Document ID: EPA-HQ-ORD-2005-0010-0020
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2005-09-28T04:00Z

NCS
Herald
Cohort
Study
Instrument
#
12
Partner
(
enrolled
preconception)
Questionnaire
Pregnancy
First
Trimester
Home
Visit
Eligibility:
All
partners
enrolled
while
woman
was
not
pregnant
but
became
pregnant
Mode
of
administration:
Interviewer,
home
visit
8/
4/
2005
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
30
minutes
per
response,
including
the
time
for
reviewing
instructions,
searching
existing
data
sources,
gathering
and
maintaining
the
data
needed,
and
completing
and
reviewing
the
collection
of
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.
Send
comments
regarding
this
burden
estimate
or
any
other
aspect
of
this
collection
of
information,
including
suggestions
for
reducing
this
burden,
to:
Dr.
Pauline
Mendola,
US
EPA,
MD­
58A,
Research
Triangle
Park,
NC
27711.
E­
mail:
mendola.
pauline@
epa.
gov.
Partner
Pregnancy
1
(
Instrument
#
12)

1
PRELOADED
DATA:

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
QUESTIONNAIRE:
Partner
Pregnancy
1
(
Instrument
#
12)

2
Occupation
(
Update)

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

1
YES

SKIP
TO
Q4
2
NO
2.
Are
you
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
[
PROGRAMMING
INSTRUCTIONS]
Q3=
YES,
STILL
WORKING

SKIP
TO
Q6
Q3=
YES,
STILL
LOOKING
FOR
WORK

GO
TO
NEXT
MODULE
Q3=
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
Partner
Pregnancy
1
(
Instrument
#
12)

3
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
Q7­
Q13
FOR
UP
TO
3
JOBS]
2
NO

GO
TO
NEXT
MODULE
{
END
OF
OCCUPATION
MODULE}
Partner
Pregnancy
1
(
Instrument
#
12)

4
Chemical
Exposures
(
Update)

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

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

1
YES

IF
NO
PREVIOUS
EXPOSURES,
SKIP
TO
END
2
NO
2.
[
IF
Q1=
1,
ASK:]
Are
you
currently
also
exposed
to
any
of
the
following
chemicals?
[
IF
Q1=
2,
ASK:]
Which
of
the
following
chemicals
are
you
currently
exposed
to?

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

YES
NO

SKIP
TO
NEXT
EXPOSURE
3.
How
often
are
you
exposed
to
[
INSERT
EXPOSURE]
?
Would
you
say.
.
.

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

2.
Currently
Exposed
Yes
=
01
No
=
02
3.
Frequency
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
4.
At
work
Yes
=
01
No
=
02
A.
Fuels,
solvents,
dry
cleaning
fluids,
degreasers,
or
adhesives
B.
Lead,
including
paints
with
lead
in
them
C.
Fumes
or
gases
(
e.
g.,
nitrous
oxide,
ethylene
oxide,
anesthetic
gases)
D.
Radiation
(
e.
g.,
fluoroscopy,
radioisotopes,
highintensity
microwaves,
x­
rays)
E.
Mercury
F.
Metal
fumes
or
particles
G.
Pesticides
that
you've
mixed
or
applied
H.
Paints,
strippers,
or
varnishes
I.
Hair
and
nail
products
(
e.
g,
hair
dye,
bleach,
hair
relaxer,
nail
polish
and
remover)
J.
Cleaning
products
(
e.
g.,
oven
cleaner,
disinfectant,
carpet
cleaner,
bleach)
K.
Carbon
black
from
copying
machines
L.
Coal
or
coal
products
from
hot
asphalt,
tar,
or
roofing
material
{
END
OF
CHEMICAL
EXPOSURES
MODULE}
Partner
Pregnancy
1
(
Instrument
#
12)

5
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
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
Partner
Pregnancy
1
(
Instrument
#
12)

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

__________________________

{
END
OF
PERSONAL
MEDICAL
HISTORY
MODULE}
Partner
Pregnancy
1
(
Instrument
#
12)

7
Feelings
about
pregnancy
(
Full)

The
next
questions
are
about
the
time
before
your
{
FILL:
wife
/
partner}
got
pregnant.

1.
Which
of
the
following
statements
best
describes
you
during
the
3
months
before
your
{
FILL:
wife
/
partner}
got
pregnant?

1
I
wanted
her
to
get
pregnant
2
I
partly
wanted
her
to
get
pregnant
and
partly
wanted
her
not
to
get
pregnant
3
I
didn't
care
one
way
or
the
other
whether
she
got
pregnant
4
I
didn't
especially
want
her
to
get
pregnant
5
I
wanted
very
much
for
her
not
to
get
pregnant
2.
How
did
you
feel
when
you
found
out
your
{
FILL:
wife
/
partner}
was
pregnant?
Were
you
 
1
Very
unhappy
2
Unhappy
3
Not
sure
4
Happy
5
Very
happy
{
END
OF
PREGNANCY
FEELINGS
MODULE}
Partner
Pregnancy
1
(
Instrument
#
12)

8
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}
Partner
Pregnancy
1
(
Instrument
#
12)

9
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
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?
Partner
Pregnancy
1
(
Instrument
#
12)

10
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}
Partner
Pregnancy
1
(
Instrument
#
12)

11
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
Q3
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
dislike
about
participating
in
this
study?
(
ENTER
VERBATIM)

____________________________

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

____________________________

{
END
OF
ACCEPTABILITY
MODULE}