NCS Herald Cohort Study

Instrument \# 24

Partner Questionnaire

Six Month Home Visit

Eligibility: All partners of women who gave birth

Mode of administration: Interviewer, home visit

8/4/2005

[PRELOADED DATA:]{.underline}

Today's date

Language of interview (English/Spanish)

Female Name

Female Address and Phone

Spouse/Partner's Name

Spouse/Partner's Address and Phone

Marital status

Occupation

Chemical exposures

Student status

[QUESTIONNAIRE]{.underline}:

**Address (update)**

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

1 YES

2 NO  Enter correct information

{END OF ADDRESS MODULE}

**Occupation (Update)**

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

1 YES  SKIP TO Q4

2 NO

2.. Are you now a student full or part-time?

1 YES, FULL-TIME

2 YES, PART-TIME

3 NO, NOT A STUDENT  SKIP TO Q4

3\. What type of school are you currently attending?

> 1 High school
>
> 2 Technical school
>
> 3 College or university
>
> 4 Graduate school
>
> 5 Professional school (for example, medical school)
>
> 6 Other (SPECIFY)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

1 YES

2 NO SKIP TO Q5

Q4=YES, STILL WORKING SKIP TO Q6\
Q4=YES, STILL LOOKING FOR WORK  GO TO NEXT MODULE

Q4=YES, STILL NOT WORKING  GO TO NEXT MODULE

5.  Are you currently...

\[ONLY DISPLAY THE OPTIONS NOT SELECTED IN PREVIOUS INTERVIEW\]

1 Working at a job or business, SKIP TO PARAGRAPH BEFORE Q7\
2 Looking for work, or GO TO NEXT MODULE

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

6.  Did you start work at any jobs since \[FILL DATE\]?

1 YES

2 NO  GO TO NEXT MODULE

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

7.  On what date did you start this job?

MM/DD/YYYY

8.  On what date did you stop working at this job?

MM/DD/YYYY

1 = STILL EMPLOYED

9.  What kind of business or industry (FILL: is/was) this? (For example:
    TV and radio management, retail shoe store, state labor department,
    farm.)

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> ENTER NAME OF BUSINESS, JOB, OR INDUSTRY

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

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> ENTER NAME OF OCCUPATION

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

\_\_\_\_ HOURS

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

1 YES

2 NO  SKIP TO Q14

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

1 YES

2 NO

14. Did you have any other jobs since \[FILL DATE\]?

1 YES \[REPEAT Q67-Q13 FOR UP TO 3 JOBS\]

2 NO  GO TO NEXT MODULE

{END OF OCCUPATION MODULE}

**Chemical Exposures (Update)**

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

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

1 YES  IF NO PREVIOUS EXPOSURES, SKIP TO END

2 NO

2.  \[IF Q1=1, ASK:\] Are you currently also exposed to any of the
    following chemicals?

\[IF Q1=2, ASK:\] Which of the following chemicals are you currently
exposed to?

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

YES

NO  SKIP TO NEXT EXPOSURE

3.  How often are you exposed to **\[INSERT EXPOSURE\]** ? Would you
    say. . .

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

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

{END OF CHEMICAL EXPOSURES MODULE}

**Activity (Full)**

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

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

*FH = Fairly hard (at least some increase in breathing and heart rate),*

*SH = Somewhat hard (moderate increase in breathing and heart rate), or*

*H = Hard or very hard (large increase in breathing and heart rate)?*

Now think about the activities you did [in the past week]{.underline}...

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

1 Not hard = did not feel any increase in breathing or heart rate

2 Fairly light = at least some increase in breathing and heart rate

3 Somewhat hard = moderate increase in breathing and heart rate

4 Hard or very hard = large increase in breathing and heart rate

5.  Think about how active you were during your non-working and
    recreational hours in the past week. Would you say your activities
    were usually...

1 not hard = you did not feel any increase in breathing or heart rate

2 fairly light = you had at least some increase in breathing and heart
rate

3 somewhat hard = you had a moderate increase in breathing and heart
rate

4 hard or very hard = you had a large increase in breathing and heart
rate

Now I will ask you to think about your typical [daily]{.underline}
activities during the past month.

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

1 You sit during the day and do not walk about very much

2 You stand or walk about quite a lot during the day, but do not have to
carry or lift things

very often

3 You lift or carry light loads, or have to climb stairs or hills often

4 You do heavy work or carry heavy loads

7.  Over the past month, on a typical day how much time altogether did
    you spend sitting and watching TV or videos or using a computer
    **outside of work**? Would you say . . .

0 Less than 1 hour

1 1 hour

2 2 hours

3 3 hours

4 4 hours

5 5 hours or more

6 You do not watch TV or videos or use a computer outside of work

8.  How does the amount of activity that you reported for the [past
    month]{.underline} compare with your physical activity for the [past
    12 months]{.underline}? Over the past month, were you . . .

