> n\. Help to quit smoking N Y
>
> o\. Help with or information about breast-feeding N Y
>
> p\. Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**MI Q 62**

> During your most recent pregnancy, did you receive any of the
> following services? **For each thing, circle Y(Yes) if you received
> the service or N(No) if you did not receive the service.**
>
> **No Yes**
>
> Did you receive:
>
> a\. Food, money or coupons to buy food, including food stamps,
>
> WIC or Focus Hope N Y
>
> b\. Help with a drug problem N Y
>
> c\. Counseling from a health care worker to help you with your
>
> problems N Y
>
> d\. Extra money to help with paying bills N Y
>
> e\. Help to reduce violence in your home N Y
>
> f\. Help to reduce violence in your community N Y
>
> g\. Help with a ride to the clinic or doctor=s office N Y
>
> h\. Help with housing problems N Y
>
> i\. Help with reading or understanding important information
>
> (for example, directions from your doctor or health provider,
>
> or instructions on medicines) N Y
>
> j\. Childbirth education N Y
>
> k\. Information on how to be a good parent N Y
>
> l\. Help to reduce stress N Y
>
> m\. Help with family problems N Y
>
> n\. Help to quit smoking N Y
>
> o\. Help with or information about breast-feeding N Y
>
> p\. Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

**NC Q 61**

Please tell us if you have heard of the following North Carolina
programs. **For each**

**program, circle Y (Yes) if you have heard about it or N (No) if you
have not heard**

**about it.**

**No Yes**

a\. First Step Hotline (1-800-FOR BABY) N Y

b\. Smart Start N Y

c\. Baby Love N Y

> d\. Child Service Coordination (CSC) N Y

e\. WIC N Y

f\. Health Check N Y

g\. Child Resource Center N Y

h\. Family Support Network N Y

**NM Q 63**

> ***During*** your pregnancy or ***since*** your delivery, did you
> participate in any of these services? **Check all that apply.**
>
> **During Since**
>
> **Pregnancy Delivery**
>
> a\. Breast-feeding class or support group \[ \] \[ \]
>
> b\. Parenting class or support group \[ \] \[ \]
>
> c\. WIC class or discussion group about nutrition \[ \] \[ \]
>
> d\. Counseling about a personal or family problem \[ \] \[ \]
>
> e\. Home visiting services \[ \] \[ \]
>
> f\. Program for pregnant or parenting teenagers \[ \] \[ \]
>
> g\. Rides from a program to get to a clinic or other services \[ \] \[
> \]
>
> h\. Program for protection from family violence \[ \] \[ \]
>
> i\. Program to stop using drugs or alcohol \[ \] \[ \]
>
> j\. A class or support group to stop smoking \[ \] \[ \]

**NM Q 65**

> If you received home visiting services during your pregnancy or since
> your delivery, who came to see you? **Check all that apply.**
>
> \[ \] Community health worker or promotora
>
> \[ \] A nurse
>
> \[ \] A volunteer from a community program
>
> \[ \] A social worker
>
> \[ \] Tribal community health representative
>
> \[ \] A breast-feeding helper
>
> \[ \] Other \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_

\[ \] I did not receive home visiting services

**NY Q 57**

> During your most recent pregnancy or since your new baby was born,
> have you used any of these services? **For each thing, circle Y(Yes)
> if you used the service or N(No) if you did not use it.**
>
> **No** **Yes**
>
> a\. Parenting classes N Y
>
> b\. Classes on how to stop smoking N Y
>
> c\. Visits to your home by a nurse or other health worker N Y
>
> d\. Advice on how to obtain food (such as food pantries,
>
> soup kitchens) N Y
>
> e\. Counseling about stress, family problems, or mental problems N Y
>
> f\. Help in obtaining transportation N Y
>
> g\. Help in getting housing N Y

**WV Q 53**

> The following are things a doctor, nurse, or other health care worker
> might have talked to you about during your pregnancy or right after
> you had your baby. **For each thing, please circle Y(Yes) if someone
> talked with you about it or N(No) if no one talked with you about
> it.**
>
> **No Yes**
>
> a\. Childbirth education (classes on labor and delivery) N Y
>
> b\. High Risk Birth Score Program N Y
>
> c\. Parenting classes N Y
>
> d\. Right From the Start Program N Y
>
> e\. Immunizations (shots) for your baby N Y
>
> f\. Diabetes (How it may affect you and your baby) N Y

***See also: State-Developed AL Q 62 in section 2, Breast-Feeding***

**31. SOCIAL STRESS**

**Core**

**Q 30** This question is about things that may have happened during the
***12 months before you delivered*** your new baby. This includes the
months before you got pregnant. **For each thing, circle Y(Yes) if it
happened to you or N(No) if it did not. It may help to use the
calendar.**

> **No Yes**
>
> a\. A close family member was very sick and had to go into
>
> the hospital N Y
>
> b\. You got separated or divorced from your husband or partner N Y
>
> c\. You moved to a new address N Y
>
> d\. You were homeless N Y
>
> e\. Your husband or partner lost his job N Y
>
> f\. You lost your job even though you wanted to go on working N Y
>
> g\. You and your husband or partner argued more than usual N Y
>
> h\. Your husband or partner said he did not want you to be
>
> pregnant N Y
>
> i\. You had a lot of bills you couldn=t pay N Y
>
> j\. You were involved in a physical fight N Y
>
> k\. You or your husband or partner went to jail N Y
>
> l\. Someone very close to you had a bad problem with drinking
>
> or drugs N Y
>
> m\. Someone very close to you died N Y

**32. SOCIAL SUPPORT**

**Standard**

**Q 23** During your most recent pregnancy, who would have helped you if
a problem had come up? (For example, who would have helped you if you
needed to borrow \$50 or if you got sick and had to be in bed for
several weeks?) **Check all that apply.**

> \[ \] My husband or partner
>
> \[ \] My mother, father, or in-laws
>
> \[ \] Other family member or relative
>
> \[ \] A friend
>
> \[ \] Someone else \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_
>
> \[ \] No one would have helped me

**Used by: GA Q 54, IN Q 57, SC Q 60, UT Q 54, WA Q 58**

**Modifications:**

> **GA** - Modifies the option AMy husband or partner@ to read AMy
> husband or boyfriend@
>
> Modifies the option AMy mother, father, or in-laws@ to read AMy mother
> or father@
>
> Adds the option AMy brother and sister@

**Q 24** During your most recent pregnancy, would you have had the kinds
of help listed below if you had needed them? **For each thing, circle
Y(Yes) if you would have had this kind of help or N(No) if you would not
have had this kind of help.**

> **No Yes**
>
> a\. Someone to loan me \$50 N Y
>
> b\. Someone to help me if I were sick and needed to be in bed N Y
>
> c\. Someone to take me to the clinic or doctor=s office if I
>
> needed a ride N Y
>
> d\. Someone to talk with about my problems N Y

**Used by: CO Q 59, OH Q 57, SC Q 59, WA Q 57**

**Modifications:**

> **SC** - Adds the following options: ASomeone to help me find a job if
> I needed it@, and ASomeone to help with grocery shopping or house
> cleaning@

**Q 25** Since you delivered your new baby, who would help you if a
problem came up? (For example, who would help you if you needed to
borrow \$50 or you got sick and had to be in bed for several weeks?)
**Check all that apply.**

> \[ \] My husband or partner
>
> \[ \] My mother, father, or in-laws
>
> \[ \] Other family member or relative
>
> \[ \] A friend
>
> \[ \] Someone else \-\-\-\--\>Please tell us:\_\_\_\_\_\_\_\_\_\_
>
> \[ \] No one would help me

