Document ID: EPA-HQ-ORD-2005-0010-0030
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2005-09-28T04:00Z

NCS
Herald
Cohort
Study
Instrument
#
22
Female
Questionnaire
One
Month
Home
Visit
Eligibility:
All
women
who
gave
birth
Mode
of
administration:
Interviewer,
home
visit
8/
9/
2005
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
45
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
1
Month
(
Instrument
#
22)

1
PRELOADED
DATA:

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

Respondent
Name
Respondent
Address
and
Phone
Spouse/
Partner's
Name
Spouse/
Partner's
Address
and
Phone
Biological
father's
name
Marital
status
Last
interview
date
Student
status
Employment
status
Flag
for
house
pets
reported
Smoking
status
QUESTIONNAIRE:
Female
1
Month
(
Instrument
#
22)

2
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,
[
ADMINISTER
INSTRUMENT
#
29,
NEW
HOME
LOCATION]

{
END
OF
ADDRESS
MODULE}
Female
1
Month
(
Instrument
#
22)

3
Partner
(
update)

1.
When
we
interviewed
you
on
{
FILL
DATE},
you
said
you
were
[
FILL
MARITAL
STATUS].
Is
this
still
correct?

1
YES

SKIP
TO
Q5
2
NO
2.
What
is
your
current
marital
status?

1
Married
2
Widowed

GO
TO
NEXT
MODULE
3
Divorced

GO
TO
NEXT
MODULE
4
Separated

GO
TO
NEXT
MODULE
5
Living
with
a
partner
in
a
committed
relationship
6
In
a
committed
relationship,
but
not
living
together
7
Single,
never
married

GO
TO
NEXT
MODULE
3.
What
is
your
[
husband's/
partner's]
name?

COLLECT
HUSBAND/
PARTNER
NAME

IF
Q2=
6,
GO
TO
Q4.
ELSE,
GO
TO
NEXT
MODULE
REFUSED

GO
TO
NEXT
MODULE
4.
[
THIS
IS
ONLY
ASKED
IF
Q2=
6]
In
order
to
determine
if
your
partner
would
also
like
to
participate
in
the
study,
we
would
like
to
collect
some
contact
information.
What
is
your
partner's
address
and
telephone
number?

COLLECT
PARTNER
CONTACT
INFO

GO
TO
NEXT
MODULE
REFUSED

GO
TO
NEXT
MODULE
5.
I
would
like
to
verify
the
information
you
gave
me
the
last
time
we
interviewed
you.
I
have
your
[
husband's/
partner's]
name
as
[
PRELOAD
NAME].
Is
this
still
correct?

1
YES

GO
TO
NEXT
MODULE
2
NO
­
9
REFUSED
6.
Please
give
me
your
[
husband's/
partner's]
name
and
address.

COLLECT
INFORMATION
ON
NEW
PARTNER
REFUSED
{
END
OF
PARTNER
MODULE}
Female
1
Month
(
Instrument
#
22)

4
Occupation
(
Update,
revised
for
post­
pregnancy)

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
currently
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]
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
new
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?
Female
1
Month
(
Instrument
#
22)

5
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
Q15
15.
Are
you
currently
on
paid
or
unpaid
maternity
leave
from
any
job?

1
YES,
PAID
LEAVE
2
YES,
UNPAID
LEAVE
3
BACK
AT
WORK

SKIP
TO
Q17
16.
When
do
you
intend
to
return
to
work?
Would
you
say 

1
Within
one
month
2
Between
1
and
3
months
3
Between
4
and
6
months
4
More
than
6
months
Female
1
Month
(
Instrument
#
22)

6
17.
[
IF
BACK
AT
WORK,
ASK]
What
type
of
early
childhood
education
program
or
other
child
care
does
your
child
participate
in
while
you
are
at
work?
[
IF
NOT
BACK
AT
WORK,
ASK]
What
plans
do
you
have
for
the
care
of
your
child
when
you
go
back
to
work?
[
IF
R
DOES
NOT
WORK,
ASK]
Do
you
have
any
usual
arrangements
for
the
care
of
your
child?

