Document ID: EPA-HQ-ORD-2005-0010-0019
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2005-09-28T04:00Z

NCS
Herald
Cohort
Study
Instrument
#
11
Female
(
enrolled
preconception)
Questionnaire
Pregnancy
First
Trimester
Home
Visit
Eligibility:
All
women
enrolled
preconception,
became
pregnant
Mode
of
administration:
Interviewer,
home
visit
8/
4/
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
Pregnancy
1
(
Instrument
#
11)

2
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
Baby
due
date
OB/
GYN
name
Hospital
planning
to
deliver
Last
interview
date
Student
status
Employment
status
Flag
for
house
pets
reported
Smoking
status
Chemical
exposures
Medications
Health
Insurance
QUESTIONNAIRE:
Female
Pregnancy
1
(
Instrument
#
11)

3
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
2.
Do
you
plan
to
move
from
this
address
before
you
have
your
baby?

1
YES
2
NO

GO
TO
NEXT
MODULE
3.
Where
do
you
plan
to
move?
(
Interviewer:
collect
complete
address
if
possible.
If
unknown,
collect
city
and
state.)

IF
MOVING
WITHIN
STUDY
AREA,
ADMINISTER
INSTRUMENT
#
29,
NEW
HOME
LOCATION
IF
MOVING
OUT
OF
STUDY
AREA,
INELIGIBLE.
SKIP
TO
END
{
END
OF
ADDRESS
MODULE}
Female
Pregnancy
1
(
Instrument
#
11)

4
Partner
(
update)

1.
When
we
last
interviewed
you,
you
said
you
were
[
FILL
MARITAL
STATUS
FROM
SCREENER].
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
­
7
REFUSED
6.
Please
give
me
your
[
husband's/
partner's]
name
and
address.

COLLECT
INFORMATION
ON
NEW
PARTNER
REFUSED
{
END
OF
PARTNER
MODULE}
Female
Pregnancy
1
(
Instrument
#
11)

5
Pregnancy
Status
(
Update,
Revised
for
pregnancy)

1.
[
IF
OB/
GYN
NAME
PRELOADED,
ASK]
Is
your
obstetrician
still
[
FILL
PRELOAD
NAME]?

1
YES

SKIP
TO
Q3
2
NO
2.
What
is
the
name
of
your
OB/
GYN
doctor?

1
NAME
(
SPECIFY)
_______________________________
2
DO
NOT
HAVE
A
DOCTOR
YET

GO
TO
NEXT
MODULE
3
REFUSED
3.
[
IF
DELIVERY
HOSPITAL
PRELOADED
ASK]
Do
you
still
plan
on
having
your
baby
at
[
FILL
HOSPITAL
NAME]?

1
YES

GO
TO
NEXT
MODULE
2
NO
4.
Where
do
you
plan
to
deliver?

1
HOSPITAL
(
SPECIFY)
_______________________________
2
OTHER
(
SPECIFY)
_______________________________
3
DON'T
KNOW
4
REFUSED
5.
What
is
your
due
date?

MM/
DD/
YYYY
DON'T
KNOW

What
was
the
first
day
of
your
last
menstrual
period?
MM/
DD/
YYYY
{
END
OF
PREGNANCY
STATUS
MODULE}
Female
Pregnancy
1
(
Instrument
#
11)

6
Occupation
(
Update
Revised
for
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
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

GO
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
jobs
since
your
last
interview
on
[
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)
one.
Female
Pregnancy
1
(
Instrument
#
11)

7
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
Q15
Female
Pregnancy
1
(
Instrument
#
11)

8
15.
Did
you
stop
working
at
any
job,
even
temporarily,
because
of
your
pregnancy?