**Used by: AK Q 53**

**Q 26** Since you delivered your new baby, would you have the kinds of
help listed below if you needed them? **For each thing, circle Y(Yes) if
you would have this kind of help or N(No) if you would not have this
kind of help.**

> **No Yes**
>
> a\. Someone to loan me \$50 N Y
>
> b\. Someone to help me if I were sick and needed to be in bed N Y
>
> c\. Someone to talk with about my problems N Y
>
> d\. Someone to take care of my baby N Y

**Used by: CO Q 60, NC Q 57, OH Q 58**

**State-Developed**

**NM Q 66**

> Who is helping you raise your new baby? Include those on whom you
> often rely for child care, money, or help with problems. **Check all
> that apply.**
>
> \[ \] My husband or partner
>
> \[ \] My mother, father, or in-laws
>
> \[ \] Other family member or relative
>
> \[ \] A friend
>
> \[ \] Someone else \-\-\-\--\>Please tell us: (**No
> Names**)\_\_\_\_\_\_\_\_\_\_

\[ \] No one (I am raising my baby on my own)

**WA Q 59**

> During your most recent pregnancy, how much emotional support did you
> receive from your husband or partner? **Emotional support includes
> things such as comfort when you are upset or sad, listening to your
> worries and concerns, sharing your joys and sorrows.**
>
> \[ \] As much as I wanted
>
> \[ \] Less than I wanted
>
> \[ \] I didn=t have a husband or partner

**33. VITAMIN USE AND FOLIC ACID**

**Core**

**Q 20** Have you ever heard or read that taking the vitamin folic acid
can help prevent some birth defects?

> \[ \] No
>
> \[ \] Yes

**State-Developed**

**AL Q 53**

> During your pregnancy, about how many days did you take prenatal
> vitamins in an average week?
>
> \[ \] Never
>
> \[ \] 1 - 3 days
>
> \[ \] 4 - 6 days
>
> \[ \] Daily

**NC Q 53**

***Before you knew you were pregnant,*** how frequently did you take
either vitamins

containing folic acid or multivitamins? Check only one.

\[ \] I took them every day

\[ \] I took them, but not every day

\[ \] I did not take them at all

**NC Q 55**

Where did you hear or read that taking the vitamin folic acid can help
prevent some birth

defects? Check all that apply.

\[ \] Doctor, nurse, or other health clinic staff

\[ \] Brochures or literature at health care provider=s office

\[ \] Media, such as magazine, newspaper, radio, or television

\[ \] Other \-\-\-\--\> Please tell us:\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**OK Q 54**

> Were you taking a multivitamin ***daily*** for one month ***before***
> you got pregnant?
>
> \[ \] No
>
> \[ \] Yes

**34. APPENDIX A - STATE-BY-STATE LIST OF TOPICS**

**AK Alaska**

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Abuse, Physical        | Q 54               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Abuse, Sexual          | Q 55               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Breast-Feeding         | Q 65a              | Standard Q 2          |
|                        |                    |                       |
|                        | Q 65b              | Standard Q 3          |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 56               | Standard Q 6          |
| Postpartum             |                    |                       |
|                        | Q 57               | Standard Q 8          |
+------------------------+--------------------+-----------------------+
| Drug Use, Alcohol      | Q 62               | State-Developed       |
|                        |                    |                       |
|                        | Q 63               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Drug Use, Tobacco      | Q 61               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Drug Use, Other        | Q 58a, Q 58b       | State-Developed       |
|                        |                    |                       |
|                        | Q 59a, Q 59b       | State-Developed       |
+------------------------+--------------------+-----------------------+
| Income                 | Q 68a              | State-Developed       |
|                        |                    |                       |
|                        | Q 68b              | Standard Q 43         |
+------------------------+--------------------+-----------------------+
| Injury Prevention      | Q 66               | Standard Q 21         |
+------------------------+--------------------+-----------------------+
| Sleeping Behaviors     | Q 67               | Standard Q 22         |
+------------------------+--------------------+-----------------------+
| Social Services        | Q 60               | Standard Q 18         |
|                        |                    |                       |
|                        | Q 64               | Standard Q 20         |
+------------------------+--------------------+-----------------------+
| Social Support         | Q 53               | Standard Q 25         |
+------------------------+--------------------+-----------------------+

**AL Alabama**

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Breast-Feeding         | Q 62               | State-Developed       |
|                        |                    |                       |
|                        | Q 63               | Standard Q 4          |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 57               | Standard Q 6          |
| Postpartum             |                    |                       |
|                        | Q 58               | Standard Q 7          |
|                        |                    |                       |
|                        | Q 59               | Standard Q 8          |
+------------------------+--------------------+-----------------------+
| HIV                    | Q 55               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Infant Health,         | Q 64               | State-Developed       |
|                        |                    |                       |
| Well Baby Care         |                    |                       |
+------------------------+--------------------+-----------------------+
| Injury Prevention      | Q 65               | Standard Q 21         |
|                        |                    |                       |
|                        | Q 66               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Physical Activity and  | Q 68               | State-Developed       |
| Work                   |                    |                       |
|                        | Q 69               | State-Developed       |
| During Pregnancy       |                    |                       |
|                        | Q 70               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Prenatal Care, Content | Q 54               | Standard Q 13         |
+------------------------+--------------------+-----------------------+
| Reproductive History,  | Q 56               | Standard Q 31         |
| Age at                 |                    |                       |
|                        |                    |                       |
| Menarche and           |                    |                       |
| Conception             |                    |                       |
|                        |                    |                       |
| of First Birth         |                    |                       |
+------------------------+--------------------+-----------------------+
| Sleeping Behaviors     | Q 67               | Standard Q 22         |
+------------------------+--------------------+-----------------------+
| Social Services        | Q 60               | Standard Q 18         |
|                        |                    |                       |
|                        | Q 61               | Standard Q 20         |
+------------------------+--------------------+-----------------------+
| Vitamin Use and Folic  | Q 53               | State-Developed       |
| Acid                   |                    |                       |
+------------------------+--------------------+-----------------------+

**AR Arkansas**\*

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Breast-Feeding         | Q 68               | Standard Q 1          |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 61               | Standard Q 6          |
| Postpartum             |                    |                       |
|                        | Q 62               | Standard Q 7          |
|                        |                    |                       |
|                        | Q 63               | Standard Q 8          |
+------------------------+--------------------+-----------------------+
| HIV                    | Q 59               | Standard Q 47         |
+------------------------+--------------------+-----------------------+
| Income                 | Q 69               | State-Developed       |
|                        |                    |                       |
|                        | Q 70               | Standard Q 43         |
+------------------------+--------------------+-----------------------+
| Infant Health,         | Q 66               | Standard Q 16         |
|                        |                    |                       |
| Well Baby Care         | Q 67               | Standard Q 17         |
+------------------------+--------------------+-----------------------+
| Parent and Infant      | Q 64               | Standard Q 27         |
| Character-             |                    |                       |
|                        |                    |                       |
| istics, Paternal Demo- |                    |                       |
|                        |                    |                       |
| graphics               |                    |                       |
+------------------------+--------------------+-----------------------+
| Parent and Infant      | Q 65               | Standard Q 29         |
| Character-             |                    |                       |
|                        |                    |                       |
| istics, Parental       |                    |                       |
| Relationship           |                    |                       |
|                        |                    |                       |
| Status                 |                    |                       |
+------------------------+--------------------+-----------------------+
| Prenatal Care, Content | Q 54               | Standard Q 11         |
|                        |                    |                       |
|                        | Q 55               | Standard Q 12         |
|                        |                    |                       |
|                        | Q 56               | Standard Q 13         |
|                        |                    |                       |
|                        | Q 57               | Standard Q 14         |
|                        |                    |                       |
|                        | Q 58               | Standard Q 15         |
+------------------------+--------------------+-----------------------+
| Prenatal Care,         | Q 53               | Standard Q 10         |
| Satisfaction           |                    |                       |
+------------------------+--------------------+-----------------------+
| Social Services        | Q 60               | Standard Q 18         |
+------------------------+--------------------+-----------------------+