1 More active

2 Less active

3 About the same

9.  Compared with most men your age, would you say that you are . . .

1 More active

2 Less active

3 About the same

\[ASK Q21 IF MAN AGE \>= 30\]

10. Compared with yourself **10 years ago**, would you say that you are
    . . .

1 More active now

2 Less active now

3 About the same

{END OF ACTIVITY MODULE}

**Personal Medical History (Update)**

Now I'd like to ask you about any changes to your general health.

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

\[CAPI: ONLY DISPLAY ITEMS = NO FOR LAST INTERVIEW\]

> 1 High blood pressure or hypertension
>
> 2 High blood sugar or diabetes
>
> 3 High cholesterol
>
> 4 Anemia (poor blood, low iron)
>
> 5 Heart problems
>
> 6 Hayfever or allergy
>
> 7 Skin allergy or eczema
>
> 8 Asthma

IF Q1 = 8, ASK Q2-4

ELSE, SKIP TO Q5

2.  Did a doctor or other medical provider tell you that you have
    asthma?

1 YES

2 NO  SKIP TO Q5

3.  Have you used any inhalers or taken any pills for asthma or wheezing
    or whistling in your chest?

1 YES

2 NO

4.  Have you [ever]{.underline} gone to an emergency room or stayed
    overnight in a hospital for your asthma?

1 YES

2 NO

5.  Since your last interview on \[FILL DATE\], have you been diagnosed
    with any other serious illnesses that I haven't asked about?

1 YES

2 NO  GO TO NEXT MODULE

5a. What were those illnesses? (ENTER VERBATIM)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

1 YES

2 NO  GO TO NEXT MODULE

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

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

{END OF PERSONAL MEDICAL HISTORY MODULE}

###  

**Alcohol (update)**

The next few questions are about alcohol consumption. A "drink" is a can
or bottle of beer, a glass of wine or a wine cooler, a shot of liquor,
or a mixed drink with liquor in it. We are not asking about times when
you only had a sip or two from a drink.

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

1 YES

2 NO  GO TO NEXT MODULE

2.  Since your last interview on \[FILL DATE\], how many alcoholic
    drinks did you have in an average week? Would you say...

1 Less than 1 drink a week,

2 1 to 3 drinks a week,

3 4 to 6 drinks a week,

4 7 to 13 drinks a week, or

5 14 drinks or more a week?

3.  Since your last interview on \[FILL DATE\], how many times did you
    drink 5 alcoholic drinks or more in one sitting? Would you say...

1 Never,

2 1 time,

3 2 or 3 times,

4 4 or 5 times, or

5 6 or more times?

{END OF ALCOHOL MODULE}

**Tobacco (update)**

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

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

1 YES

2 NO

2.  Since your last interview, have you smoked a cigar or tobacco pipe,
    even once?

1 YES\
2 NO  SKIP TO Q3

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

\_\_\_\_\_ NUMBER OF TIMES

> ENTER UNIT
>
> 1 DAY
>
> 2 WEEK
>
> 3 MONTH

\[IF SMOKER FROM PREVIOUS INTERVIEW, ASK Q3-Q4 \]

\[IF NON-SMOKER IN PREVIOUS INTERVIEW, SKIP TO Q5 \]

3.  Do you still smoke cigarettes?

1 YES  SKIP TO Q6

2 NO

4.  When did you stop smoking?

MM/YYYY  SKIP TO Q7

5.  In your last interview you reported that you were [not]{.underline}
    smoking cigarettes. Are you currently smoking cigarettes now?

1 YES

2 NO  SKIP TO Q7

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

1 Less than 1 cigarette per day,

2 1 to 5 cigarettes,

3 6 to 10 cigarettes,

4 11 to 20 cigarettes,

5 21 to 40 cigarettes, or

6 41 cigarettes or more?

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

1 YES  SKIP TO Q9

2 NO

8.  Not including yourself, how many cigarette smokers live in your home
    *now*?

\_\_\_\_\_

9.  About how many hours per day are you in the same room with someone
    who is smoking cigarettes, cigars, or tobacco pipes?

**\_\_\_\_\_** Hours

999 Less than 1 hour a day

{END OF TOBACCO MODULE}

**Acceptability**

**(To be administered at the end of the home visit)**

This study will be able to answer health questions best if we are able
to keep people involved in the study. To do this, we would like to get
some feedback from you about the study overall and this visit today to
help improve the study in the future.

1.  Was participating in the visit today convenient for you?

> 1 YES  SKIP TO Q6
>
> 2 NO

2\. Did you have to take time off from work to have this interview
today?

1 YES

2 NO

3\. Did you need to find childcare to have this interview today?

> 1 YES
>
> 2 NO

4\. Were there any other major obstacles for you to have this interview
today?

> 1 YES
>
> 2 NO  SKIP TO Q6

5\. What were they? (ENTER VERBATIM)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7.  Is there anything you especially *dis*like about participating in
    this study? (ENTER VERBATIM)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[]{.mark}

8.  Finally, do you have any recommendations as to what we could do
    differently in the overall study or in these interviews? (ENTER
    VERBATIM)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[]{.mark}

{END OF ACCEPTABILITY MODULE}