1
EMPLOYER­
SPONSORED
EARLY
CHILDHOOD
EDUCATION
PROGRAMS
OR
CHILD
CARE
2
OTHER
EARLY
CHILDHOLD
EDUCATION
PROGRAMS
OR
CHILD
CARE
3
CARE
PROVIDED
BY
FAMILY
MEMBER
4
CARE
PROVIDED
BY
FRIEND
5
OTHER
(
SPECIFY)__________

18.
How
many
hours
per
week
does
your
child
spend
in
[
INSERT
ANSWER
FROM
Q5]?
____
hours
{
END
OF
OCCUPATION
MODULE}
Female
1
Month
(
Instrument
#
22)

7
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,
GO
TO
NEXT
MODULE
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}
Female
1
Month
(
Instrument
#
22)

8
Pets
and
Pests
(
update,
revised
for
post­
pregnancy)

1.
[
ASK
IF
R
REPORTED
HAVING
PETS
IN
LAST
INTERVIEW]
In
your
last
interview
on
[
FILL
DATE],
you
said
you
had
{
FILL
NUMBER
AND
TYPE
OF
HOUSEPETS}.
Is
this
still
correct?

1
YES

SKIP
TO
Q3
2
NO
2.
How
many
of
the
following
pets
do
you
currently
have?
[
READ
EACH
TYPE
OF
PET.
IF
1
OR
MORE,
ASK:

2a.
[
FILL:
Is
this
pet
/
How
many
of
these
pets
are]
kept
indoors?

Total
Number
Number
kept
indoors
a.
dogs
b.
cats
c.
gerbils,
hamsters
and
guinea
pigs
d.
rabbits
e.
birds
f.
other
(
specify)
_________________

3.
Are
any
of
your
pets
kept
in
the
same
room
where
your
baby
sleeps
most
of
the
time?

1
YES
2
NO
4.
Do
any
of
your
pets
sleep
on
the
same
bedding
as
your
baby?

1
YES
2
NO
5.
Are
any
chemicals
used
on
the
pets
to
control
fleas
and
ticks?
(
e.
g.
treated
collars,
dips,
powders,
drops,
etc.)

1
YES
2
NO

SKIP
TO
Q7
6.
What
is
the
name
of
the
products
last
used
on
your
pets
to
control
fleas
or
ticks?

IF
RESPONDENT
DOES
NOT
KNOW,
ASK
TO
SEE
THE
CONTAINERS
_____________________
_____________________

7.
Since
your
last
interview
on
{
FILL
DATE},
have
you
seen
signs
of
mice,
rats,
or
other
rodents
in
your
home
(
not
including
pets)?

1
YES
2
NO
Female
1
Month
(
Instrument
#
22)

9
8.
Since
your
last
interview,
have
you
seen
cockroaches
in
your
home?

1
YES
2
NO
{
END
OF
PETS
AND
PESTS
MODULE}
Female
1
Month
(
Instrument
#
22)

10
Medical
History
 
Child
1
month
(
Full)

The
next
questions
are
about
your
baby's
birth
and
general
health.

1.
Did
you
have
twins
or
more
than
one
baby?

1
YES
2
NO

FILL
1A
WITH
`
1'
AND
SKIP
TO
Q2
1a.
How
many
babies
did
you
have?

______

I'd
like
to
get
some
information
about
{
FILL:
your
baby
/
each
of
your
babies}.
[
CAPI
INSTRUCTION:
LOOP
THROUGH
Q2
 
Q14
FOR
NUMBER
ENTERED
IN
1A]

2.
What
is
your
{
FILL:
first/
next}
baby's
name?

___________________

3.
Is
{
FILL
NAME}
a
boy
or
a
girl?

1
MALE
2
FEMALE
4.
What
did
{
FILL
NAME}
weigh
when
{
he/
she}
was
born?

_____
lb
______
oz
5.
What
was
{
his/
her}
length?

______
inches
6.
After
your
baby
was
born,
was
{
he/
she}
put
in
an
intensive
care
unit?

1
YES
2
NO
­
9
DON'T
KNOW
7.
After
your
baby
was
born,
how
long
did
{
he/
she}
stay
in
the
hospital?

1
Less
than
24
hours
(
less
than
1
day)
2
24
to
48
hours
(
1
to
2
days)
3
3
days
4
4
days
5
5
days
6
6
days
or
more
7
My
baby
was
not
born
in
a
hospital
8
My
baby
is
still
in
the
hospital
Female
1
Month
(
Instrument
#
22)

11
8.
Has
your
baby
had
jaundice
at
any
time
since
{
he/
she}
was
born?

