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

NCS
Herald
Cohort
Study
Instrument
#
2
Female
Screener
Eligibility:
All
potentially
eligible
women
Mode
of
Administration:
Interviewer,
home
visit
8/
4/
2005
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
10
minutes
per
response,
including
the
time
for
reviewing
instructions,
searching
existing
data
sources,
gathering
and
maintaining
the
data
needed,
and
completing
and
reviewing
the
collection
of
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.
Send
comments
regarding
this
burden
estimate
or
any
other
aspect
of
this
collection
of
information,
including
suggestions
for
reducing
this
burden,
to:
Dr.
Pauline
Mendola,
US
EPA,
MD­
58A,
Research
Triangle
Park,
NC
27711.
E­
mail:
mendola.
pauline@
epa.
gov.
Female
Screener
(
Instrument
#
2)

2
PRELOADED
DATA:
Today's
date
Mode
of
administration
(
in­
person/
telephone)

Respondent
Name
(
preload
from
household
rostering)

Respondent
Address
(
preload
from
household
rostering)

(
INTERVIEWER:
IF
THE
SCREENING
RESPONDENT
IS
NOT
THE
ROSTERING
RESPONDENT,
NEED
TO
INTRODUCE
SELF
AND
STUDY)

Hello,
my
name
is
______
with
RTI
International
in
North
Carolina.
We
are
conducting
a
study
of
children's
health
sponsored
by
the
U.
S.
Environmental
Protection
Agency.
You
should
have
received
a
letter
explaining
the
study.
(
HAND
R
COPY
OF
LETTER
)
Also,
we
spoke
to
someone
in
this
household
who
provided
us
information
that
you
might
be
eligible
to
participate
in
this
study.
I
have
just
a
few
questions
to
ask
you,
let's
begin.

[
FI:
IF
RESPONDENT
SPEAKS
ENGLISH,
CONTINUE.

IF
RESPONDENT
SPEAKS
SPANISH
AND
YOU
ARE
UNABLE
TO
DETERMINE
IF
SHE
IS
ABLE
TO
COMPLETE
THE
INTERVIEW
IN
ENGLISH,
GIVE
HER
SPANISH
LANGUAGE
CARD
(
WHICH
ASKS
IF
SHE
WOULD
RATHER
COMPLETE
IN
SPANISH
AND
IF
YES
EXPLAINS
A
SPANISH
SPEAKING
INTERVIEWER
WILL
CONTACT
HER.
CODE
AS
"
SPANISHLANGUAGE

IF
RESPONDENT
IS
UNABLE
TO
CONTINUE
IN
ENGLISH
OR
SPANISH,
CODE
AS
"
LANGUAGE
BARRIER­
OTHER"].

QUESTIONNAIRE:

1.
Just
to
verify,
is
your
name
(
insert
name
from
preload)?

1
YES
2
NO

(
Interviewer,
ask
to
speak
to
correct
respondent)

1a.
Could
I
have
your
full
name?
_______________________

2.
What
is
your
date
of
birth?

MM/
DD/
YYYY

(
calculate
age;
If
less
than
18
years
of
age,
respondent
is
ineligible

GO
TO
END
SCRIPT
#
2
3.
Are
you
of
Hispanic
or
Spanish
origin?

1
YES
2
NO

SKIP
TO
Q4
3a.
Are
you 
(
Interviewer,
read
responses.
Code
all
that
apply.)

1
Mexican,
Mexican­
American,
or
Chicano
Female
Screener
(
Instrument
#
2)

3
2
Puerto­
Rican
3
Cuban
4
Other
(
specify)

4.
What
is
your
race?
(
Code
all
that
apply)

1
WHITE
2
BLACK
OR
AFRICAN­
AMERICAN
3
AMERICAN
INDIAN
OR
ALASKA
NATIVE
4
NATIVE
HAWAIIAN
5
GUAMANIAN
OR
CHAMORRO
6
SAMOAN
7
OTHER
PACIFIC
ISLANDER
(
SPECIFY)
8
ASIAN
INDIAN
9
CHINESE
10
FILIPINO
11
JAPANESE
12
KOREAN
13
VIETNAMESE
14
OTHER
ASIAN
(
SPECIFY)
15
OTHER
RACE
(
SPECIFY)

5.
In
what
country
were
you
born?

1
USA
2
OTHER
(
SPECIFY)
_______________________

6.
What
is
the
highest
grade
or
level
of
school
that
you
have
completed
or
the
highest
degree
you
have
received?

1
No
high
school
degree

What
is
the
highest
grade
of
school
you
completed?
(
Enter
grade)
____
2
High
school
diploma
3
GED
or
equivalent
4
Some
college
5
Associate
(
2­
year)
degree
6
Bachelor's
degree
7
Master's
degree
8
Professional
degree
9
Doctoral
degree
7.
Are
you
currently
pregnant?