\*Uses English and Spanish questionnaires

**CO Colorado**\*

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Health Insurance       | Q 54               | State-Developed       |
|                        |                    |                       |
|                        | Q 55               | State-Developed       |
|                        |                    |                       |
|                        | Q 56               | State-Developed       |
|                        |                    |                       |
|                        | Q 57               | State-Developed       |
+------------------------+--------------------+-----------------------+
| HIV                    | Q 58               | Standard Q 47         |
+------------------------+--------------------+-----------------------+
| Income                 | Q 68a              | State-Developed       |
|                        |                    |                       |
|                        | Q 68b              | Standard Q 43         |
+------------------------+--------------------+-----------------------+
| Injury Prevention      | Q 63               | State-Developed       |
|                        |                    |                       |
|                        | Q 64               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Mental Health          | Q 65               | Standard Q 44         |
|                        |                    |                       |
|                        | Q 66               | Standard Q 45         |
|                        |                    |                       |
|                        | Q 67               | Standard Q 46         |
+------------------------+--------------------+-----------------------+
| Parent and Infant      | Q 62               | Standard Q 29         |
| Character-             |                    |                       |
|                        |                    |                       |
| istics, Parental       |                    |                       |
| Relationship           |                    |                       |
|                        |                    |                       |
| Status                 |                    |                       |
+------------------------+--------------------+-----------------------+
| Prenatal Care,         | Q 53               | Standard Q 10         |
| Satisfaction           |                    |                       |
+------------------------+--------------------+-----------------------+
| Social Services        | Q 61               | Standard Q 20         |
+------------------------+--------------------+-----------------------+
| Social Support         | Q 59               | Standard Q 24         |
|                        |                    |                       |
|                        | Q 60               | Standard Q 26         |
+------------------------+--------------------+-----------------------+

\*Uses English and Spanish questionnaires

**FL Florida**\*

+-------------------------+-------------------+-----------------------+
| **Topic**               | **Questionnaire** | **Standard or**       |
|                         |                   |                       |
|                         | **Number**        | **State-Developed**   |
+-------------------------+-------------------+-----------------------+
| Abuse, Other            | Q 72              | State-Developed       |
+-------------------------+-------------------+-----------------------+
| Breast-Feeding          | Q 64              | Standard Q 4          |
+-------------------------+-------------------+-----------------------+
| Contraception,          | Q 59              | Standard Q 6          |
| Postpartum              |                   |                       |
|                         | Q 60              | Standard Q 7          |
|                         |                   |                       |
|                         | Q 61              | Standard Q 8          |
+-------------------------+-------------------+-----------------------+
| Health Insurance        | Q 56              | State-Developed       |
+-------------------------+-------------------+-----------------------+
| HIV                     | Q 57              | Standard Q 47         |
+-------------------------+-------------------+-----------------------+
| Income                  | Q 74              | State-Developed       |
+-------------------------+-------------------+-----------------------+
| Infant Health, Sick     | Q 68              | State-Developed       |
| Baby Care               |                   |                       |
+-------------------------+-------------------+-----------------------+
| Infant Health, Well     | Q 66              | Standard Q 16         |
| Baby Care               |                   |                       |
|                         | Q 67              | Standard Q 17         |
+-------------------------+-------------------+-----------------------+
| Injury Prevention       | Q 69              | Standard Q 21         |
+-------------------------+-------------------+-----------------------+
| Lead Exposure           | Q 73              | State-Developed       |
+-------------------------+-------------------+-----------------------+
| Morbidity, Infant       | Q 65              | State-Developed       |
+-------------------------+-------------------+-----------------------+
| Parent and Infant       | Q 62              | State-Developed       |
| Character-              |                   |                       |
|                         |                   |                       |
| istics, Paternal Demo-  |                   |                       |
|                         |                   |                       |
| graphics                |                   |                       |
+-------------------------+-------------------+-----------------------+
| Prenatal Care,          | Q 53              | State-Developed       |
| Satisfaction            |                   |                       |
+-------------------------+-------------------+-----------------------+
| Reproductive History,   | Q 58              | State-Developed       |
| Age                     |                   |                       |
|                         |                   |                       |
| at Menarche and         |                   |                       |
| Conception              |                   |                       |
|                         |                   |                       |
| of First Birth          |                   |                       |
+-------------------------+-------------------+-----------------------+
| School Status           | Q 70              | State-Developed       |
|                         |                   |                       |
|                         | Q 71              | State-Developed       |
+-------------------------+-------------------+-----------------------+
| Social Services         | Q 54              | State-Developed       |
|                         |                   |                       |
|                         | Q 55              | State-Developed       |
|                         |                   |                       |
|                         | Q 63              | Standard Q 20         |
+-------------------------+-------------------+-----------------------+

\*Uses English and Spanish questionnaires

**GA Georgia**\*

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 58               | Standard Q 6          |
| Postpartum             |                    |                       |
|                        | Q 59               | Standard Q 7          |
+------------------------+--------------------+-----------------------+
| Douching               | Q 61               | State-Developed       |
|                        |                    |                       |
|                        | Q 62               | State-Developed       |
+------------------------+--------------------+-----------------------+
| HIV                    | Q 71               | Standard Q 47         |
+------------------------+--------------------+-----------------------+
| Incentive              | Q 72               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Income                 | Q 70               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Injury Prevention      | Q 63               | Standard Q 21         |
+------------------------+--------------------+-----------------------+
| Mental Health          | Q 68               | State-Developed       |
|                        |                    |                       |
|                        | Q 69               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Parent and Infant      | Q 55               | Standard Q 27         |
| Character-             |                    |                       |
|                        |                    |                       |
| istics, Paternal Demo- |                    |                       |
|                        |                    |                       |
| graphics               |                    |                       |
+------------------------+--------------------+-----------------------+
| Parent and Infant      | Q 56               | Standard Q 29         |
| Character-             |                    |                       |
|                        | Q 57               | State-Developed       |
| istics, Parental       |                    |                       |
| Relationship           |                    |                       |
|                        |                    |                       |
| Status                 |                    |                       |
+------------------------+--------------------+-----------------------+
| Physical Activity and  | Q 64               | State-Developed       |
| Work                   |                    |                       |
|                        | Q 65               | State-Developed       |
|                        |                    |                       |
|                        | Q 66               | State-Developed       |
|                        |                    |                       |
|                        | Q 67               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Social Services        | Q 53               | State-Developed       |
|                        |                    |                       |
|                        | Q 60               | Standard Q 18         |
+------------------------+--------------------+-----------------------+
| Social Support         | Q 54               | Standard Q 23         |
+------------------------+--------------------+-----------------------+

\*Uses English and Spanish questionnaires

**IL Illinois**\*

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Breast-Feeding         | Q 63               | Standard Q 1          |
|                        |                    |                       |
|                        | Q 64               | Standard Q 4          |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 58               | Standard Q 6          |
| Postpartum             |                    |                       |
|                        | Q 59               | Standard Q 8          |
|                        |                    |                       |
|                        | Q 60               | Standard Q 9          |
+------------------------+--------------------+-----------------------+
| HIV                    | Q 56               | Standard Q 47         |
+------------------------+--------------------+-----------------------+
| Income                 | Q 65               | State-Developed       |
|                        |                    |                       |
|                        | Q 66               | Standard Q 43         |
+------------------------+--------------------+-----------------------+
| Infant Health, Well    | Q 61               | Standard Q 16         |
| Baby                   |                    |                       |
|                        | Q 62               | Standard Q 17         |
| Care                   |                    |                       |
+------------------------+--------------------+-----------------------+
| Oral Health            | Q 57               | Standard Q 48         |
+------------------------+--------------------+-----------------------+
| Prenatal Care, Content | Q 54               | Standard Q 14         |
|                        |                    |                       |
|                        | Q 55               | Standard Q 15         |
+------------------------+--------------------+-----------------------+
| Prenatal Care,         | Q 53               | Standard Q 10         |
| Satisfaction           |                    |                       |
+------------------------+--------------------+-----------------------+