1
YES
2
NO

SKIP
TO
Q10
9.
How
was
the
jaundice
treated?
(
CODE
ALL
THAT
APPLY)

1
Fed
formula
in
addition
to
breastfeeding
for
a
while
2
Stopped
breastfeeding
for
a
while
3
Baby
was
placed
under
a
lamp
(
phototherapy)
4
Baby
was
placed
in
the
sun
5
Baby
received
an
exchange
transfusion
6
Baby
received
some
other
treatment
7
No
treatment
was
given
10.
Not
counting
the
time
your
baby
was
bornl,
has
{
he/
she}
been
hospitalized
for
any
reason
or
has
your
baby
been
taken
to
a
hospital
for
any
outpatient
procedure
or
surgery?

1
YES
2
NO

SKIP
TO
Q12
11.
How
many
nights
was
your
baby
in
the
hospital
for
the
most
recent
problem?
(
WRITE
0
IF
BABY
DID
NOT
STAY
OVERNIGHT)

___________
NIGHTS
12.
Has
your
baby
had
any
of
the
following
illnesses
or
problems
since
{
he/
she}
was
born?
(
CODE
ALL
THAT
APPLY)

1
Fever
2
Diarrhea
3
Vomiting
4
Ear
infection
5
Colic
6
Fussy
or
irritable
7
Runny
nose
or
cold
8
Cough
or
wheeze
9
Respiratory
Syncytial
Virus
(
RSV)
10
Weight
loss
or
poor
weight
gain
13.
Does
your
baby
have
any
severe,
long­
term
medical
problems
that
you
are
aware
of?

1
YES
2
NO

SKIP
TO
Q14
13a.
What
medical
problems?

__________________________________
Female
1
Month
(
Instrument
#
22)

12
14.
How
would
you
describe
{
FILL
NAME}'
s
health
now?

1
Excellent
2
Good
3
Fair
4
Poor
Female
1
Month
(
Instrument
#
22)

13
Developmental/
Sleep
(
1
month)

Now
I'd
like
to
ask
you
about
your
child's
behavior
and
characteristics.

1.
Below
is
a
list
of
things
your
baby
may
already
do
or
may
start
doing
when
{
he/
she}
gets
older.
How
often
does
your
baby 

Rarely
Some
of
the
time
Almost
always
Always
a.
Look
at
your
face
when
you
hold
or
feed
him/
her?
0
1
2
3
b.
Follow
you
with
his/
her
eyes?
0
1
2
3
c.
Smile
when
you
smile
at
him/
her?
0
1
2
3
d.
Smile
by
himself/
herself?
0
1
2
3
e.
Laugh
or
squeal?
0
1
2
3
f.
Lift
his/
her
head
when
lying
on
stomach?
0
1
2
3
g.
Startle
or
react
to
a
sound?
0
1
2
3
2.
Compared
to
other
babies,
do
you
think
your
baby
cries
more,
the
same,
or
less?

1
MORE
2
THE
SAME
3
LESS
3.
Can
you
usually
calm
or
console
your
baby
when
{
he/
she}
cries
1
YES
2
NO
4.
How
often
does
your
baby
have
colic,
or
times
when
{
he/
she}
cries
and
can't
be
calmed
or
consoled?

0
Rarely
1
Some
of
the
time
2
Almost
always
3
Always
5.
Do
you
think
your
baby's
crying
is
a
problem?

1
YES
2
NO
6.
Even
though
your
baby
is
only
4
weeks
old,
{
he/
she}
may
show
emotions
or
other
actions.
Overall,
would
you
describe
your
baby
as 

Yes
No
a.
Calm?
1
2
b.
Worried?
1
2
c.
Sociable
or
outgoing?
1
2
d.
Angry?
1
2
e.
Shy
or
quiet?
1
2
f.
Stubborn?
1
2
Female
1
Month
(
Instrument
#
22)

14
g.
Happy?
1
2
Now
I'll
ask
you
about
your
baby's
sleeping.

7.
In
what
position
do
you
most
often
lay
your
baby
down
for
naps?

1
Side
2
Stomach
[
IF
THIS
CHOICE
SELECTED,
GIVE
PARTICIPANT
PUBLIC
HEALTH
BROCHURE
ABOUT
SAFE
SLEEPING
POSITIONS]
3
Back
8.
In
what
position
do
you
most
often
lay
your
baby
down
to
sleep
at
night?

