Follow-up for The Study- Moms Who Already Participated

Mom/Woman's Name *

First

Last

Date of Baby's Delivery -or- Estimated Due Date *

What was the date of delivery for your baby? Or your estimated due date if your baby has not been born yet.

Mom's Date of Birth *

Has baby been born? Or has pregnancy ended? *

Baby's Gender *

Birth/Delivery Outcomes

Vaginal Birth
C-Section (Cesearean)
Miscarriage or Abortion

How many babies did you deliver?

For this current or recent pregnancy.

Birth/Delivery Details *

Check all that apply for your most recent delivery.

How many 'weeks' was baby when they were born? *

Did baby need special medical care or were they admitted to the NICU (neonatal intensive care unit)? *

Did YOU need special medical care or were you admitted to the hospital BEFORE or AFTER delivery?

Brief Questionnaire Section

Index of Race Related Stress – Brief Version (IRSS-B)  Please circle the number on the scale (0 to 4) that indicates the reaction you had to the event at the time it happened. Do not leave any items blank. If an event has happened more than once refer to the first time it happened. If an event did not happen mark 0 and go on to the next item.  *

	Never Happened 0	Happened but did not bother me 1	Happened and I was slightly upset 2	Happened and I was upset 3	Happened and I was extremely upset 4
You notice that crimes committed by White people tend to be romanticized, whereas the same crime committed by a Black person is portrayed as savagery, and the Black person who committed it, as an animal.	Never Happened 0You notice that crimes committed by White people tend to be romanticized, whereas the same crime committed by a Black person is portrayed as savagery, and the Black person who committed it, as an animal.  Never Happened 0	Happened but did not bother me 1You notice that crimes committed by White people tend to be romanticized, whereas the same crime committed by a Black person is portrayed as savagery, and the Black person who committed it, as an animal.  Happened but did not bother me 1	Happened and I was slightly upset 2You notice that crimes committed by White people tend to be romanticized, whereas the same crime committed by a Black person is portrayed as savagery, and the Black person who committed it, as an animal.  Happened and I was slightly upset 2	Happened and I was upset 3You notice that crimes committed by White people tend to be romanticized, whereas the same crime committed by a Black person is portrayed as savagery, and the Black person who committed it, as an animal.  Happened and I was upset 3	Happened and I was extremely upset 4You notice that crimes committed by White people tend to be romanticized, whereas the same crime committed by a Black person is portrayed as savagery, and the Black person who committed it, as an animal.  Happened and I was extremely upset 4
Sales people/clerks did not say thank you or show other forms of courtesy and respect (i.e. put your things in a bag) when you shopped at some White/non-Black owned businesses.	Never Happened 0Sales people/clerks did not say thank you or show other forms of courtesy and respect (i.e. put your things in a bag) when you shopped at some White/non-Black owned businesses.  Never Happened 0	Happened but did not bother me 1Sales people/clerks did not say thank you or show other forms of courtesy and respect (i.e. put your things in a bag) when you shopped at some White/non-Black owned businesses.  Happened but did not bother me 1	Happened and I was slightly upset 2Sales people/clerks did not say thank you or show other forms of courtesy and respect (i.e. put your things in a bag) when you shopped at some White/non-Black owned businesses.  Happened and I was slightly upset 2	Happened and I was upset 3Sales people/clerks did not say thank you or show other forms of courtesy and respect (i.e. put your things in a bag) when you shopped at some White/non-Black owned businesses.  Happened and I was upset 3	Happened and I was extremely upset 4Sales people/clerks did not say thank you or show other forms of courtesy and respect (i.e. put your things in a bag) when you shopped at some White/non-Black owned businesses.  Happened and I was extremely upset 4
You notice that when Black people are killed by the police the media informs the public of the Victim’s criminal record or negative information in their background, suggesting they got what they deserved.	Never Happened 0You notice that when Black people are killed by the police the media informs the public of the Victim’s criminal record or negative information in their background, suggesting they got what they deserved.  Never Happened 0	Happened but did not bother me 1You notice that when Black people are killed by the police the media informs the public of the Victim’s criminal record or negative information in their background, suggesting they got what they deserved.  Happened but did not bother me 1	Happened and I was slightly upset 2You notice that when Black people are killed by the police the media informs the public of the Victim’s criminal record or negative information in their background, suggesting they got what they deserved.  Happened and I was slightly upset 2	Happened and I was upset 3You notice that when Black people are killed by the police the media informs the public of the Victim’s criminal record or negative information in their background, suggesting they got what they deserved.  Happened and I was upset 3	Happened and I was extremely upset 4You notice that when Black people are killed by the police the media informs the public of the Victim’s criminal record or negative information in their background, suggesting they got what they deserved.  Happened and I was extremely upset 4
