Document ID: EPA-HQ-ORD-2005-0010-0013
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2005-09-28T04:00Z

NCS
Herald
Cohort
Study
Instrument
#
5
Mental
Health
and
Financial
Security
Self­
Administered
Questionnaire
for
Females
and
Partners
Preconception
Initial
Visit
Eligibility:
All
women
enrolled
preconception,
not
yet
pregnant,
and
their
partners
Mode
of
Administration:
Self­
administered,
take
home
8/
4/
2005
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
15
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.
Mental
Health/
Financial
Security
Preconception
1
(
Instrument
#
5)

1
PRELOADED
DATA:
Today's
date
Language
of
interview
(
English/
Spanish)

Respondent
Name
Respondent
Address
and
Phone
Spouse/
Partner's
Name
(
Preload
from
screener)

Spouse/
Partner's
Address
and
Phone
(
Preload
from
screener)

Marital
status
(
Preload
from
screener)

QUESTIONNAIRE:
Mental
Health/
Financial
Security
Preconception
1
(
Instrument
#
5)

2
SECTION
A.
MOS
For
this
section,
please
think
about
the
past
month.

A.
1.
How
many
relatives
do
you
have
that
you
feel
close
to­­
people
you
feel
comfortable
with,
can
talk
with
about
personal
things,
or
can
ask
for
help
if
you
need
it?
(
Include
your
husband,
parents,
children
and
other
relatives.)

_____
relatives
A.
2.
How
many
close
friends
do
you
have
that
you
feel
close
to­­
people
you
feel
comfortable
with,
can
talk
with
about
personal
things,
or
can
ask
for
help
if
you
need
it?

_____
friends
People
sometimes
look
to
others
for
companionship,
assistance,
or
other
types
of
support.
Please
circle
one
number
to
indicate
how
often
you
feel
each
of
the
following
kinds
of
support
has
been
available
to
you
if
you
needed
it.
Remember
to
think
about
how
you
have
felt
during
the
past
month.

DURING
THE
PAST
MONTH,
HOW
OFTEN
WAS
THIS
SUPPORT
AVAILABLE
TO
YOU:
rarely
or
none
of
the
time
a
little
of
the
time
some
of
the
time
most
of
the
time
all
of
the
time
A.
3.
Someone
to
help
me
if
I
were
confined
to
bed
1
2
3
4
5
A.
4.
Someone
I
could
count
on
to
listen
to
me
when
I
need
to
talk
1
2
3
4
5
A.
5.
Someone
to
give
me
good
advice
about
a
crisis
1
2
3
4
5
A.
6.
Someone
to
take
me
to
the
doctor
if
I
needed
it
1
2
3
4
5
A.
7.
Someone
who
shows
me
love
and
affection
1
2
3
4
5
A.
8.
Someone
to
have
a
good
time
with
1
2
3
4
5
Mental
Health/
Financial
Security
Preconception
1
(
Instrument
#
5)

3
DURING
THE
PAST
MONTH,
HOW
OFTEN
WAS
THIS
SUPPORT
AVAILABLE
TO
YOU:
rarely
or
none
of
the
time
a
little
of
the
time
some
of
the
time
most
of
the
time
all
of
the
time
A.
9.
Someone
to
give
me
information
to
help
me
understand
a
situation
1
2
3
4
5
A.
10.
Someone
to
confide
in
or
talk
to
about
myself
or
my
problems
1
2
3
4
5
A.
11.
Someone
who
hugs
me
1
2
3
4
5
A.
12.
Someone
to
get
together
with
for
relaxation
1
2
3
4
5
A.
13.
Someone
to
prepare
my
meals
if
I
were
unable
to
do
it
myself
1
2
3
4
5
A.
14.
Someone
whose
advice
I
really
want
1
2
3
4
5
A.
15.
Someone
to
do
things
with
to
help
me
get
my
mind
off
things
1
2
3
4
5
A.
16.
Someone
to
help
with
daily
chores
if
I
were
sick
1
2
3
4
5
A.
17.
Someone
to
share
my
most
private
worries
and
fears
with
1
2
3
4
5
A.
18.
Someone
to
turn
to
for
suggestions
about
how
to
deal
with
a
personal
problem
1
2
3
4
5
A.
19.
Someone
to
do
something
enjoyable
with
1
2
3
4
5
A.
20.
Someone
who
understands
my
problems
1
2
3
4
5
A.
21.
Someone
to
love
and
make
me
feel
wanted
1
2
3
4
5
Mental
Health/
Financial
Security
Preconception
1
(
Instrument
#
5)

4
SECTION
B.
CESD
For
this
section,
please
think
about
the
past
week.

Below
is
a
list
of
some
of
the
ways
you
may
have
felt
or
behaved.
Please
indicate
how
often
you
have
felt
this
way
during
the
past
week
by
circling
one
number
for
each
item.