1
YES
2
NO

GO
TO
NEXT
MODULE
16.
Which
job
was
that?
[
DISPLAY
LIST
OF
ALL
JOBS
HELD]

17.
Did
you
stop
working
for
any
of
these
reasons?
(
CODE
ALL
THAT
APPLY)

1
doctor
recommended
it
2
didn't
feel
well
enough
3
decided
not
to
work
4
other
medical
reason
5
family
encouraged
you
to
quit
6
non­
family
encouraged
you
to
quit
7
some
other
reason
(
SPECIFY)
_____________________

{
END
OF
OCCUPATION
MODULE}
Female
Pregnancy
1
(
Instrument
#
11)

9
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}
Female
Pregnancy
1
(
Instrument
#
11)

10
Pets
and
Pests
(
update)

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
Q4
2
NO
2.
How
many
of
the
following
pets
do
you
currently
have?
[
READ
EACH
TYPE
OF
PET.
IF
1
OR
MORE,
ASK:

3.
[
FILL:
Is
this
pet
/
How
many
of
these
pets
are]
kept
indoors?

Total
Number
Number
kept
indoors
1.
dogs
2.
cats
3.
gerbils,
hamsters
and
guinea
pigs
4.
rabbits
5.
birds
6.
Other
pets
(
specify)
____________

4.
Are
any
chemicals
used
on
the
pets
to
control
fleas
and
ticks?

1
YES
2
NO

SKIP
TO
Q6
5.
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
_____________________
_____________________

6.
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
7.
Since
your
last
interview,
have
you
seen
cockroaches
in
your
home?

1
YES
2
NO
{
END
OF
PETS
AND
PESTS
MODULE}
Female
Pregnancy
1
(
Instrument
#
11)

11
Female
Pregnancy
1
(
Instrument
#
11)

12
Personal
Medical
History
(
update,
revised
for
pregnancy)

Now
I'd
like
to
ask
you
some
questions
about
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
sugar
(
diabetes)
that
started
before
this
pregnancy
2
High
blood
sugar
(
diabetes)
that
started
during
this
pregnancy
3
Vaginal
bleeding
or
spotting
4
Kidney
or
bladder
(
urinary
tract)
infection
5
Severe
nausea,
vomiting,
or
dehydration
6
High
blood
pressure
or
hypertension
that
started
before
this
pregnancy
7
High
blood
pressure
or
hypertension
that
started
during
this
pregnancy
(
including
pregnancy­
induced
hypertension
[
PIH],
preeclampsia,
or
toxemia)
8
High
cholesterol
9
Anemia
(
poor
blood,
low
iron)
10
Heart
problems
11
Asthma
IF
Q1
=
11,
ASK
Q2­
4
ELSE,
SKIP
TO
Q5
2.
Did
a
doctor
or
other
medical
provider
ever
tell
you
that
you
had
asthma?

1
YES
2
NO

SKIP
TO
Q8
3.
In
the
past
6
months,
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.
Some
women
experience
several
days
or
weeks
of
nausea
or
feeling
sick
to
their
stomach
when
they
are
pregnant
while
other
women
do
not.
Have
you
had
any
times
when
you
had
a
feeling
of
nausea
during
this
pregnancy?

1
YES
2
NO

SKIP
TO
Q9
Female
Pregnancy
1
(
Instrument
#
11)

13
6.
Did
your
nausea
cause
you
to:
[
read
choices
and
circle
all
that
apply]

1.
eat
less
food
than
you
usually
did
before
you
were
pregnant
2.
not
be
able
to
do
your
normal
daily
activities
3.
not
be
able
to
take
your
prenatal
vitamin
0.
none
of
the
above
7.
Have
you
vomited
during
this
pregnancy
because
of
nausea
related
to
being
pregnant?

1
YES
2
NO

SKIP
TO
Q9
8.
Have
you
vomited
more
than
4
times
in
a
week
for
at
least
one
week
during
this
pregnancy?