\*Uses English and Spanish questionnaires

**IN Indiana**

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 59               | Standard Q 6          |
| Postpartum             |                    |                       |
|                        | Q 60               | Standard Q 8          |
+------------------------+--------------------+-----------------------+
| Health Insurance       | Q 61               | State-Developed       |
|                        |                    |                       |
|                        | Q 62               | State-Developed       |
+------------------------+--------------------+-----------------------+
| HIV                    | Q 56               | Standard Q 47         |
+------------------------+--------------------+-----------------------+
| Income                 | Q 67               | State-Developed       |
|                        |                    |                       |
|                        | Q 68               | Standard Q 43         |
+------------------------+--------------------+-----------------------+
| Injury Prevention      | Q 66               | Standard Q 21         |
+------------------------+--------------------+-----------------------+
| Parent and Infant      | Q 54               | State-Developed       |
| Character-             |                    |                       |
|                        |                    |                       |
| istics, Maternal Demo- |                    |                       |
|                        |                    |                       |
| graphics               |                    |                       |
+------------------------+--------------------+-----------------------+
| Pre-Conception         | Q 53               | State-Developed       |
| Readiness              |                    |                       |
+------------------------+--------------------+-----------------------+
| Prenatal Care,         | Q 55               | State-Developed       |
| Satisfaction           |                    |                       |
+------------------------+--------------------+-----------------------+
| Reproductive History,  | Q 58               | Standard Q 31         |
| Age                    |                    |                       |
|                        |                    |                       |
| at Menarche and        |                    |                       |
| Conception             |                    |                       |
|                        |                    |                       |
| of First Birth         |                    |                       |
+------------------------+--------------------+-----------------------+
| Social Services        | Q 63               | State-Developed       |
|                        |                    |                       |
|                        | Q 64               | State-Developed       |
|                        |                    |                       |
|                        | Q 65               | Standard Q 18         |
+------------------------+--------------------+-----------------------+
| Social Support         | Q 57               | Standard Q 23         |
+------------------------+--------------------+-----------------------+

**LA Louisiana**\*\*

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Breast-Feeding         | Q 63               | Standard Q 1          |
|                        |                    |                       |
|                        | Q 64               | Standard Q 4          |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 58               | Standard Q 6          |
| Postpartum             |                    |                       |
|                        | Q 59               | Standard Q 7          |
|                        |                    |                       |
|                        | Q 60               | Standard Q 8          |
+------------------------+--------------------+-----------------------+
| House and Household    | Q 57               | Standard Q 34         |
|                        |                    |                       |
| Characteristics,       |                    |                       |
| Composition            |                    |                       |
|                        |                    |                       |
| of Residents           |                    |                       |
+------------------------+--------------------+-----------------------+
| Income                 | Q 67               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Infant Health, Well    | Q 65               | Standard Q 16         |
| Baby                   |                    |                       |
|                        | Q 66               | Standard Q 17         |
| Care                   |                    |                       |
+------------------------+--------------------+-----------------------+
| Injury Prevention      | Q 62               | Standard Q 21         |
+------------------------+--------------------+-----------------------+
| Oral Health            | Q 55               | Standard Q 48         |
+------------------------+--------------------+-----------------------+
| Prenatal Care, Content | Q 53               | Standard Q 11         |
|                        |                    |                       |
|                        | Q 54               | Standard Q 14         |
+------------------------+--------------------+-----------------------+
| Reproductive History,  | Q 56               | Standard Q 31         |
| Age at                 |                    |                       |
|                        |                    |                       |
| Menarche and           |                    |                       |
| Conception             |                    |                       |
|                        |                    |                       |
| of First Birth         |                    |                       |
+------------------------+--------------------+-----------------------+
| Social Services        | Q 61               | Standard Q 18         |
+------------------------+--------------------+-----------------------+

\*\*Uses English mail questionnaires; English and Spanish telephone
questionnaires

**ME Maine**

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Breast-Feeding         | Q 61               | Standard Q 1          |
|                        |                    |                       |
|                        | Q 62               | Standard Q 2          |
|                        |                    |                       |
|                        | Q 63               | Standard Q 3          |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 56               | Standard Q 6          |
| Postpartum             |                    |                       |
|                        | Q 57               | Standard Q 8          |
+------------------------+--------------------+-----------------------+
| Incentive              | Q 73               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Income                 | Q 71               | State-Developed       |
|                        |                    |                       |
|                        | Q 72               | Standard Q 43         |
+------------------------+--------------------+-----------------------+
| Infant Health, Sick    | Q 67               | Standard Q 40         |
| Baby                   |                    |                       |
|                        | Q 68               | Standard Q 41         |
| Care                   |                    |                       |
|                        | Q 69               | Standard Q 42         |
|                        |                    |                       |
|                        | Q 70               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Infant Health, Well    | Q 64               | Standard Q 16         |
| Baby                   |                    |                       |
|                        | Q 65               | Standard Q 17         |
| Care                   |                    |                       |
|                        | Q 66               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Morbidity, Maternal    | Q 58               | Standard Q 37         |
|                        |                    |                       |
|                        | Q 59               | Standard Q 38         |
+------------------------+--------------------+-----------------------+
| Parent and Infant      | Q 55               | Standard Q 27         |
| Character-             |                    |                       |
|                        |                    |                       |
| istics, Paternal Demo- |                    |                       |
|                        |                    |                       |
| graphics               |                    |                       |
+------------------------+--------------------+-----------------------+
| Prenatal Care,         | Q 53               | State-Developed       |
| Barriers               |                    |                       |
|                        | Q 54               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Social Services        | Q 60               | Standard Q 20         |
+------------------------+--------------------+-----------------------+

**MI Michigan**

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Breast-Feeding         | Q 55               | Standard Q 1          |
|                        |                    |                       |
|                        | Q 56               | Standard Q 2          |
|                        |                    |                       |
|                        | Q 57               | Standard Q 3          |
+------------------------+--------------------+-----------------------+
| Income                 | Q 63               | State-Developed       |
|                        |                    |                       |
|                        | Q 64               | Standard Q 43         |
+------------------------+--------------------+-----------------------+
| Infant Health, Sick    | Q 58               | Standard Q 40         |
| Baby                   |                    |                       |
|                        | Q 59               | Standard Q 41         |
| Care                   |                    |                       |
|                        | Q 60               | Standard Q 42         |
+------------------------+--------------------+-----------------------+
| Prenatal Care, Content | Q 53               | Standard Q 13         |
+------------------------+--------------------+-----------------------+
| Prenatal Care,         | Q 54               | Standard Q 10         |
| Satisfaction           |                    |                       |
+------------------------+--------------------+-----------------------+
| Social Services        | Q 61               | State-Developed       |
|                        |                    |                       |
|                        | Q 62               | State-Developed       |
+------------------------+--------------------+-----------------------+