DURING
THE
PAST
WEEK,
HOW
OFTEN
DID
YOU
FEEL
THIS
WAY?
rarely
or
none
of
the
time
(
less
than
one
day)
some
or
a
little
of
the
time
(
1­
2
days)
occasionally
or
moderate
amount
of
time
(
3­
4
days)
most
or
all
of
the
time
(
5­
7
days)

B.
1.
I
was
bothered
by
things
that
didn't
usually
bother
me.
1
2
3
4
B.
2.
I
did
not
feel
like
eating;
my
appetite
was
poor.
1
2
3
4
B.
3.
I
felt
that
I
could
not
shake
off
the
blues
even
with
help
from
my
family
and
friends.
1
2
3
4
B.
4.
I
felt
that
I
was
just
as
good
as
other
people.
1
2
3
4
B.
5
I
felt
I
had
trouble
keeping
my
mind
on
what
I
was
doing.
1
2
3
4
B.
6.
I
felt
depressed.
1
2
3
4
B.
7
I
felt
that
everything
I
did
was
an
effort.
1
2
3
4
B.
8.
I
felt
hopeful
about
the
future.
1
2
3
4
B.
9
I
thought
my
life
had
been
a
failure.
1
2
3
4
B.
10.
I
felt
fearful.
1
2
3
4
B.
11.
I
felt
my
sleep
was
restless.
1
2
3
4
Mental
Health/
Financial
Security
Preconception
1
(
Instrument
#
5)

5
DURING
THE
PAST
WEEK,
HOW
OFTEN
DID
YOU
FEEL
THIS
WAY?
rarely
or
none
of
the
time
(
less
than
one
day)
some
or
a
little
of
the
time
(
1­
2
days)
occasionally
or
moderate
amount
of
time
(
3­
4
days)
most
or
all
of
the
time
(
5­
7
days)

B.
12.
I
was
happy.
1
2
3
4
B.
13.
I
talked
less
than
usual.
1
2
3
4
B.
14.
I
felt
lonely.
1
2
3
4
B.
15.
I
felt
people
were
unfriendly.
1
2
3
4
B.
16.
I
enjoyed
life.
1
2
3
4
B.
17.
I
had
crying
spells.
1
2
3
4
B.
18.
I
felt
sad.
1
2
3
4
B.
19.
I
felt
that
people
disliked
me.
1
2
3
4
B.
20.
I
could
not
A
get
going."
1
2
3
4
Mental
Health/
Financial
Security
Preconception
1
(
Instrument
#
5)
6
SECTION
C.

Listed
below
are
some
things
that
might
have
occurred
to
you
during
the
past
month
(
the
last
4
weeks
or
so).

Please
circle
yes
for
those
items
you
have
experienced
during
the
past
month,
and
circle
no
if
you
have
not
experienced
the
item.

If
you
circle
yes,
then
circle
one
of
the
next
numbers
to
show
whether
you
think
this
had
a
negative
or
bad
impact,
or
a
positive
or
good
impact.

For
example,
circle
 
3
if
it
was
an
extremely
negative
or
bad
impact.
Circle
0
if
you
thought
there
was
no
impact.
Circle
+
3
to
indicate
an
extremely
positive
impact.
Negative/
Bad
or
Positive/
Good
impact
on
your
life?