1
Side
2
Stomach
[
IF
THIS
CHOICE
SELECTED,
GIVE
PARTICIPANT
PUBLIC
HEALTH
BROCHURE
ABOUT
SAFE
SLEEPING
POSITIONS]
3
Back
9.
Does
your
baby
usually
sleep
in
your
room
or
in
a
different
room
at
night?

1
IN
YOUR
ROOM
2
IN
A
DIFFERENT
ROOM
10.
What
does
your
baby
usually
sleep
in
at
night?

1
Bassinette
2
Crib
3
Co­
sleeper
(
attaches
to
the
side
of
your
bed)
4
In
bed
or
other
place
with
you
5
In
something
else
{
END
OF
DEVELOPMENTAL
MODULE}
Female
1
Month
(
Instrument
#
22)

15
Infant
Safety
(
Full)

1.
I'm
going
to
read
you
some
statements
about
safety.
Do
any
of
these
statements
apply
to
you?

a.
My
infant
was
brought
home
from
the
hospital
in
an
infant
car
seat
Y
N
b.
My
home
has
a
working
smoke
alarm
Y
N
c.
There
are
loaded
guns,
rifles,
or
other
firearms
in
my
home
Y
N
[
IF
Q1a=
N,
Q1b=
N,
or
Q1c=
Y,
HAND
OUT
APPROPRIATE
PUBLIC
HEALTH
BROCHURES]

2.
Did
you
worry
that
wearing
your
seat
belt
during
pregnancy
would
hurt
your
new
baby?

1
YES
2
NO
3.
When
your
new
baby
rides
in
a
car,
truck,
or
van,
how
often
does
he
or
she
ride
in
an
infant
car
seat?

1
Always
2
Often
3
Sometimes
4
Rarely
5
Never

GO
TO
NEXT
MODULE
[
Give
participant
public
health
brochure
about
benefits
of
infant
safety
car
seats]

4.
When
your
new
baby
rides
in
an
infant
car
seat,
is
he
or
she
usually
in
the
front
or
back
seat
of
the
car,
truck,
or
van?

1
Front
seat
[
GIVE
PUBLIC
HEALTH
BROCHURE]
2
Back
seat
5.
When
your
new
baby
rides
in
an
infant
car
seat,
is
he
or
she
usually
facing
forward
or
facing
the
rear
of
the
car,
truck,
or
van?

1
Facing
forward
[
GIVE
PUBLIC
HEALTH
BROCHURE]
2
Facing
the
rear
6.
Does
the
car,
truck,
or
van
that
your
new
baby
usually
rides
in
have
an
airbag
on
the
passenger
side?

1
YES
2
NO
{
END
OF
INFANT
SAFETY
MODULE}
Female
1
Month
(
Instrument
#
22)

16
Child
Diet
1
Month
(
full)

The
next
questions
are
about
feeding
your
baby.

1.
About
how
long
after
your
delivery
did
you
breastfeed
or
try
to
breastfeed
your
baby
for
the
very
first
time?

1
NEVER
BREASTFED
2
LESS
THAN
1
HOUR
3
1
 
6
HOURS
4
7­
12
HOURS
5
13­
24
HOURS
6
1
­
2
DAYS
7
MORE
THAN
2
DAYS
2.
How
long
did
it
take
for
your
milk
to
come
in?

1
1
DAY
OR
LESS
2
2
DAYS
3
3
DAYS
4
4
DAYS
5
MORE
THAN
4
DAYS
3.
While
you
were
in
the
hospital
or
birth
center,
was
your
baby
fed
water,
formula,
or
sugar
water
at
any
time?
(
CODE
ALL
THAT
APPLY)

1
WATER
2
FORMULA
3
SUGAR
WATER
4.
When
you
left
the
hospital
or
birth
center,
how
were
you
feeding
your
baby?

1
Breastfeeding
only
2
Formula
feeding
only,
or
3
Both
breast
and
formula
feeding
5.
During
the
first
few
days
after
your
baby
was
born,
did
you
feed
him
or
her
1
Whenever
he
or
she
cried
or
seemed
hungry
2
On
a
schedule
or
routine
3
Sometimes
on
a
schedule
AND
sometimes
when
he
or
she
cried
or
seemed
hungry
6.
In
the
past
7
days,
how
often
was
your
baby
fed
each
item
listed
below?
Include
feedings
by
everyone
who
feeds
the
baby
and
include
snacks
and
night­
time
feedings.