**NC North Carolina**\*

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Abuse, Physical        | Q 65               | State-Developed       |
|                        |                    |                       |
|                        | Q 66               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 58               | Standard Q 6          |
| Postpartum             |                    |                       |
|                        | Q 59               | Standard Q 7          |
+------------------------+--------------------+-----------------------+
| HIV                    | Q 56               | Standard Q 47         |
+------------------------+--------------------+-----------------------+
| Income                 | Q 70               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Injury Prevention      | Q 67               | Standard Q 21         |
+------------------------+--------------------+-----------------------+
| Mental Health          | Q 68               | Standard Q 44         |
|                        |                    |                       |
|                        | Q 69               | Standard Q 45         |
+------------------------+--------------------+-----------------------+
| Morbidity, Maternal    | Q 62               | State-Developed       |
|                        |                    |                       |
|                        | Q 63               | State-Developed       |
|                        |                    |                       |
|                        | Q 64               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Pre-conception         | Q53                | State-Developed       |
| Readiness              |                    |                       |
+------------------------+--------------------+-----------------------+
| Prenatal Care, Content | Q 54a              | Standard Q 11         |
|                        |                    |                       |
|                        | Q 54b              | Standard Q 12         |
|                        |                    |                       |
|                        | Q 54c              | Standard Q 13         |
|                        |                    |                       |
|                        | Q 54d              | State-Developed       |
|                        |                    |                       |
|                        | Q 54e              | State-Developed       |
+------------------------+--------------------+-----------------------+
| Social Services        | Q 60               | Standard Q 18         |
|                        |                    |                       |
|                        | Q 61               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Social Support         | Q 57               | Standard Q 26         |
+------------------------+--------------------+-----------------------+
| Vitamin Use and Folic  | Q 55               | State-Developed       |
| Acid                   |                    |                       |
+------------------------+--------------------+-----------------------+

\*Uses English and Spanish questionnaires

**NM New Mexico**\*

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 60               | Standard Q 6          |
| Postpartum             |                    |                       |
|                        | Q 61               | Standard Q 7          |
|                        |                    |                       |
|                        | Q 62               | Standard Q 8          |
+------------------------+--------------------+-----------------------+
| Income                 | Q 68               | State-Developed       |
|                        |                    |                       |
|                        | Q 69               | Standard 43           |
+------------------------+--------------------+-----------------------+
| Infant Health, Well    | Q 67               | State-Developed       |
| Baby                   |                    |                       |
|                        |                    |                       |
| Care                   |                    |                       |
+------------------------+--------------------+-----------------------+
| Mental Health          | Q 54               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Morbidity, Maternal    | Q 55               | State-Developed       |
|                        |                    |                       |
|                        | Q 64               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Oral Health            | Q 56               | Standard Q 48         |
+------------------------+--------------------+-----------------------+
| Parent and Infant      | Q 53               | State-Developed       |
| Character-             |                    |                       |
|                        | Q 57               | State-Developed       |
| istics, Maternal Demo- |                    |                       |
|                        | Q 58               | State-Developed       |
| graphics               |                    |                       |
+------------------------+--------------------+-----------------------+
| Physical Activity and  | Q 59               | State-Developed       |
| Work                   |                    |                       |
+------------------------+--------------------+-----------------------+
| Social Services        | Q 63               | State-Developed       |
|                        |                    |                       |
|                        | Q 65               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Social Support         | Q 66               | State-Developed       |
+------------------------+--------------------+-----------------------+

\*Uses English and Spanish questionnaires

**NY New York**\*

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Abuse, Physical        | Q 67b              | State-Developed       |
+------------------------+--------------------+-----------------------+
| Abuse, Verbal          | Q 67a              | State-Developed       |
+------------------------+--------------------+-----------------------+
| Breast-Feeding         | Q 61               | Standard Q 1          |
|                        |                    |                       |
|                        | Q 62               | Standard Q 4          |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 55               | Standard Q 6          |
| Postpartum             |                    |                       |
|                        | Q 56               | Standard Q 8          |
+------------------------+--------------------+-----------------------+
| HIV                    | Q 54               | Standard Q 47         |
+------------------------+--------------------+-----------------------+
| Income                 | Q 68               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Injury Prevention      | Q 63               | Standard Q 21         |
+------------------------+--------------------+-----------------------+
| Mental Health          | Q 65               | Standard Q 44         |
|                        |                    |                       |
|                        | Q 66               | Standard Q 45         |
+------------------------+--------------------+-----------------------+
| Morbidity, Maternal    | Q 58               | Standard Q 37         |
|                        |                    |                       |
|                        | Q 59               | Standard Q 38         |
|                        |                    |                       |
|                        | Q 60               | Standard Q 39         |
+------------------------+--------------------+-----------------------+
| Physical Activity and  | Q 64               | State-Developed       |
| Work                   |                    |                       |
+------------------------+--------------------+-----------------------+
| Prenatal Care, Content | Q 53               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Social Services        | Q 57               | State-Developed       |
+------------------------+--------------------+-----------------------+

\*Uses English and Spanish questionnaires

**OH Ohio**

+---------------------------+-----------------+-----------------------+
| **Topic**                 | **              | **Standard or**       |
|                           | Questionnaire** |                       |
|                           |                 | **State-Developed**   |
|                           | **Number**      |                       |
+---------------------------+-----------------+-----------------------+
| Breastfeeding             | Q 62            | Standard Q 1          |
|                           |                 |                       |
|                           | Q 63            | Standard Q 4          |
+---------------------------+-----------------+-----------------------+
| Contraception, Postpartum | Q 59            | Standard Q 9          |
|                           |                 |                       |
|                           | Q 60            | Standard Q 6          |
|                           |                 |                       |
|                           | Q 61            | Standard Q 8          |
+---------------------------+-----------------+-----------------------+
| HIV                       | Q 55            | Standard Q 47         |
+---------------------------+-----------------+-----------------------+
| Income                    | Q 68            | State-Developed       |
|                           |                 |                       |
|                           | Q 69            | Standard Q 43         |
+---------------------------+-----------------+-----------------------+
| Infant Health, Well Baby  | Q 64            | Standard Q 16         |
| Care                      |                 |                       |
|                           | Q 65            | Standard Q 17         |
+---------------------------+-----------------+-----------------------+
| Injury Prevention         | Q 66            | Standard Q 21         |
+---------------------------+-----------------+-----------------------+
| Prenatal Care, Content    | Q 53            | Standard Q 14         |
|                           |                 |                       |
|                           | Q 54            | Standard Q 15         |
+---------------------------+-----------------+-----------------------+
| Sleeping Behaviors        | Q 67            | Standard Q 22         |
+---------------------------+-----------------+-----------------------+
| Social Services           | Q 56            | Standard Q 18         |
+---------------------------+-----------------+-----------------------+
| Social Support            | Q 57            | Standard Q 24         |
|                           |                 |                       |
|                           | Q 58            | Standard Q 26         |
+---------------------------+-----------------+-----------------------+