You have been threatened with physical violence by an individual or group of White/non-Blacks.	Never Happened 0You have been threatened with physical violence by an individual or group of White/non-Blacks. Never Happened 0	Happened but did not bother me 1You have been threatened with physical violence by an individual or group of White/non-Blacks. Happened but did not bother me 1	Happened and I was slightly upset 2You have been threatened with physical violence by an individual or group of White/non-Blacks. Happened and I was slightly upset 2	Happened and I was upset 3You have been threatened with physical violence by an individual or group of White/non-Blacks. Happened and I was upset 3	Happened and I was extremely upset 4You have been threatened with physical violence by an individual or group of White/non-Blacks. Happened and I was extremely upset 4
You have observed that White kids who commit violent crimes are portrayed as “boys being boys”, while Black kids who commit similar crimes are wild animals.	Never Happened 0You have observed that White kids who commit violent crimes are portrayed as “boys being boys”, while Black kids who commit similar crimes are wild animals. Never Happened 0	Happened but did not bother me 1You have observed that White kids who commit violent crimes are portrayed as “boys being boys”, while Black kids who commit similar crimes are wild animals. Happened but did not bother me 1	Happened and I was slightly upset 2You have observed that White kids who commit violent crimes are portrayed as “boys being boys”, while Black kids who commit similar crimes are wild animals. Happened and I was slightly upset 2	Happened and I was upset 3You have observed that White kids who commit violent crimes are portrayed as “boys being boys”, while Black kids who commit similar crimes are wild animals. Happened and I was upset 3	Happened and I was extremely upset 4You have observed that White kids who commit violent crimes are portrayed as “boys being boys”, while Black kids who commit similar crimes are wild animals. Happened and I was extremely upset 4
You seldom hear or read anything positive about Black people on radio, T.V., newspapers, or in history books.	Never Happened 0You seldom hear or read anything positive about Black people on radio, T.V., newspapers, or in history books. Never Happened 0	Happened but did not bother me 1You seldom hear or read anything positive about Black people on radio, T.V., newspapers, or in history books. Happened but did not bother me 1	Happened and I was slightly upset 2You seldom hear or read anything positive about Black people on radio, T.V., newspapers, or in history books. Happened and I was slightly upset 2	Happened and I was upset 3You seldom hear or read anything positive about Black people on radio, T.V., newspapers, or in history books. Happened and I was upset 3	Happened and I was extremely upset 4You seldom hear or read anything positive about Black people on radio, T.V., newspapers, or in history books. Happened and I was extremely upset 4
While shopping at a store the salesclerk assumed that you couldn’t afford certain items (i.e. you were directed toward the items on sale).	Never Happened 0While shopping at a store the salesclerk assumed that you couldn’t afford certain items (i.e. you were directed toward the items on sale).  Never Happened 0	Happened but did not bother me 1While shopping at a store the salesclerk assumed that you couldn’t afford certain items (i.e. you were directed toward the items on sale).  Happened but did not bother me 1	Happened and I was slightly upset 2While shopping at a store the salesclerk assumed that you couldn’t afford certain items (i.e. you were directed toward the items on sale).  Happened and I was slightly upset 2	Happened and I was upset 3While shopping at a store the salesclerk assumed that you couldn’t afford certain items (i.e. you were directed toward the items on sale).  Happened and I was upset 3	Happened and I was extremely upset 4While shopping at a store the salesclerk assumed that you couldn’t afford certain items (i.e. you were directed toward the items on sale).  Happened and I was extremely upset 4
You were the victim of a crime, and the police treated you as if you should just accept it as part of being Black.	Never Happened 0You were the victim of a crime, and the police treated you as if you should just accept it as part of being Black.  Never Happened 0	Happened but did not bother me 1You were the victim of a crime, and the police treated you as if you should just accept it as part of being Black.  Happened but did not bother me 1	Happened and I was slightly upset 2You were the victim of a crime, and the police treated you as if you should just accept it as part of being Black.  Happened and I was slightly upset 2	Happened and I was upset 3You were the victim of a crime, and the police treated you as if you should just accept it as part of being Black.  Happened and I was upset 3	Happened and I was extremely upset 4You were the victim of a crime, and the police treated you as if you should just accept it as part of being Black.  Happened and I was extremely upset 4