­­­­­­­­
Negative/
Bad
­­­­­­­­
­­­­­­­
Positive/
Good
­­­­­­­­

DURING
THE
PAST
MONTH,

HAVE
YOU:
Did
this
happen
during
the
past
month?
Extremely
negative
Moderately
negative
somewhat
negative
no
impact
somewhat
positive
moderately
positive
extremely
positive
C.
1.
gotten
married
[
wedding
during
past
month]
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
2.
been
in
jail
or
a
similar
institution
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
3.
had
your
spouse
or
partner
die
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
4.
had
a
major
change
in
your
sleeping
habits
(
much
more
sleep
or
much
less
sleep)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
5.
experienced
the
death
of
a
close
family
member
(
your
child,
father,
mother,
sister,
brother,

grandparent
or
other)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
6.
had
a
major
change
in
your
eating
habits
(
ate
much
more
or
less
food)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
7.
experienced
a
foreclosure
on
a
mortgage
or
a
loan
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
8.
experienced
the
death
of
a
close
friend
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
9.
had
an
outstanding
personal
achievement
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
Mental
Health/
Financial
Security
Preconception
1
(
Instrument
#
5)
7
Negative/
Bad
or
Positive/
Good
impact
on
your
life?

­­­­­­­­
Negative/
Bad
­­­­­­­­
­­­­­­­
Positive/
Good
­­­­­­­­

DURING
THE
PAST
MONTH,

HAVE
YOU:
Did
this
happen
during
the
past
month?
extremely
negative
Moderately
negative
somewhat
negative
no
impact
somewhat
positive
moderately
positive
extremely
positive
C.
10.
had
a
minor
law
violation
(
such
as
a
traffic
ticket
or
disturbing
the
peace)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
11.
changed
your
work
situation
(
such
as
different
work
responsibility,
a
major
change
in
working
conditions
or
working
hours)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
12.
started
a
new
job
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
13.
had
one
of
your
close
family
members
have
a
serious
illness
or
injury
(
your
spouse/
partner,

child,
father,
mother,
sister,
brother,

grandparent
or
other)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
14.
had
sexual
difficulties
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
15.
had
trouble
with
your
boss
(
such
as
you
were
in
danger
of
losing
your
job,
being
suspended,
or
demoted)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
16.
had
trouble
with
your
in­
laws
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
17.
had
a
major
change
in
your
financial
status
(
a
lot
better
off
or
a
lot
worse
off)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
18.
had
a
major
change
in
your
closeness
to
family
members
(
increased
or
decreased
closeness)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
19.
gained
a
new
family
member
(
through
adoption
or
a
family
member
moving
in)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
20.
moved
to
a
new
place
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
Mental
Health/
Financial
Security
Preconception
1
(
Instrument
#
5)
8
Negative/
Bad
or
Positive/
Good
impact
on
your
life?

­­­­­­­­
Negative/
Bad
­­­­­­­­
­­­­­­­
Positive/
Good
­­­­­­­­

DURING
THE
PAST
MONTH,

HAVE
YOU:
Did
this
happen
during
the
past
month?
extremely
negative
Moderately
negative
somewhat
negative
no
impact
somewhat
positive
moderately
positive
extremely
positive
C.
21.
had
a
separation
from
your
spouse
or
partner
because
you
were
not
getting
along
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
22.
had
a
major
change
in
church
activities
(
increased
or
decreased
attendance)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
23.
got
back
together
with
your
spouse
or
partner
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
24.
had
a
major
change
in
the
number
of
arguments
you
have
with
your
spouse
or
partner
(
a
lot
more
or
a
lot
fewer
arguments)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
25.
had
a
change
in
your
spouse's
or
partner's
work
(
lost
job
or
started
a
new
job)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
26.
had
a
major
change
in
the
usual
type
and/
or
amount
of
recreation
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
27.
borrowed
more
than
$
15,000
(
such
as
buying
a
home
or
business)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
28.
borrowed
less
than
$
15,000
(
such
as
buying
a
car
or
getting
a
school
loan)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
29.
been
fired
from
a
job
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
30.
had
a
major
personal
illness
or
injury
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
31.
had
a
major
change
in
social
activities,
such
as
parties,
movies,
visiting,
either
increased
or
decreased
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
Mental
Health/
Financial
Security
Preconception
1
(
Instrument
#
5)
9
Negative/
Bad
or
Positive/
Good
impact
on
your
life?