FEEDINGS
PER
DAY
Breast
milk
...................................................................
_______
Formula
........................................................................
_______
Water............................................................................
_______
Sugar
water...................................................................
_______
Female
1
Month
(
Instrument
#
22)

17
Other
milk
(
soy,
rice,
goat
milk)
...................................
_______
Other
(
SPECIFY)
_______________________________
_______

7.
Which
of
the
following
was
your
baby
given
in
vitamin
or
mineral
drops
at
least
3
days
a
week
during
the
past
2
weeks?
(
CODE
ALL
THAT
APPLY)

1
Fluoride
2
Iron
3
Vitamin
D
4
Other
vitamins
8.
How
old
was
your
baby
when
{
he/
she}
was
first
fed
formula?

1
1
day
old
or
less
2
2­
6
days
old
3
7­
13
days
old
4
14­
20
days
old
5
More
than
20
days
old
6
Never
fed
formula

SKIP
TO
Q13
[
SKIP
TO
Q13
IF
`
0'
ENTERED
FOR
FORMULA
IN
Q6]

9.
How
often
does
your
baby
drink
all
of
his
or
her
bottle
of
formula?

1
Always
2
Most
of
the
time
3
Sometimes
4
Rarely
5
Never
10.
In
the
past
7
days,
on
the
average,
how
many
ounces
of
formula
did
your
baby
drink
at
each
feeding?

_______
oz
11.
Which
brand
of
infant
formula
was
fed
to
your
baby
in
the
past
7
days?
Please
tell
me
the
group
number
for
each
infant
formula
your
baby
was
fed.
(
INTERVIEWER:
USE
SHOW
CARD)

1
Group
1
2
Group
2
3
Group
3
4
Group
4
5
Group
5
6
Group
6
12.
What
type
of
infant
formula
is
it?
(
CODE
ALL
THAT
APPLY)

1
Ready
to
feed
2
Liquid
concentrate
3
Powder
 
from
can
that
makes
more
than
one
bottle
4
Powder
 
from
single
serving
packs
Female
1
Month
(
Instrument
#
22)

18
[
GO
TO
NEXT
MODULE
IF
`
0'
FOR
BREASTMILK
IN
Q6]

13.
Does
your
baby
usually
feed
from
both
breasts
at
each
feeding?

1
YES
2
NO
3
BABY
IS
FED
ONLY
PUMPED
MILK

SKIP
TO
Q15
14.
Does
your
baby
usually
let
go
of
the
breast
him
or
herself
when
finished
feeding?

1
YES,
BOTH
BREASTS
2
YES,
FIRST
BREAST
ONLY
3
YES,
SECOND
BREAST
ONLY
4
NO
15.
In
an
average
24­
hour
period,
what
is
the
LONGEST
time
for
you,
the
mother,
between
breastfeedings
or
expressing
milk,
that
is,
from
the
start
of
one
breastfeeding
or
expressing
session
to
the
start
of
the
next?
Please
think
of
time
between
feedings
during
both
night
and
day
to
find
the
longest
time.
(
WRITE
IN
THE
NUMBER
OF
HOURS
AND
MINUTES)

______
HOURS
________
MINUTES
16.
How
many
times
in
the
past
7
days
has
your
baby
been
given
expressed
or
pumped
breast
milk
to
drink?

______
TIMES
17.
Since
you
have
been
breastfeeding,
have
you
stopped
eating
or
eaten
less
of
the
following
foods,
or
have
you
eaten
more
or
about
the
same
of
the
foods?

Stopped
Eating
Eat
Less
Eat
More
Eat
about
the
same
Did
not
eat
before
Milk
or
other
dairy
foods
1
2
3
4
0
Soy
milk
or
other
soy
foods
1
2
3
4
0
Eggs
1
2
3
4
0
Fish,
including
canned
tuna
1
2
3
4
0
Shellfish
1
2
3
4
0
Onions
or
garlic
1
2
3
4
0
Broccoli,
cauliflower,
or
cabbage
1
2
3
4
0
Citrus
fruit
such
as
oranges
and
grapefruit
1
2
3
4
0
Nuts,
peanuts,
or
peanut
butter
1
2
3
4
0
Alcoholic
drinks,
including
beer
1
2
3
4
0
Vitamin
or
mineral
supplement
1
2
3
4
0
Any
herbal
or
botanical
supplement
1
2
3
4
0
{
END
OF
1
MONTH
CHILD
DIET
MODULE}
Female
1
Month
(
Instrument
#
22)

19
Personal
Medical
History
(
Update,
revised
for
post­
pregnancy)

Now
I'd
like
to
ask
you
about
your
delivery.