**OK Oklahoma**\*

+---------------------------+-----------------+-----------------------+
| **Topic**                 | **              | **Standard or**       |
|                           | Questionnaire** |                       |
|                           |                 | **State-Developed**   |
|                           | **Number**      |                       |
+---------------------------+-----------------+-----------------------+
| Health Insurance          | Q 58            | State-Developed       |
|                           |                 |                       |
|                           | Q 59            | State-Developed       |
|                           |                 |                       |
|                           | Q 60            | State-Developed       |
+---------------------------+-----------------+-----------------------+
| HIV                       | Q 63            | Standard Q 47         |
+---------------------------+-----------------+-----------------------+
| Income                    | Q 69a           | State-Developed       |
|                           |                 |                       |
|                           | Q 69b           | Standard Q 43         |
+---------------------------+-----------------+-----------------------+
| Infant Health, General    | Q 68            | State-Developed       |
| Baby Care                 |                 |                       |
+---------------------------+-----------------+-----------------------+
| Intendedness of Pregnancy | Q 55            | State-Developed       |
|                           |                 |                       |
|                           | Q 56            | State-Developed       |
|                           |                 |                       |
|                           | Q 57            | State-Developed       |
+---------------------------+-----------------+-----------------------+
| Length of Stay, Maternal  | Q 66            | State-Developed       |
+---------------------------+-----------------+-----------------------+
| Morbidity, Infant         | Q 67            | State-Developed       |
+---------------------------+-----------------+-----------------------+
| Parent and Infant         | Q 62            | State-Developed       |
| Character-                |                 |                       |
|                           |                 |                       |
| istics, Maternal Demo-    |                 |                       |
|                           |                 |                       |
| graphics                  |                 |                       |
+---------------------------+-----------------+-----------------------+
| Parent and Infant         | Q 65            | Standard Q 27         |
| Character-                |                 |                       |
|                           |                 |                       |
| istics, Paternal Demo-    |                 |                       |
|                           |                 |                       |
| graphics                  |                 |                       |
+---------------------------+-----------------+-----------------------+
| Parent and Infant         | Q 64            | State-Developed       |
| Character-                |                 |                       |
|                           |                 |                       |
| istics, Parental          |                 |                       |
| Relationship              |                 |                       |
|                           |                 |                       |
| Status                    |                 |                       |
+---------------------------+-----------------+-----------------------+
| Pre-Conception Readiness  | Q 53            | State-Developed       |
+---------------------------+-----------------+-----------------------+
| Prenatal Care, Content    | Q 61            | Standard Q 12         |
+---------------------------+-----------------+-----------------------+
| Reproductive History, Age | Q 70            | State-Developed       |
| at                        |                 |                       |
|                           |                 |                       |
| Menarche and Conception   |                 |                       |
|                           |                 |                       |
| of First Birth            |                 |                       |
+---------------------------+-----------------+-----------------------+
| Vitamin Use and Folic     | Q 54            | State-Developed       |
| Acid                      |                 |                       |
+---------------------------+-----------------+-----------------------+

\*Uses English and Spanish questionnaires

**SC South Carolina**

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 61               | State-Developed       |
| Pre-Pregnancy          |                    |                       |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 62               | Standard Q 6          |
| Postpartum             |                    |                       |
|                        | Q 63               | Standard Q 7          |
|                        |                    |                       |
|                        | Q 64               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Health Insurance       | Q 54               | State-Developed       |
|                        |                    |                       |
|                        | Q 55               | State-Developed       |
|                        |                    |                       |
|                        | Q 56               | State-Developed       |
|                        |                    |                       |
|                        | Q 57               | State-Developed       |
|                        |                    |                       |
|                        | Q 58               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Income                 | Q 65               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Infant Health, Sick    | Q 66               | State-Developed       |
| Baby                   |                    |                       |
|                        |                    |                       |
| Care                   |                    |                       |
+------------------------+--------------------+-----------------------+
| Reproductive History,  | Q 53               | Standard Q 31         |
| Age at                 |                    |                       |
|                        |                    |                       |
| Menarche and           |                    |                       |
| Conception             |                    |                       |
|                        |                    |                       |
| of First Birth         |                    |                       |
+------------------------+--------------------+-----------------------+
| Social Support         | Q 59               | Standard Q 24         |
|                        |                    |                       |
|                        | Q 60               | Standard Q 23         |
+------------------------+--------------------+-----------------------+

**UT Utah**\*

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Abuse, Physical        | Q 63               | State-Developed       |
|                        |                    |                       |
|                        | Q 64               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Breastfeeding          | Q 58               | Standard Q 2          |
|                        |                    |                       |
|                        | Q 59               | Standard Q 3          |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 55               | Standard Q 6          |
| Postpartum             |                    |                       |
|                        | Q 56               | Standard Q 7          |
|                        |                    |                       |
|                        | Q 57               | Standard Q 8          |
+------------------------+--------------------+-----------------------+
| Income                 | Q 61               | State-Developed       |
|                        |                    |                       |
|                        | Q 62               | Standard Q 43         |
+------------------------+--------------------+-----------------------+
| Mental Health          | Q 60               | Standard Q 45         |
+------------------------+--------------------+-----------------------+
| Prenatal Care, Content | Q 53a              | Standard Q 11         |
|                        |                    |                       |
|                        | Q 53b              | Standard Q 12         |
|                        |                    |                       |
|                        | Q 53c              | Standard Q 13         |
|                        |                    |                       |
|                        | Q 53d              | Standard Q 14         |
|                        |                    |                       |
|                        | Q 53e              | Standard Q 15         |
+------------------------+--------------------+-----------------------+
| Social Support         | Q 54               | Standard Q 23         |
+------------------------+--------------------+-----------------------+

\*Uses English and Spanish questionnaires

**WA Washington**\*

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 61               | Standard Q 9          |
| Postpartum             |                    |                       |
|                        | Q 62               | Standard Q 6          |
|                        |                    |                       |
|                        | Q 63               | Standard Q 8          |
+------------------------+--------------------+-----------------------+
| House and Household    | Q 54               | Standard Q 34         |
|                        |                    |                       |
| Characteristics,       |                    |                       |
| Composition            |                    |                       |
|                        |                    |                       |
| of Residents           |                    |                       |
+------------------------+--------------------+-----------------------+
| Income                 | Q 55               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Infant Health, Well    | Q 65               | State-Developed       |
| Baby                   |                    |                       |
|                        |                    |                       |
| Care                   |                    |                       |
+------------------------+--------------------+-----------------------+
| Injury Prevention      | Q 66               | State-Developed       |
|                        |                    |                       |
|                        | Q 67               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Intendedness of        | Q 53               | State-Developed       |
| Pregnancy              |                    |                       |
+------------------------+--------------------+-----------------------+
| Length of Stay,        | Q 60               | State-Developed       |
| Maternal               |                    |                       |
+------------------------+--------------------+-----------------------+
| Mental Health          | Q 56a              | Standard Q 46         |
+------------------------+--------------------+-----------------------+
| Prenatal Care, Content | Q 56b              | Standard Q 13         |
|                        |                    |                       |
|                        | Q 56c              | Standard Q 11         |
|                        |                    |                       |
|                        | Q 56d              | Standard Q 12         |
+------------------------+--------------------+-----------------------+
| Social Support         | Q 57               | Standard Q 24         |
|                        |                    |                       |
|                        | Q 58               | Standard Q 23         |
|                        |                    |                       |
|                        | Q 59               | State-Developed       |
+------------------------+--------------------+-----------------------+

\*Uses English and Spanish questionnaires

**WV West Virginia**

+------------------------+--------------------+-----------------------+
| **Topic**              | **Questionnaire**  | **Standard or**       |
|                        |                    |                       |
|                        | **Number**         | **State-Developed**   |
+------------------------+--------------------+-----------------------+
| Breast-Feeding         | Q 60               | Standard Q 4          |
+------------------------+--------------------+-----------------------+
| Contraception,         | Q 57               | Standard Q 6          |
| Postpartum             |                    |                       |
|                        | Q 58               | Standard Q 7          |
+------------------------+--------------------+-----------------------+
| HIV                    | Q 54               | Standard Q 47         |
+------------------------+--------------------+-----------------------+
| Income                 | Q 69               | State-Developed       |
|                        |                    |                       |
|                        | Q 70               | Standard Q 43         |
+------------------------+--------------------+-----------------------+
| Infant Health, Sick    | Q 66               | Standard Q 40         |
| Baby                   |                    |                       |
|                        | Q 67               | Standard Q 42         |
| Care                   |                    |                       |
|                        | Q 68               | State-Developed       |
+------------------------+--------------------+-----------------------+
| Injury Prevention      | Q 64               | Standard Q 21         |
+------------------------+--------------------+-----------------------+
| Morbidity, Maternal    | Q 61               | Standard Q 37         |
|                        |                    |                       |
|                        | Q 62               | Standard Q 38         |
|                        |                    |                       |
|                        | Q 63               | Standard Q 39         |
+------------------------+--------------------+-----------------------+
| Reproductive History,  | Q 55               | Standard Q 30         |
| Age at                 |                    |                       |
|                        | Q 56               | Standard Q 31         |
| Menarche and           |                    |                       |
| Conception             |                    |                       |
|                        |                    |                       |
| of First Birth         |                    |                       |
+------------------------+--------------------+-----------------------+
| Sleeping Behaviors     | Q 65               | Standard Q 22         |
+------------------------+--------------------+-----------------------+
| Social Services        | Q 53               | State-Developed       |
|                        |                    |                       |
|                        | Q 59               | Standard Q 20         |
+------------------------+--------------------+-----------------------+