1
YES
2
NO

SKIP
TO
Q9
3
DON'T
KNOW

SKIP
TO
Q9
8.
What
is
your
due
date?

MM/
DD/
YYYY

SKIP
TO
Q14
Don't
know

What
was
the
first
day
of
your
last
menstrual
period?
MM/
DD/
YYYY
[
SKIP
TO
Q14]
Female
Screener
(
Instrument
#
2)

4
9.
Which
of
the
following
statements
best
describes
your
current
feelings
about
becoming
pregnant?

1
I
am
trying
to
get
pregnant
now
2
I
don't
wish
to
get
pregnant
now,
but
I
would
like
to
get
pregnant
within
the
next
three
months
3
I
would
like
to
get
pregnant
sometime
in
the
future,
but
not
in
the
next
three
months
4
I
do
not
ever
wish
to
get
pregnant
10.
Have
you
ever
been
told
by
a
doctor
that
it
would
be
impossible
for
you
to
get
pregnant
without
medical
help?

1
YES

Ineligible.
SKIP
TO
END
SCRIPT
#
2
2
NO
11.
Are
you
currently
sexually
active?

1
YES
2
NO

SKIP
TO
Q14
12.
Do
you
currently
use
any
form
of
birth
control?
By
birth
control,
I
mean
anything
that
you
might
have
done
to
prevent
pregnancy.

1
YES
2
NO

SKIP
TO
Q14
13.
What
form(
s)
of
birth
control
do
you
use?
(
Code
all
that
apply)

1
Birth
control
pills
2
IUD
3
Depo­
Provera/
Norplant
4
Condoms
5
Rhythm
Method
6
Diaphragm
7
Other
(
SPECIFY)_________________

14.
My
records
indicate
that
your
home
address
is
[
PRELOAD
STREET
ADDRESS
FROM
HOUSEHOLD
ENUMERATION].
Is
this
correct?

1
YES
2
NO

What
is
your
home
address?
(
Specify)
__________________

15.
How
long
have
you
lived
at
this
address?

___
Years
___
Months
16.
(
If
pregnant,
ask)
Do
you
plan
to
move
from
this
address
before
you
have
your
baby?
(
If
not
pregnant,
ask)
Do
you
plan
to
move
from
this
address
within
the
next
year?

1
YES
2
NO

IF
PREGNANT,
SKIP
TO
Q18.
IF
NOT
PREGNANT,
SKIP
TO
END
SCRIPT
#
1
Female
Screener
(
Instrument
#
2)

5
17.
Where
do
you
plan
to
move?
(
Interviewer:
collect
complete
address
if
possible.
If
unknown,
collect
city
and
state.)

________________________________________________________________________

[
IF
MOVING
OUT
OF
STUDY
AREA,
INELIGIBLE.
SKIP
TO
END
SCRIPT
#
2]

18.
(
If
pregnant,
ask)
What
is
the
name
of
your
OB/
GYN
doctor?

1
NAME
(
SPECIFY_
_______________________________
2
DO
NOT
HAVE
A
DOCTOR
YET
3
REFUSED
19.
(
If
pregnant,
ask)
Where
do
you
plan
to
deliver?

1
HOSPITAL
(
SPECIFY)
_______________________________
2
OTHER
(
SPECIFY)
______________________________
3
DON'T
KNOW
4
REFUSED
20.
What
is
your
current
marital
status?
Are
you 

1
Married,
2
Widowed,
3
Divorced,
4
Separated,
5
Living
with
a
partner
in
a
committed
relationship,
6
In
a
committed
relationship,
but
not
living
together,
or
7
Single,
never
married?

[
RULES
FOR
CAPTURING
HUSBAND/
PARTNER
INFORMATION

If
the
woman
is
PREGNANT
but
is
widowed,
divorced,
separated,
or
single,
capture
contact
information
about
the
father
of
her
child

If
the
woman
is
PREGNANT
and
married
or
has
a
partner,
capture
contact
information
about
husband
or
whomever
she
identifies
as
her
partner

If
the
woman
is
NOT
PREGNANT
and
married
or
has
a
partner,
capture
contact
information
about
her
husband
or
partner.]

In
order
to
determine
if
{
FILL:
your
husband/
your
partner/
the
father
of
your
child}
would
also
like
to
participate
in
the
study,
we
would
like
to
collect
some
contact
information.