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
9a.
What
were
those
illnesses?
(
ENTER
VERBATIM)

_______________________

10.
Since
[
FILL
DATE],
have
you
been
hospitalized
for
any
reason?

1
YES
2
NO

SKIP
TO
END
10a.
Why
were
you
hospitalized?
(
ENTER
VERBATIM)

_______________________

{
END
OF
PERSONAL
MEDICAL
HISTORY
MODULE}
Female
Pregnancy
1
(
Instrument
#
11)

14
Dental
Health
(
Update)

1.
Since
your
last
interview
on
[
FILL
INTERVIEW
DATE],
have
you
been
to
the
dentist
for
a
routine
cleaning?

1
YES
2
NO

SKIP
TO
Q3
2.
When
was
your
last
routine
cleaning?

MM/
YYYY
3.
Do
you
currently
have
any
of
the
following
dental
problems?

[
READ
EACH
CATEGORY]

IF
YES,
ASK:
When
was
the
last
time
you
saw
a
dentist
for
this
condition?

a.
Plaque
YES
NO
MM/
YYYY
0
=
NEVER
b.
Bleeding
gums
or
other
gum
disease
YES
NO
MM/
YYYY
0
=
NEVER
c.
Tooth
decay
YES
NO
MM/
YYYY
0
=
NEVER
d.
Tooth
ache
YES
NO
MM/
YYYY
0
=
NEVER
e.
Dentist­
diagnosed
gingivitis
YES
NO
MM/
YYYY
0
=
NEVER
f.
Dentist­
diagnosed
periodontitis
YES
NO
MM/
YYYY
0
=
NEVER
g.
Missing
or
broken
teeth?
YES
NO
MM/
YYYY
0
=
NEVER
g.
Any
other
dental
problems?
(
SPECIFY)
YES
NO
MM/
YYYY
0
=
NEVER
{
END
OF
DENTAL
HEALTH
MODULE}
Female
Pregnancy
1
(
Instrument
#
11)

15
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

SKIP
TO
END
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
Pregnancy
1
(
Instrument
#
11)

16
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
Pregnancy
1
(
Instrument
#
11)

17
Supplements,
Vitamins,
Etc.
(
update)

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,
Centrum,
or
prenatal
vitamins?

1
YES
2
NO

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

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)

1.
BETA­
CAROTENE
2.
VITAMIN
A
3.
VITAMIN
B­
6
OR
B­
COMPLEX
4.
VITAMIN
C
5.
VITAMIN
E
6.
CALCIUM
OR
CALCIUM­
CONTAINING
ANTACIDS
7.
VITAMIN
D,
INCLUDING
VITAMIN
D
TAKEN
AS
PART
OF
A
CALCIUM
SUPPLEMENT
8.
BREWER'S
YEAST
9.
COD
LIVER
OIL
10.
COENZYME
Q
11.
FISH
OIL
(
OMEGA
3
FATTY
ACIDS)
12.
FOLIC
ACID/
FOLATE
13.
GLUCOSAMINE
14.
HYDROXYTRYPTOPHAN
(
HTP)
15.
IRON
16.
NIACIN
17.
SELENIUM
18.
ZINC
Female
Pregnancy
1
(
Instrument
#
11)

18
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)

1.
ALOE
VERA
2.
BILBERRY
3.
CAYENNE
4.
CRANBERRY
5.
DONG
KUAI
(
TANGKWEI)
6.
ECHINACEA
7.
EVENING
PRIMROSE
OIL
8.
FEVERFEW
9.
GARLIC
10.
GINGER
11.
GINKGO
BILOBA
12.
GINSENG
(
AMERICAN
OR
ASIAN)
13.
GOLDENSEAL
14.
GRAPESEED
EXTRACT
15.
KAVA
16.
MILK
THISTLE
17.
SIBERIAN
GINSENG
18.
ST.
JOHN'S
WORT
19.
VALERIAN
20.
OTHER
(
SPECIFY)_____________________

{
END
OF
VITAMINS/
SUPPLEMENTS
MODULE}
Female
Pregnancy
1
(
Instrument
#
11)

19
Health
Care
Access/
Insurance
(
update,
revised
for
pregnancy)

The
next
few
questions
are
about
health
care
and
insurance.