**35. APPENDIX B - LIST OF STANDARD QUESTIONS**

**AND STATES USING THE STANDARD QUESTIONS**

**[BREAST-FEEDING]{.underline}**

**Standard Q 1**

> **Used by:** AR Q 68, IL Q 63, LA Q 63, ME Q 61, MI Q 55, NY Q 61, OH
> Q 62
>
> **Modifications:** None

**Standard Q 2**

> **Used by:** AK Q 65a, ME Q 62, MI Q 56, UT Q 58
>
> **Modifications:** None

**Standard Q 3**

> **Used by:** AK Q 65b, ME Q 63, MI Q 57, UT Q 59
>
> **Modifications:** None

**Standard Q 4**

> **Used by:** AL Q 63, FL Q 64, IL Q 64, LA Q 64, NY Q 62, OH Q 63, WV
> Q 60
>
> **Modifications:** None

**Standard Q 5**

> **Used by:** None
>
> **Modifications:** None

**[CONTRACEPTION]{.underline}**

**[POSTPARTUM]{.underline}**

**Standard Q 6**

> **Used by:** AK Q 56, AL Q 57, AR Q 61, FL Q 59, GA Q 58, IL Q 58, IN
> Q 59, LA Q 58, ME Q 56, NC Q 58, NM Q 60, NY Q 55, OH Q 60, SC Q 62,
> UT Q 55, WA Q 62, WV Q 57

**Modifications:**

> **AK** - Includes AIUD@ in sentence ABirth control means \...@
>
> **FL** - Modifies ABirth control means \...@ sentence to read as
> follows: ABirth control means the pill, IUD, condoms, diaphragm, the
> shot, and other ways to keep from getting pregnant.@
>
> **SC** - Includes Aabstinence@ in sentence ABirth control means \...@
>
> **UT -** ABirth control means \...@ sentence appears above the
> question.

**Standard Q 7**

> **Used by:** AL Q 58, AR Q 62, FL Q 60, GA Q 59, LA Q 59, NC Q 59, NM
> Q 61, SC Q 63, UT Q 56, WV Q 58

**Modifications:**

> **FL** - Adds option AIUD@
>
> **SC** - Modifies option ACondoms@ to read ACondoms (rubbers)@
>
> Modifies option AFoam, jelly, cream@ to read AFoam, jelly, cream, or
> suppositories@
>
> Modifies option ANorplant@ to read ANorplant (little tubes placed
> under the skin)@
>
> Does not use option AWithdrawal@
>
> Adds option ADiaphragm, cap, or sponge@

Adds option ARhythm method/ Natural family planning@

Adds option AI am not planning to have sex (abstinence)@

> **UT -** Adds option AAbstinence@

**Standard Q 8**

> **Used by:** AK Q 57, AL Q 59, AR Q 63, FL Q 61, IL Q 59, IN Q 60, LA
> Q 60, ME Q 57, NM Q 62, NY Q 56, OH Q 61, UT Q 57, WA Q 63

**Modifications:**

> **FL** - Adds option AIt=s against my religion@
>
> **NM** - Adds option AI haven=t started my period yet@

**Standard Q 9**

> **Used by:** IL Q 60, OH Q 59, WA Q 61
>
> **Modifications:** None

**[PRENATAL CARE]{.underline}**

**[SATISFACTION]{.underline}**

**Standard Q 10**

> **Used by:** AR Q 53, CO Q 53, IL Q 53, MI Q 54
>
> **Modifications:** None

**[CONTENT]{.underline}**

**Standard Q 11**

> **Used by:** AR Q 54, LA Q 53, NC Q 54a, UT 53a, WA Q 56c

**Modifications:**

> **NC -** Uses Q11-Q13 in list format; adds two options to list:

APlacing your baby to sleep on his or her back or side@

AHow vaginal infections (for example, yeast, vaginosis, STDs) may be
related to

the baby being born prematurely@

> **UT -** Uses Q11-Q15 in list format
>
> **WA -** Modifies question to read AAt any time \... that could run in
> your family or your partner=s family?@

Uses Q11-Q13 in list format; adds one option to list.

Possible responses: 1=No, 2=Yes, 7=Don=t know, 9=Blank

**Standard Q 12**

> **Used by:** AR Q 55, NC Q 54b, OK Q 61, UT Q 53b, WA Q 56d

**Modifications:**

> **NC -** Uses Q11-Q13 in list format; adds two options to list:

APlacing your baby to sleep on his or her back or side@

AHow vaginal infections (for example, yeast, vaginosis, STDs) may be
related to

the baby being born prematurely@

> **UT -** Uses Q11-Q15 in list format
>
> **WA -** Modifies question to read AAt any time \... that could run in
> your family or your partner=s family?@

Uses Q11-Q13 in list format; adds one option to list.

Possible responses: 1=No, 2=Yes, 7=Don=t know, 9=Blank

**Standard Q 13**

> **Used by:** AL Q 54, AR Q 56, MI Q 53, NC Q 54c, UT Q 53c, WA Q 56b

**Modifications:**

> **AL -** Modifies the AYes@ response to read AYes\-\-\-\--\>How many
> pounds did he or she recommend that you gain? \_\_\_\_\_Pounds@
>
> **NC -** Uses Q11-Q13 in list format; adds two options to list:

APlacing your baby to sleep on his or her back or side@

AHow vaginal infections (for example, yeast, vaginosis, STDs) may be
related to

the baby being born prematurely@

> **UT -** Uses Q11-Q15 in list format
>
> **WA -** Modifies question to read AAt any time \... that could run in
> your family or your partner=s family?@

Uses Q11-Q13 in list format; adds one option to list.

Possible responses: 1=No, 2=Yes, 7=Don=t know, 9=Blank

**Standard Q 14**

> **Used by:** AR Q 57, IL Q 54, LA Q 54, OH Q 53, UT Q 53d

**Modifications:**

> **UT -** Uses Q11-Q15 in list format

**Standard Q 15**

> **Used by:** AR Q 58, IL Q 55, OH Q 54, UT Q 53e
>
> **UT -** Uses Q11-Q15 in list format

**[INFANT HEALTH]{.underline}**

**[WELL BABY CARE]{.underline}**

**Standard Q 16**

> **Used by:** AR Q 66, FL Q 66, IL Q 61, LA Q 65, ME Q 64, OH Q 64
>
> **Modifications:** None

**Standard Q 17**

> **Used by:** AR Q 67, FL Q 67, IL Q 62, LA Q 66, ME Q 65, OH Q 65
>
> **Modifications:** None

**[SOCIAL SERVICES]{.underline}**

**Standard Q 18**

> **Used by:** AK Q 60, AL Q 60, AR Q 60, GA Q 60, IN Q 65, LA Q 61, NC
> Q 60, OH Q 56

**Modifications:**

> **AR** - Adds the option ADental care from a dentist or clinic@
>
> **GA** - Adds the option AInstructions on how to breast-feed@
>
> **IN** - Does not use the option AParenting classes@
>
> Adds the following options: ABreast-feeding classes@, AClasses about
> sick baby care@ and AHelp from an organization such as United Way or
> your church to get baby supplies (diapers, formula, etc.)@