You were treated with less respect and courtesy than Whites and other non-Blacks while in a store, restaurant, or other business establishment.	Never Happened 0You were treated with less respect and courtesy than Whites and other non-Blacks while in a store, restaurant, or other business establishment.  Never Happened 0	Happened but did not bother me 1You were treated with less respect and courtesy than Whites and other non-Blacks while in a store, restaurant, or other business establishment.  Happened but did not bother me 1	Happened and I was slightly upset 2You were treated with less respect and courtesy than Whites and other non-Blacks while in a store, restaurant, or other business establishment.  Happened and I was slightly upset 2	Happened and I was upset 3You were treated with less respect and courtesy than Whites and other non-Blacks while in a store, restaurant, or other business establishment.  Happened and I was upset 3	Happened and I was extremely upset 4You were treated with less respect and courtesy than Whites and other non-Blacks while in a store, restaurant, or other business establishment.  Happened and I was extremely upset 4
You were passed over for an important project although you were more qualified and competent than the White/non-Black person given the task.	Never Happened 0You were passed over for an important project although you were more qualified and competent than the White/non-Black person given the task.  Never Happened 0	Happened but did not bother me 1You were passed over for an important project although you were more qualified and competent than the White/non-Black person given the task.  Happened but did not bother me 1	Happened and I was slightly upset 2You were passed over for an important project although you were more qualified and competent than the White/non-Black person given the task.  Happened and I was slightly upset 2	Happened and I was upset 3You were passed over for an important project although you were more qualified and competent than the White/non-Black person given the task.  Happened and I was upset 3	Happened and I was extremely upset 4You were passed over for an important project although you were more qualified and competent than the White/non-Black person given the task.  Happened and I was extremely upset 4
Whites/non-Blacks have stared at you as if you didn’t belong in the same place with them; whether it was at a restaurant, theater, or other place of business.	Never Happened 0Whites/non-Blacks have stared at you as if you didn’t belong in the same place with them; whether it was at a restaurant, theater, or other place of business.  Never Happened 0	Happened but did not bother me 1Whites/non-Blacks have stared at you as if you didn’t belong in the same place with them; whether it was at a restaurant, theater, or other place of business.  Happened but did not bother me 1	Happened and I was slightly upset 2Whites/non-Blacks have stared at you as if you didn’t belong in the same place with them; whether it was at a restaurant, theater, or other place of business.  Happened and I was slightly upset 2	Happened and I was upset 3Whites/non-Blacks have stared at you as if you didn’t belong in the same place with them; whether it was at a restaurant, theater, or other place of business.  Happened and I was upset 3	Happened and I was extremely upset 4Whites/non-Blacks have stared at you as if you didn’t belong in the same place with them; whether it was at a restaurant, theater, or other place of business.  Happened and I was extremely upset 4
You have observed the police treat White/non-Blacks with more respect and dignity than they do Blacks.	Never Happened 0You have observed the police treat White/non-Blacks with more respect and dignity than they do Blacks.  Never Happened 0	Happened but did not bother me 1You have observed the police treat White/non-Blacks with more respect and dignity than they do Blacks.  Happened but did not bother me 1	Happened and I was slightly upset 2You have observed the police treat White/non-Blacks with more respect and dignity than they do Blacks.  Happened and I was slightly upset 2	Happened and I was upset 3You have observed the police treat White/non-Blacks with more respect and dignity than they do Blacks.  Happened and I was upset 3	Happened and I was extremely upset 4You have observed the police treat White/non-Blacks with more respect and dignity than they do Blacks.  Happened and I was extremely upset 4
You have been subjected to racist jokes by Whites/non-Blacks in positions of authority and you did not protest for fear they might have held it against you.	Never Happened 0You have been subjected to racist jokes by Whites/non-Blacks in positions of authority and you did not protest for fear they might have held it against you.  Never Happened 0	Happened but did not bother me 1You have been subjected to racist jokes by Whites/non-Blacks in positions of authority and you did not protest for fear they might have held it against you.  Happened but did not bother me 1	Happened and I was slightly upset 2You have been subjected to racist jokes by Whites/non-Blacks in positions of authority and you did not protest for fear they might have held it against you.  Happened and I was slightly upset 2	Happened and I was upset 3You have been subjected to racist jokes by Whites/non-Blacks in positions of authority and you did not protest for fear they might have held it against you.  Happened and I was upset 3	Happened and I was extremely upset 4You have been subjected to racist jokes by Whites/non-Blacks in positions of authority and you did not protest for fear they might have held it against you.  Happened and I was extremely upset 4