1.
Which
types
of
health
professional
was
your
birth
attendant?
(
CODE
ALL
THAT
APPLY)

1
An
obstetrician
2
A
family
doctor,
general
practitioner,
or
other
physician
3
A
midwife
or
nurse
midwife
4
Another
type
of
health
care
provider
5
No
health
professional
was
present
2.
Other
than
medical
staff,
who
was
with
your
during
your
labor?
(
CODE
ALL
THAT
APPLY)

1
The
baby's
father
2
Relatives
or
friends
3
A
professional
labor
support
person,
such
as
a
doula
3.
How
was
your
baby
delivered?

1
Vaginally
and
not
induced
2
Vaginally
and
induced
3
A
planned
cesarean
4
An
unplanned
or
emergency
cesarean
4.
How
long
did
you
stay
in
the
hospital
after
delivering
your
baby?

1
Less
than
24
hours
(
less
than
1
day)
2
24
to
48
hours
(
1
to
2
days)
3
3
days
4
4
days
5
5
days
6
6
days
or
more
The
next
few
questions
are
about
changes
to
your
general
health,
not
related
to
pregnancy
or
delivery.

5.
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
Q5
=
8,
ASK
Q6­
8
ELSE,
SKIP
TO
Q9
Female
1
Month
(
Instrument
#
22)

20
6.
Did
a
doctor
or
other
medical
provider
tell
you
that
you
have
asthma?

1
YES
2
NO

SKIP
TO
Q9
7.
Have
you
used
any
inhalers
or
taken
any
pills
for
asthma
or
wheezing
or
whistling
in
your
chest?

1
YES
2
NO
8.
Have
you
ever
gone
to
an
emergency
room
or
stayed
overnight
in
a
hospital
for
your
asthma?

1
YES
2
NO
9.
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
9a.
What
were
those
illnesses?
(
ENTER
VERBATIM)

_______________________

10.
Since
[
FILL
DATE],
have
you
been
hospitalized
overnight
for
any
reason
(
other
than
for
delivering
your
baby)?

1
YES
2
NO

GO
TO
NEXT
MODULE
10a.
Why
were
you
hospitalized?
(
ENTER
VERBATIM)

__________________________

Now
I
would
like
to
confirm
the
name
of
the
place
where
you
gave
birth,
and
also
the
healthcare
providers
you
used
/
are
planning
to
use.

1.
Where
did
you
deliver
your
baby?
(
Specify
name
of
facility)
___________________________

2.
What
is
the
name
of
your
OB/
GYN
doctor?

(
Specify
name
of
OB/
GYN)
_______________________________

3.
What
is
the
name
of
your
pediatrician?
(
Specify
name
of
pediatrician)
_____________________
888
DO
NOT
HAVE
ONE
999
DON'T
KNOW
Female
1
Month
(
Instrument
#
22)

21
{
END
OF
PERSONAL
MEDICAL
HISTORY
MODULE}
Female
1
Month
(
Instrument
#
22)

22
Medications
(
Update)

I'll
be
asking
you
about
prescription
and
non­
prescription
medications
you
are
currently
taking.
If
you
do
not
remember
the
specific
names
of
your
medications,
I
can
wait
for
you
to
gather
them.

1.
Are
you
currently
taking
any
new
prescription
medications
that
you
were
not
taking
when
we
last
interviewed
you
on
[
FILL
DATE]?

1
YES
2
NO

SKIP
TO
Q3
2.
Please
tell
me
what
prescription
medications
you
are
taking.
Are
you
currently
taking
any 

Medication
Type
IF
YES:
What
is
the
name
of
the
[
INSERT
MED
TYPE]
you
are
taking?
a.
Antibiotics?
1
YES
2
NO
b.
Allergy
medications,
antihistamines,
or
decongestants?
1
YES
2
NO
c.
Pain
Killers?
1
YES
2
NO
d.
Medications
for
depression?
1
YES
2
NO
e.
Medications
for
asthma?
1
YES
2
NO
f.
Other
prescription
medications?
1
YES
2
NO
3.
Do
you
currently
take
any
non­
prescription,
or
over­
the­
counter,
medications
on
a
regular
basis?