1.
When
we
last
spoke
on
{
FILL
DATE},
you
had
the
following
health
care
coverage:
{
FILL
TYPE
OF
HEALTH
INSURANCE}.
Is
this
still
correct?

1
YES

SKIP
TO
Q3
2
NO
2.
What
kind
of
health
insurance
or
health
care
coverage
do
you
have?
Include
those
that
pay
for
only
one
type
of
service
(
nursing
home
care,
accidents,
or
dental
care).
Exclude
private
plans
that
only
provide
extra
cash
while
hospitalized.
(
INTERVIEWER:
USE
SHOW
CARD)

1
PRIVATE
HEALTH
INSURANCE
PLAN
FROM
EMPLOYER
OR
WORKPLACE
2
PRIVATE
HEALTH
INSURANCE
PLAN
PURCHASED
DIRECTLY
3
PRIVATE
HEALTH
INSURANCE
PLAN
THROUGH
A
STATE
OR
LOCAL
GOVERNMENT
PROGRAM
OR
COMMUNITY
PROGRAM
4
MEDICARE
5
MEDI­
GAP
6
MEDICAID
({
DISPLAY
STATE
PLAN
NAME})
7
CHIP
(
CHILDREN'S
HEALTH
INSURANCE
PROGRAM)
8
MILITARY
HEALTH
CARE/
VA
9
CHAMPUS/
TRICARE/
CHAMP­
VA
10
INDIAN
HEALTH
SERVICE
11
STATE­
SPONSORED
HEALTH
PLAN
({
DISPLAY
STATE
PLAN
NAME})
12
OTHER
GOVERNMENT
PROGRAM
13
SINGLE
SERVICE
PLAN
(
E.
G.,
DENTAL,
VISION,
PRESCRIPTIONS)

3.
Are
you
currently
on
WIC
(
The
Special
Supplemental
Nutrition
Program
for
Women,
Infants,
and
Children)?

1
YES
2
NO
4.
Has
anyone,
such
as
your
health
care
provider,
family,
or
friends,
spoken
to
you
about
getting
prenatal
care
during
your
pregnancy?

1
YES
2
NO
2.
Are
you
now,
or
do
you
plan
to
get,
prenatal
care
during
this
pregnancy?

1
YES
2
NO

[
Give
participant
public
health
brochure
about
the
importance
of
prenatal
care]
GO
TO
NEXT
MODULE
Female
Pregnancy
1
(
Instrument
#
11)

20
3.
What
kind
of
place
do
you
plan
to
go
to
receive
your
prenatal
care?

1
Hospital
clinic
2
Health
department
clinic
3
Private
doctor's
office
or
HMO
clinic
4
Other
(
SPECIFY)
______________________

{
END
OF
HEALTH
CARE
ACCESS/
INSURANCE
MODULE}
Female
Pregnancy
1
(
Instrument
#
11)

21
Feelings
about
pregnancy
(
Full)

The
next
questions
are
about
the
time
before
you
got
pregnant.

1.
Which
of
the
following
statements
best
describes
you
during
the
3
months
before
you
got
pregnant?

1
I
was
trying
to
get
pregnant
2
I
wasn't
trying
to
get
pregnant
or
trying
to
keep
from
getting
pregnant
3
I
was
trying
to
keep
from
getting
pregnant
but
was
not
trying
very
hard
4
I
was
trying
hard
to
keep
from
getting
pregnant
2.
Which
of
the
following
statements
best
describes
your
husband
or
partner
during
the
3
months
before
you
got
pregnant?