While shopping at a store, or when attempting to make a purchase you were ignored as if you were not a serious customer or didn’t have any money.	Never Happened 0While shopping at a store, or when attempting to make a purchase you were ignored as if you were not a serious customer or didn’t have any money.  Never Happened 0	Happened but did not bother me 1While shopping at a store, or when attempting to make a purchase you were ignored as if you were not a serious customer or didn’t have any money.  Happened but did not bother me 1	Happened and I was slightly upset 2While shopping at a store, or when attempting to make a purchase you were ignored as if you were not a serious customer or didn’t have any money.  Happened and I was slightly upset 2	Happened and I was upset 3While shopping at a store, or when attempting to make a purchase you were ignored as if you were not a serious customer or didn’t have any money.  Happened and I was upset 3	Happened and I was extremely upset 4While shopping at a store, or when attempting to make a purchase you were ignored as if you were not a serious customer or didn’t have any money.  Happened and I was extremely upset 4
You have observed situations where other Blacks were treated harshly or unfairly by Whites/non-Blacks due to their race.	Never Happened 0You have observed situations where other Blacks were treated harshly or unfairly by Whites/non-Blacks due to their race.  Never Happened 0	Happened but did not bother me 1You have observed situations where other Blacks were treated harshly or unfairly by Whites/non-Blacks due to their race.  Happened but did not bother me 1	Happened and I was slightly upset 2You have observed situations where other Blacks were treated harshly or unfairly by Whites/non-Blacks due to their race.  Happened and I was slightly upset 2	Happened and I was upset 3You have observed situations where other Blacks were treated harshly or unfairly by Whites/non-Blacks due to their race.  Happened and I was upset 3	Happened and I was extremely upset 4You have observed situations where other Blacks were treated harshly or unfairly by Whites/non-Blacks due to their race.  Happened and I was extremely upset 4
You have heard reports of White people/non-Blacks who have committed crimes, and in an effort to cover up their deeds falsely reported that a Black man was responsible for the crime.	Never Happened 0You have heard reports of White people/non-Blacks who have committed crimes, and in an effort to cover up their deeds falsely reported that a Black man was responsible for the crime.   Never Happened 0	Happened but did not bother me 1You have heard reports of White people/non-Blacks who have committed crimes, and in an effort to cover up their deeds falsely reported that a Black man was responsible for the crime.   Happened but did not bother me 1	Happened and I was slightly upset 2You have heard reports of White people/non-Blacks who have committed crimes, and in an effort to cover up their deeds falsely reported that a Black man was responsible for the crime.   Happened and I was slightly upset 2	Happened and I was upset 3You have heard reports of White people/non-Blacks who have committed crimes, and in an effort to cover up their deeds falsely reported that a Black man was responsible for the crime.   Happened and I was upset 3	Happened and I was extremely upset 4You have heard reports of White people/non-Blacks who have committed crimes, and in an effort to cover up their deeds falsely reported that a Black man was responsible for the crime.   Happened and I was extremely upset 4
You notice that the media plays up those stories that cast Blacks in negative ways (child, abusers, rapists, muggers, etc. [or as savages] Wild Man of 96th St., Wolf Pack, etc.), usually accompanied by a large picture of a Black person looking angry or disturbed.	Never Happened 0You notice that the media plays up those stories that cast Blacks in negative ways (child, abusers, rapists, muggers, etc. [or as savages] Wild Man of 96th St., Wolf Pack, etc.), usually accompanied by a large picture of a Black person looking angry or disturbed. Never Happened 0	Happened but did not bother me 1You notice that the media plays up those stories that cast Blacks in negative ways (child, abusers, rapists, muggers, etc. [or as savages] Wild Man of 96th St., Wolf Pack, etc.), usually accompanied by a large picture of a Black person looking angry or disturbed. Happened but did not bother me 1	Happened and I was slightly upset 2You notice that the media plays up those stories that cast Blacks in negative ways (child, abusers, rapists, muggers, etc. [or as savages] Wild Man of 96th St., Wolf Pack, etc.), usually accompanied by a large picture of a Black person looking angry or disturbed. Happened and I was slightly upset 2	Happened and I was upset 3You notice that the media plays up those stories that cast Blacks in negative ways (child, abusers, rapists, muggers, etc. [or as savages] Wild Man of 96th St., Wolf Pack, etc.), usually accompanied by a large picture of a Black person looking angry or disturbed. Happened and I was upset 3	Happened and I was extremely upset 4You notice that the media plays up those stories that cast Blacks in negative ways (child, abusers, rapists, muggers, etc. [or as savages] Wild Man of 96th St., Wolf Pack, etc.), usually accompanied by a large picture of a Black person looking angry or disturbed. Happened and I was extremely upset 4
You have heard racists remarks or comments about Black people spoken with impunity by White public officials or other influential White people.	Never Happened 0You have heard racists remarks or comments about Black people spoken with impunity by White public officials or other influential White people. Never Happened 0	Happened but did not bother me 1You have heard racists remarks or comments about Black people spoken with impunity by White public officials or other influential White people. Happened but did not bother me 1	Happened and I was slightly upset 2You have heard racists remarks or comments about Black people spoken with impunity by White public officials or other influential White people. Happened and I was slightly upset 2	Happened and I was upset 3You have heard racists remarks or comments about Black people spoken with impunity by White public officials or other influential White people. Happened and I was upset 3	Happened and I was extremely upset 4You have heard racists remarks or comments about Black people spoken with impunity by White public officials or other influential White people. Happened and I was extremely upset 4