1
YES

IF
PREVIOUS
OTC
MEDS
REPORTED,
GO
TO
Q4.
IF
NOT,
GO
TO
Q5
2
NO

GO
TO
NEXT
MODULE
4.
[
CAPI
INSTRUCTION:
DISPLAY
PREVIOUS
OTC
MEDS
FROM
TABLE
BELOW
AND
FREQUENCY
REPORTED]
Last
time,
you
said
you
took
{
FILL
MED
NAME}
{
FILL
FREQUENCY}.
Has
this
changed?

4a.
Are
you
currently
taking
any
of
these
other
non­
prescription
medications
in
a
regular
basis?
[
CAPI
INSTRUCTION:
DISPLAY
OTC
MEDS
NOT
REPORTED
DURING
LAST
INTERVIEW]

5.
Please
tell
me
which
non­
prescription
medications
you
currently
take
on
a
regular
basis.
Do
you
take 
Female
1
Month
(
Instrument
#
22)

23
Medication
Type
IF
YES:
How
often
do
you
usually
take
this
medication?
a.
Tylenol
(
Acetominophen)?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
b.
Advil
or
Motrin
(
Ibuprofen)?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
c.
Cough
or
cold
medicine?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
d.
Allergy
medications,
antihistamines,
or
decongestants?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
e.
Aspirin?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
f.
Other
nonprescription
medications?
(
SPECIFY)
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
{
END
OF
MEDICATIONS
MODULE}
Female
1
Month
(
Instrument
#
22)

24
Supplements,
Vitamins,
Etc.
(
update,
revised
for
post­
pregnancy)

Now
I
will
ask
you
similar
questions
about
vitamins
and
supplements
you
are
taking.

1.
Are
you
currently
taking
any
multivitamins
such
as
One­
a­
Day
or
Centrum?

1
YES
2
NO

SKIP
TO
Q4
2.
How
often
do
you
take
any
multivitamins?

1
Every
day
2
4
 
6
days
per
week
3
1
 
3
days
per
week
4
1
 
3
days
per
month
3.
Do
your
multivitamins
usually
contain
minerals
such
as
iron,
zinc,
etc.?

1
YES
2
NO
4.
Are
you
currently
taking
any
vitamins,
minerals,
or
supplements
other
than
your
multivitamins?

1
YES
2
NO

GO
TO
NEXT
MODULE
5.
Do
you
take
any
of
the
following
supplements
that
are
not
part
of
a
multivitamin?
(
INTERVIEWER:
HAND
SHOW
CARD
TO
RESPONDENT.
CODE
ALL
THAT
APPLY)

a.
BETA­
CAROTENE
b.
VITAMIN
A
c.
VITAMIN
B­
6
OR
B­
COMPLEX
d.
VITAMIN
C
e.
VITAMIN
E
f.
CALCIUM
OR
CALCIUM­
CONTAINING
ANTACIDS
g.
VITAMIN
D,
INCLUDING
VITAMIN
D
TAKEN
AS
PART
OF
A
CALCIUM
SUPPLEMENT
h.
BREWER'S
YEAST
i.
COD
LIVER
OIL
j.
COENZYME
Q
k.
FISH
OIL
(
OMEGA
3
FATTY
ACIDS)
l.
FOLIC
ACID/
FOLATE
m.
GLUCOSAMINE
n.
HYDROXYTRYPTOPHAN
(
HTP)
o.
IRON
p.
NIACIN
q.
SELENIUM
r.
ZINC
6.
Please
tell
me
if
you
take
any
of
the
following
herbal
or
botanical
supplements
more
than
once
per
week.
Include
only
supplements
and
teas,
not
use
of
the
herb
in
food.
(
INTERVIEWER:
HAND
SHOW
CARD
TO
RESPONDENT.
CODE
ALL
THAT
APPLY)
Female
1
Month
(
Instrument
#
22)