21.
What
is
{
FILL:
your
husband's
name/
your
partner's
name/
the
name
of
the
father
of
your
child}?

COLLECT
HUSBAND/
PARTNER/
BIODAD
NAME
­
7
REFUSED

SKIP
TO
END
SCRIPT
1
Female
Screener
(
Instrument
#
2)

6
22.
[
CAPI
INSTRUCTION:
AUTOMATICALLY
FILL
`
MALE'
IF
Q20=
1
OR
IF
WOMAN
IS
PREGNANT
AND
Q20=
2,
3,
4,
OR
7.
THEN
GO
TO
NEXT
QUESTION
]
INTERVIEWER,
CODE
WHETHER
PARTNER
IS
MALE
OR
FEMALE
BASED
ON
NAME
REPORTED
IN
QUESTION
21.
IF
UNSURE,
ASK:
Is
your
partner
male
or
female?

1
MALE
2
FEMALE
23.
What
is
{
FILL:
his/
her}
address
and
telephone
number?

COLLECT
CONTACT
INFO

IF
PREGNANT,
SKIP
TO
END
SCRIPT
#
1
­
7
REFUSED

SKIP
TO
END
SCRIPT
#
1
24.
[
ASK
ONLY
IF
PREGNANT
AND
MARRIED
OR
HAS
MALE
PARTNER]
Is
this
person
the
biological
father
of
your
child?

1
YES
2
NO
END
SCRIPT
#
1:
Thank
you
for
answering
these
questions.
Based
on
your
answers,
you
are
eligible
to
participate
in
this
important
study.

[
CAPI
will
assign
woman
to
a
category
based
on
responses
to
screener.
High=
women
currently
trying
to
get
pregnant
or
those
who
are
sexually
active
and
not
using
birth
control
Moderate=
sexually
active
women
using
barrier
or
rhythm
methods
Low=
women
not
sexually
active
or
sexually
active
and
using
hormonal
contraception
or
IUD]

(
INTERVIEWER:
HAND
[
FILL:
HIGH
/
MODERATE/
LOW
/
PREGNANT]
CARD
TO
RESPONDENT
DESCRIBING
THE
STUDY,
AND
REVIEW
WITH
WOMAN.)

25.
Would
you
like
to
participate
in
the
study?

1
YES

SKIP
TO
Q27
2
NO
26.
What
are
the
reasons
that
you
are
not
interested
in
participating?
(
CODE
ALL
THAT
APPLY)

1
IT
WILL
TAKE
TOO
MUCH
TIME
2
IT
IS
TOO
INVOLVED
3
DO
NOT
WANT
TO
PROVIDE
BIOLOGIC
SAMPLES
4
THERE'S
NOTHING
IN
IT
FOR
ME
(
E.
G.
INCENTIVE
INSUFFICIENT)
5
UNCOMFORTABLE
BEING
IN
GOVERNMENT
STUDY
6
CONCERNED
ABOUT
RISKS
TO
MY
HEALTH
/
MY
CHILD'S
HEALTH
7
OTHER
(
SPECIFY)
______________

[
IF
Q25=
NO,
READ:
Thank
you
very
much,
let
me
leave
my
name
and
number
in
case
you
change
your
mind.
]
Female
Screener
(
Instrument
#
2)

7
27.
What
is
the
best
telephone
number
to
reach
you
at?

###­###­####

28.
What
are
the
best
days
and
times
to
reach
you?

DAYS:
TIMES:
MON
MORNING
(
9
AM
 
NOON)
TUE
EARLY
AFTERNOON
(
NOON
 
3
PM)
WED
LATE
AFTERNOON/
EARLY
EVENING
(
3
PM
 
6
PM)
THU
EVENING
(
6
PM
 
9
PM)
FRI
SAT
SUN
29.
Is
there
someone
else
who
would
know
how
to
contact
you
in
case
you
move?

1
YES
2
NO
­
9
REFUSED
30.
May
I
have
this
person's
name
and
contact
information?

NAME
ADDRESS
TELEPHONE
NUMBER
31.
What
is
this
person's
relation
to
you?

1
HUSBAND
OR
PARTNER
2
PARENT
3
SIBLING
4
HUSBAND'S/
PARTNER'S
PARENT
5
OTHER
RELATIVE
6
FRIEND
7
OTHER
(
SPECIFY)
______________

READ
TO
PARTICIPANT:
"
Thank
you
for
your
time
today.
We
will
be
in
contact
shortly
to
schedule
a
convenient
time
to
begin
your
participation
in
this
study.
Have
a
good
day.
"
[
END]

END
SCRIPT
#
2:
Thank
you
for
your
time,
but
based
on
your
answers
to
these
questions
you
are
not
eligible
to
participate
in
this
study.