You have been given more work, or the most undesirable jobs at your place of employment while the White/non-Blacks of equal or less seniority and credentials is given less work, and more desirable tasks.	Never Happened 0You have been given more work, or the most undesirable jobs at your place of employment while the White/non-Blacks of equal or less seniority and credentials is given less work, and more desirable tasks.  Never Happened 0	Happened but did not bother me 1You have been given more work, or the most undesirable jobs at your place of employment while the White/non-Blacks of equal or less seniority and credentials is given less work, and more desirable tasks.  Happened but did not bother me 1	Happened and I was slightly upset 2You have been given more work, or the most undesirable jobs at your place of employment while the White/non-Blacks of equal or less seniority and credentials is given less work, and more desirable tasks.  Happened and I was slightly upset 2	Happened and I was upset 3You have been given more work, or the most undesirable jobs at your place of employment while the White/non-Blacks of equal or less seniority and credentials is given less work, and more desirable tasks.  Happened and I was upset 3	Happened and I was extremely upset 4You have been given more work, or the most undesirable jobs at your place of employment while the White/non-Blacks of equal or less seniority and credentials is given less work, and more desirable tasks.  Happened and I was extremely upset 4
You have heard or seen other Black people express the desire to be White or to have White physical characteristics because they disliked being Black or thought it was ugly.	Never Happened 0You have heard or seen other Black people express the desire to be White or to have White physical characteristics because they disliked being Black or thought it was ugly. Never Happened 0	Happened but did not bother me 1You have heard or seen other Black people express the desire to be White or to have White physical characteristics because they disliked being Black or thought it was ugly. Happened but did not bother me 1	Happened and I was slightly upset 2You have heard or seen other Black people express the desire to be White or to have White physical characteristics because they disliked being Black or thought it was ugly. Happened and I was slightly upset 2	Happened and I was upset 3You have heard or seen other Black people express the desire to be White or to have White physical characteristics because they disliked being Black or thought it was ugly. Happened and I was upset 3	Happened and I was extremely upset 4You have heard or seen other Black people express the desire to be White or to have White physical characteristics because they disliked being Black or thought it was ugly. Happened and I was extremely upset 4
White people or other non-Blacks have treated you as if you were unintelligent and needed things explained to you slowly or numerous times.	Never Happened 0White people or other non-Blacks have treated you as if you were unintelligent and needed things explained to you slowly or numerous times.  Never Happened 0	Happened but did not bother me 1White people or other non-Blacks have treated you as if you were unintelligent and needed things explained to you slowly or numerous times.  Happened but did not bother me 1	Happened and I was slightly upset 2White people or other non-Blacks have treated you as if you were unintelligent and needed things explained to you slowly or numerous times.  Happened and I was slightly upset 2	Happened and I was upset 3White people or other non-Blacks have treated you as if you were unintelligent and needed things explained to you slowly or numerous times.  Happened and I was upset 3	Happened and I was extremely upset 4White people or other non-Blacks have treated you as if you were unintelligent and needed things explained to you slowly or numerous times.  Happened and I was extremely upset 4
You were refused an apartment or other housing; you suspect it was because you are Black.	Never Happened 0You were refused an apartment or other housing; you suspect it was because you are Black.  Never Happened 0	Happened but did not bother me 1You were refused an apartment or other housing; you suspect it was because you are Black.  Happened but did not bother me 1	Happened and I was slightly upset 2You were refused an apartment or other housing; you suspect it was because you are Black.  Happened and I was slightly upset 2	Happened and I was upset 3You were refused an apartment or other housing; you suspect it was because you are Black.  Happened and I was upset 3	Happened and I was extremely upset 4You were refused an apartment or other housing; you suspect it was because you are Black.  Happened and I was extremely upset 4

Thank You Gift Section

Would you like a thank you gift card -or- diapers?

Please share the brand diapers if yours was not listed. And please feel free to give any other details.

Current Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Address you receive mail at (for diapers/gift card).