25
a.
ALOE
VERA
b.
BILBERRY
c.
CAYENNE
d.
CRANBERRY
e.
DONG
KUAI
(
TANGKWEI)
f.
ECHINACEA
g.
EVENING
PRIMROSE
OIL
h.
FEVERFEW
i.
GARLIC
j.
GINGER
k.
GINKGO
BILOBA
l.
GINSENG
(
AMERICAN
OR
ASIAN)
m.
GOLDENSEAL
n.
GRAPESEED
EXTRACT
o.
KAVA
p.
MILK
THISTLE
q.
SIBERIAN
GINSENG
r.
ST.
JOHN'S
WORT
s.
VALERIAN
t.
OTHER
SPECIFY_____________________

{
END
OF
VITAMINS/
SUPPLEMENTS
MODULE}
Female
1
Month
(
Instrument
#
22)

26
Post­
partum
depression
(
Full)

I'm
going
to
ask
you
some
questions
about
how
you
felt
during
your
most
recent
pregnancy.
1.
At
any
time
during
your
most
recent
pregnancy
or
after
delivery,
did
a
doctor,
nurse,
or
other
health
care
worker
talk
with
you
about
"
baby
blues"
or
postpartum
depression?

1
YES
2
NO
2.
Did
you
seek
help
for
depression
from
a
doctor,
nurse,
or
other
health
care
worker?

1
YES
2
NO

SKIP
TO
Q6
3.
At
any
time
during
your
most
recent
pregnancy,
did
you
get
counseling
for
your
depression?

1
YES
2
NO
4.
At
any
time
during
your
most
recent
pregnancy,
did
a
doctor,
nurse,
or
other
health
care
worker
diagnose
you
with
depression?

1
YES
2
NO

SKIP
TO
Q6
5.
At
any
time
during
your
most
recent
pregnancy,
did
you
take
prescription
medicine
for
your
depression?

1
YES
2
NO
6.
How
would
you
describe
the
time
during
your
most
recent
pregnancy?

1
One
of
the
happiest
times
of
my
life
2
A
happy
time
with
few
problems
3
A
moderately
hard
time
4
A
very
hard
time
5
One
of
the
worst
times
of
my
life
Now
I'm
going
to
ask
you
similar
questions
about
how
you
have
felt
since
your
new
baby
was
born.

7.
Since
your
new
baby
was
born,
how
often
have
you
felt
down,
depressed,
or
hopeless?

1
Always
2
Often
3
Sometimes
4
Rarely
5
Never
Female
1
Month
(
Instrument
#
22)

27
8.
Since
your
new
baby
was
born,
how
often
have
you
had
little
interest
or
little
pleasure
in
doing
things?

1
Always
2
Often
3
Sometimes
4
Rarely
5
Never
9.
Since
your
new
baby
was
born,
did
you
seek
help
for
depression
from
a
doctor,
nurse,
or
other
health
care
worker?

1
YES
2
NO

GO
TO
NEXT
MODULE
10.
Have
you
gotten
counseling
for
your
depression?

1
YES
2
NO
11.
Has
a
doctor,
nurse,
or
other
health
care
worker
diagnosed
you
with
depression?

1
YES
2
NO
12.
Since
your
new
baby
was
born,
have
you
taken
prescription
medicine
for
your
depression?

1
YES
2
NO
Female
1
Month
(
Instrument
#
22)

28
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.
Why
did
you
decide
to
participate
in
this
study?
(
CODE
ALL
THAT
APPLY)

1
THE
STUDY
WOULD
BENEFIT
MYSELF
OR
MY
CHILD
2
CONTRIBUTE
TO
IMPROVE
HEALTH
OF
CHILDREN
AND
PREGNANT
WOMEN
IN
THE
FUTURE
3
INTERESTING
PROJECT
TO
BE
INVOLVED
IN
4
CURIOSITY
5
DESIRE
TO
BELONG
TO
A
GROUP
OR
COMMUNITY
OF
SIMILAR
PEOPLE
6
DIDN'T
FEEL
COMFORTABLE
SAYING
NO
7
OTHER
REASON
(
SPECIFY)
____________________

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

____________________________

8.
Is
there
anything
you
especially
dislike
about
participating
in
this
study?
(
ENTER
VERBATIM)

____________________________

9.
Finally,
do
you
have
any
recommendations
as
to
what
we
could
do
differently
in
the
overall
study
or
in
these
interviews?
(
ENTER
VERBATIM)
Female
1
Month
(
Instrument
#
22)

29
____________________________

{
END
OF
ACCEPTABILITY
MODULE}