**NC** - Adds the option ATreatment for alcohol or other drugs@

**Standard Q 19**

> **Used by:** None
>
> **Modifications:** None

**Standard Q 20**

> **Used by:** AK Q 64, AL Q 61, CO Q 61, FL Q 63, ME Q 60, WV Q 59

**Modifications:**

> **CO** - Doesn=t skip if baby not alive or not with mom

**[INJURY PREVENTION]{.underline}**

**Standard Q 21**

> **Used by:** AK Q 66, AL Q 65, FL Q 69, GA Q 63, IN Q 66, LA Q 62, NC
> Q 67, NY Q 63, OH Q 66, WV Q 64

**Modifications:**

> **AL** - Does not use the option AMy baby always rides in an infant
> car seat@
>
> **AK** - Does not use the option AThere are loaded guns, rifles, or
> other firearms in my home@
>
> **IN** - Does not use the option AMy infant was brought home from the
> hospital in an infant car seat@
>
> Adds the option AThe electrical outlets are child-proof in my home@

**NC** - Adds the options AThere are guns, rifles, or other firearms in
my home@,

AThere are loaded guns, rifles, or other firearms with trigger locks in
my home@,

AThere is a member of my household who smokes inside my home@

**[SLEEPING BEHAVIORS]{.underline}**

**Standard Q 22**

> **Used by:** AK Q 67, AL Q 67, OH Q 67, WV Q 65
>
> **Modifications:** None

**[SOCIAL SUPPORT]{.underline}**

**Standard Q 23**

> **Used by:** GA Q 54, IN Q 57, SC Q 60, UT Q 54, WA Q 58

**Modifications:**

> **GA** - Modifies the option AMy husband or partner@ to read AMy
> husband or boyfriend@
>
> Modifies the option AMy mother, father, or in-laws@ to read AMy mother
> or father@
>
> Adds the option AMy brother and sister@

**Standard Q 24**

> **Used by:** CO Q 59, OH Q 57, SC Q 59, WA Q 57

**Modifications:**

> **SC** - Adds the following options: ASomeone to help me find a job if
> I needed it@ and ASomeone to help with grocery shopping or house
> cleaning@

**Standard Q 25**

> **Used by:** AK Q 53
>
> **Modifications:** None

**Standard Q 26**

> **Used by:** CO Q 60, NC Q 57, OH Q 58
>
> **Modifications:** None

**[PARENT AND INFANT CHARACTERISTICS]{.underline}**

**[PATERNAL DEMOGRAPHICS]{.underline}**

**Standard Q 27**

> **Used by:** AR Q 64, GA Q 55, ME Q 55, OK Q 65
>
> **Modifications:** None

**[PARENTAL RELATIONSHIP STATUS]{.underline}**

**Standard Q 28**

> **Used by:** None
>
> **Modifications:** None

**Standard Q 29**

> **Used by:** AR Q 65, CO Q 62, GA Q 56
>
> **Modifications:** None

**[REPRODUCTIVE HISTORY]{.underline}**

**[AGE AND MENARCHE AND CONCEPTION OF FIRST BIRTH]{.underline}**

**Standard Q 30**

> **Used by:** WV Q 55
>
> **Modifications:** None

**Standard Q 31**

> **Used by:** AL Q 56, IN Q 58, LA Q 56, SC Q 53, WV Q 56
>
> **Modifications:** None

**[HOUSE AND HOUSEHOLD CHARACTERISTICS]{.underline}**

**[TELEPHONE COVERAGE]{.underline}**

**Standard Q 32**

> **Used by:** None
>
> **Modifications:** None

**Standard Q 33**

> **Used by:** None
>
> **Modifications:** None

**[COMPOSITION OF RESIDENTS]{.underline}**

**Standard Q 34**

> **Used by:** LA Q 57, WA Q 54

**Modifications:**

> **WA** - Changes the phrase AWhen you got pregnant\...@ to AWhen you
> found out that you were pregnant\...@
>
> Does not use the following options: AMy mother@, AMy father@, AMy
> husband=s or partner=s parent(s)@, AFriend or roommate@, AOther
> relative@, AOther, Please tell us@. Adds option AOther adults@. Adds
> option AHow many \[other adults\]?@

**Standard Q 35**

> **Used by:** None
>
> **Modifications:** None

**Standard Q 36**

> **Used by:** None
>
> **Modifications:** None

**[MORBIDITY]{.underline}**

**[MATERNAL]{.underline}**

**Standard Q 37**

> **Used by:** ME Q 58, NY Q 58, WV Q 61

**Modifications:**

> **ME** - Does not skip this question if baby not alive or not living
> with mom. ME also does not use Std Q 39 - Baby=s age in weeks at mom=s
> postpartum hospitalization.

**Standard Q 38**

> **Used by:** ME Q 59, NY Q 59, WV Q 62

**Modifications:**

> **ME** - Does not skip this question if baby not alive or not living
> with mom. ME also does not use Std Q 39 - Baby=s age in weeks at mom=s
> postpartum hospitalization.

**Standard Q 39**

> **Used by:** NY Q 60, WV Q 63

**Modifications:**

> **NY** - Adds the option ALess than one week old@

**[INFANT HEALTH]{.underline}**

**[SICK BABY CARE]{.underline}**

**Standard Q 40**

> **Used by:** ME Q 67, MI Q 58, WV Q 66
>
> **Modifications:** None

**Standard Q 41**

> **Used by:** ME Q 68, MI Q 59

**Modifications:**

> **ME** - Selects as *State Options*: APrivate doctor=s office@, and
> ARural health center@
>
> **MI** - Selects as *State Options*: APrivate doctor=s office@, and
> ACommunity or rural health center@

**Standard Q 42**

> **Used by:** ME Q 69, MI Q 60, WV Q 67
>
> **Modifications:** None

**[INCOME]{.underline}**

**Standard Q 43**

> **Used by:** AK Q 68b, AR Q 70, CO Q 68b, IL Q 66, IN Q 68, ME Q 72,
> MI Q 64, NM Q 69, OH Q 69, OK Q 69b, UT Q 62, WV Q 70

**Modifications:**

> **AR** - Includes the phrase, ABefore your delivery, how many \...@
>
> **CO** - Includes the phrase, A\...depended on this income ***when you
> got pregnant***?@
>
> **IN** - Includes the phrase, A**Do not include your new baby.**@
>
> **OK** - Includes the phrase, A\...depended on this income when you
> got pregnant?@

**[MENTAL HEALTH]{.underline}**

**Standard Q 44**

> **Used by:** CO Q 65, NC Q 68, NY Q 65
>
> **Modifications:** None

**Standard Q 45**

> **Used by:** CO Q 66, NC Q69, NY Q 66, UT Q 60
>
> **Modifications:** None

**Standard Q 46**

> **Used by:** CO Q 67
>
> **Modifications:** None

**[HIV]{.underline}**

**Standard Q 47**

> **Used by:** AR Q 59, CO Q 58, FL Q 57, GA Q 71, IL Q 56, IN Q 56, NC
> Q 56, NY Q 54, OH Q 55, OK Q 63, WV Q 54
>
> **Modifications:** None

**[ORAL HEALTH]{.underline}**

**Standard Q 48**

> **Used by:** IL Q 57, LA Q 55, NM Q 56

**Modifications:**

> **NM** - Respondents check all that apply rather than choosing Yes/No
> for each statement. NM also adds the option AI did not go for dental
> care@.