1
He
wanted
me
to
get
pregnant
2
He
partly
wanted
me
to
get
pregnant
and
partly
wanted
me
not
to
get
pregnant
3
He
didn't
care
one
way
or
the
other
whether
I
got
pregnant
4
He
didn't
especially
want
me
to
get
pregnant
5
He
wanted
very
much
for
me
not
to
get
pregnant
3.
How
did
you
feel
when
you
found
out
you
were
pregnant
with
your
new
baby?
Were
you
 
1
Very
unhappy
to
be
pregnant
2
Unhappy
to
be
pregnant
3
Not
sure
4
Happy
to
be
pregnant
5
Very
happy
to
be
pregnant
{
END
OF
PREGNANCY
FEELINGS
MODULE}
Female
Pregnancy
1
(
Instrument
#
11)

22
Neighborhood
(
Full.)

Now
I'd
like
to
ask
you
about
the
neighborhood
you
live
in.

1.
In
your
opinion,
is
your
neighborhood 

1
A
very
good
place
to
live
2
A
fairly
good
place
to
live
3
Not
a
very
good
place
to
live,
or
4
Not
at
all
a
good
place
to
live?

2.
How
often
do
people
in
your
neighborhood 

Never
Rarely
Sometimes
Often
Always
DK
a.
Visit
your
home?
0
1
2
3
4
­
1
b.
Argue
with
you?
0
1
2
3
4
­
1
c.
Look
after
your
children?
0
1
2
3
4
­
1
d.
Keep
to
themselves?
0
1
2
3
4
­
1
e.
Attend
religious
services?
0
1
2
3
4
­
1
3.
Is
your
neighborhood 

Not
at
all
Sometimes
Usually
a.
Lively?
0
1
2
b.
Polluted/
dirty?
0
1
2
c.
Friendly?
0
1
2
d.
Noisy?
0
1
2
e.
Clean?
0
1
2
f.
Attractive?
0
1
2
4.
Have
you
ever
asked
a
neighbor 
(
CODE
ALL
THAT
APPLY)

1.
To
help
with
minor
household
tasks
or
repairs?
2.
To
give
you
a
ride
somewhere?
3.
To
help
take
care
of
you
or
a
family
member
when
you
are
sick?
4.
To
borrow
money?
5.
To
borrow
other
items
such
as
food
or
tools?

5.
Do
you
feel
that
your
neighborhood
is 

1
Very
safe
2
Somewhat
safe
3
Somewhat
unsafe,
or
4
Very
unsafe?

6.
In
your
opinion,
does
your
neighborhood
have
problems
with 
(
CODE
ALL
THAT
APPLY)

a.
Property
crimes
such
as
break­
ins
or
burglaries?
b.
Personal
crimes
such
as
muggings
or
beatings?
c.
Violent
crimes?
d.
Drug
dealing?
Female
Pregnancy
1
(
Instrument
#
11)

23
7.
From
where
you
live,
is
it
relatively
easy
for
you
to
get
to 
(
CODE
ALL
THAT
APPLY)

1
stores
to
get
the
groceries
you
need?
2
public
parks
or
recreational
facilities?
3
doctor's
offices
or
clinics?
4
your
religious
institution?
5
your
children's
schools?
[
DISPLAY
ONLY
IF
R
HAS
CHILD]
6
daycare
programs?
[
DISPLAY
ONLY
IF
R
HAS
CHILD]

8.
Are
you
a
member
of
any
religious
faith?

1
YES
2
NO

GO
TO
NEXT
MODULE
9.
How
often
do
you
go
to
a
place
of
worship?

1
At
least
once
a
week
2
At
least
once
a
month
3
At
least
once
a
year
4
Or
not
at
all?

{
END
OF
NEIGHBORHOOD
MODULE}
Female
Pregnancy
1
(
Instrument
#
11)

24
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}
Female
Pregnancy
1
(
Instrument
#
11)

25
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?
Female
Pregnancy
1
(
Instrument
#
11)

26
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}
Female
Pregnancy
1
(
Instrument
#
11)

27
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
Pregnancy
1
(
Instrument
#
11)

28
____________________________

{
END
OF
ACCEPTABILITY
MODULE}