­­­­­­­­
Negative/
Bad
­­­­­­­­
­­­­­­­
Positive/
Good
­­­­­­­­

DURING
THE
PAST
MONTH,

HAVE
YOU:
Did
this
happen
during
the
past
month?
extremely
negative
Moderately
negative
somewhat
negative
no
impact
somewhat
positive
moderately
positive
extremely
positive
C.
32.
had
a
major
change
in
living
conditions
of
your
family
(
built
a
new
home,
remodeled,
had
your
home
or
neighborhood
decline)
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
33.
got
a
divorce
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
34.
had
a
close
friend
with
a
serious
injury
or
illness
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
35.
had
a
son
or
daughter
leave
home,
such
as
because
of
a
marriage
or
school
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
36.
ended
your
formal
schooling
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
37.
had
a
separation
from
your
spouse
because
of
work,
travel,
or
family
needs
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
38.
got
engaged
to
be
married
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
C.
39.
left
home
for
the
first
time
no
yes

­
3
­
2
­
1
0
+
1
+
2
+
3
Mental
Health/
Financial
Security
Preconception
1
10
Section
D
Cohen
Perceived
Stress
Scale
Now
think
about
how
often
you
felt
or
thought
these
certain
ways
during
the
past
month.

Although
some
of
the
questions
are
similar,
there
are
differences
between
them.
Be
sure
to
treat
each
one
as
a
separate
question.
Don't
spend
too
much
time
thinking
about
your
answer
­
the
best
approach
is
to
answer
each
question
quickly.

In
the
past
month,
how
often
have
you 

Never
Almost
never
Sometimes
Fairly
Often
Very
Often
D.
1.
been
upset
because
of
something
that
happened
unexpectedly?
0
1
2
3
4
D.
2.
felt
that
you
were
unable
to
control
the
important
things
in
your
life?
0
1
2
3
4
D.
3.
felt
nervous
and
Astressed?@
0
1
2
3
4
D.
4.
felt
confident
about
your
ability
to
handle
your
personal
problems?
0
1
2
3
4
D.
5.
felt
that
things
were
going
your
way?
0
1
2
3
4
D.
6.
found
that
you
could
not
cope
with
all
the
things
that
you
had
to
do?
0
1
2
3
4
D.
7.
been
able
to
control
irritations
in
your
life?
0
1
2
3
4
D.
8.
felt
that
you
were
on
top
of
things?
0
1
2
3
4
D.
9.
been
angered
because
of
things
that
happened
that
were
outside
your
control?
0
1
2
3
4
D.
10.
felt
difficulties
were
piling
up
so
high
that
you
could
not
overcome
them?
0
1
2
3
4
Mental
Health/
Financial
Security
Preconception
1
11
SECTION
E.

The
next
few
questions
are
about
whether
you
feel
you
have
enough
money
for
yourself
and
the
people
in
your
house.

E.
1.
At
this
time,
do
you
feel
you
are
able
to
afford
a
home
suitable
for
yourself
and
your
family?

1
YES
2
NO
E.
2.
Do
you
feel
you
are
able
to
afford
the
furniture
or
household
equipment
that
you
need
at
this
time?

1
YES
2
NO
E.
3.
Do
you
feel
you
are
you
able
to
afford
the
kind
of
car
you
need?

1
YES
2
NO
E.
4.
At
this
time,
do
you
have
enough
money
for
the
kind
of
food
you
think
you
and
your
family
should
have?

1
YES
2
NO
E.
5.
Do
you
have
enough
money
for
the
kind
of
medical
care
you
and
your
family
should
have?

1
YES
2
NO
E.
6.
At
this
time,
do
you
have
enough
money
for
the
kind
of
clothing
you
and
your
family
should
have?

1
YES
2
NO
E.
7.
Do
you
have
enough
money
for
the
leisure
activities
you
and
your
family
want?

1
YES
2
NO
Mental
Health/
Financial
Security
Preconception
1
12
E.
8.
How
difficult
is
it
for
you
and
your
family
to
pay
your
bills?

1.
Very
difficult
2.
Somewhat
difficult
3.
Not
very
difficult
4.
Not
difficult
at
all
E.
9.
At
the
end
of
the
month,
how
much
money
would
you
say
you
end
up
with?

1.
Not
enough
money
2.
Just
enough
money
3.
Some
money
left
over
4.
A
lot
of
money
left
over
E.
10
In
the
last
12
months,
did
you
or
any
member
of
your
household
receive
benefits
from
the
WIC
program,
that
is,
the
Women,
Infants
and
Children
program?

1
YES
2
NO
E.
11
In
the
last
12
months,
were
you
or
any
members
of
your
household
authorized
to
receive
Food
Stamps
(
which
includes
a
food
stamp
card
or
voucher,
or
cash
grants
from
the
state
for
food)?

1
YES
2
NO