Document ID: EPA-HQ-ORD-2005-0010-0018
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2005-09-28T04:00Z

NCS
Herald
Cohort
Study
Instrument
#
10
Female
Preconception
Telephone
Follow­
Up
Eligibility:
All
women
enrolled
preconception,
not
yet
pregnant
Mode
of
administration:
Interviewer,
telephone
call
8/
4/
2005
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
5
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
Preconception
Telephone
Follow­
up
(
Instrument
#
10)

2
PRELOADED
DATA:

Today's
date
Language
of
interview
(
English/
Spanish)

Mode
of
administration
(
telephone)

Respondent
Name
Respondent
Address
QUESTIONNAIRE:
Female
Preconception
Telephone
Follow­
up
(
Instrument
#
10)

3
Pregnancy
Status
(
Update)

Now
I'd
like
to
ask
you
about
your
pregnancy
status
and
plans.

1.
Are
you
currently
pregnant?

1
YES
2
NO

SKIP
TO
Q3
3
DON'T
KNOW

SKIP
TO
Q3
2.
What
is
your
due
date?

MM/
DD/
YYYY

SKIP
TO
Q6
DON'T
KNOW

What
was
the
first
day
of
your
last
menstrual
period?
MM/
DD/
YYYY

SKIP
TO
Q6
3.
Which
of
the
following
statements
best
describes
your
current
feelings
about
becoming
pregnant?

1
I
am
trying
to
get
pregnant
now
2
I
don't
wish
to
get
pregnant
now,
but
I
would
like
to
get
pregnant
within
the
next
three
months
3
I
would
like
to
get
pregnant
sometime
in
the
future,
but
not
in
the
next
three
months
4
I
do
not
ever
wish
to
get
pregnant
4.
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
Q6
5.
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)

6.
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)
_________________

7.
(
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
before
{
FILL
END
DATE
FOR
FOLLOWUP

1
YES
2
NO

IF
PREGNANT,
SKIP
TO
Q9.
IF
NOT
PREGNANT,
SKIP
TO
END
Female
Preconception
Telephone
Follow­
up
(
Instrument
#
10)

4
8.
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
9.
(
If
pregnant,
ask)
What
is
the
name
of
your
OB/
GYN
doctor?

DO
NOT
HAVE
A
DOCTOR
YET
REFUSED
SPECIFY
NAME
_______________________________

10.
(
If
pregnant,
ask)
Where
do
you
plan
to
deliver?

1
DON'T
KNOW
2
REFUSED
3
SPECIFY
HOSPITAL
_______________________________
4
OTHER
(
SPECIFY)
_______________________________

[
IF
PREGNANT:
SCHEDULE
1ST
PREGNANCY
HOME
VISIT
(
INSTRUMENT
#
11)]
[
END]

[
IF
NOT
PREGNANT
READ
THE
FOLLOWING
SCRIPT:
"
Thank
you
for
your
time
today,
please
remember
to
contact
us
should
you
find
out
that
you
are
pregnant.
Have
a
good
day."
[
END]]