Not Assigned Child Mental Health Brief Questionnaire

Page 1 of 4

2007 NHIS Questionnaire - Sample Child

Child Mental Health Brief Questionnaire

Document Version Date: 12-Jul-06

Question ID: CMB.010_00.000 Instrument Variable Name: CMHCOPY QuestionnaireFileName: Sample Child

QuestionText: * The following statements are not to be read to the respondent. They are displayed and included here for legal reasons.

* The next 6 items contained in CMHMF_1 through CMHDIFF are included in this survey with permission as indicated

below.

* The SDQ questions are copyrighted by Robert Goodman, Ph.D., FRCPSYCH, MRCP. State and local agencies may

use these questions without charge and without seeking separate permission provided the wording is not modified, all the

questions are retained, and Dr. Goodman's copyright is acknowledged.

* Enter 1 to Continue.

1 Enter 1 to continue

UniverseText: Sample children GE 4

SkipInstructions: <1> [goto CMHMF_1]

Question ID: CMB.020_01.000 Instrument Variable Name: CMHMF_1 QuestionnaireFileName: Sample Child

QuestionText: (book) C7

I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,

SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS.

[fill2: He/She...]

...is generally well behaved, usually does what adults request.

1 Not true

2 Somewhat true

3 Certainly true

7 Refused

9 Don't know

UniverseText: Sample children GE 4

SkipInstructions: <1-3,D,R> [goto CMHMF_2]

Page 2 of 4

2007 NHIS Questionnaire - Sample Child

Child Mental Health Brief Questionnaire

Document Version Date: 12-Jul-06

Question ID: CMB.020_02.000 Instrument Variable Name: CMHMF_2 QuestionnaireFileName: Sample Child

QuestionText: (book) C7

* Read if necessary.

I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,

SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS.

[fill2: He/She...]

...has many worries, or often seems worried.

1 Not true

2 Somewhat true

3 Certainly true

7 Refused

9 Don't know

UniverseText: Sample children GE 4

SkipInstructions: <1-3,D,R> [goto CMHMF_3]

Question ID: CMB.020_03.000 Instrument Variable Name: CMHMF_3 QuestionnaireFileName: Sample Child

QuestionText: (book) C7

* Read if necessary.

I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,

SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS.

[fill2: He/She...]

...is often unhappy, depressed, or tearful.

1 Not true

2 Somewhat true

3 Certainly true

7 Refused

9 Don't know

UniverseText: Sample children GE 4

SkipInstructions: <1-3,R,D> [goto CMHMF_4]

Page 3 of 4

2007 NHIS Questionnaire - Sample Child

Child Mental Health Brief Questionnaire

Document Version Date: 12-Jul-06

Question ID: CMB.020_04.000 Instrument Variable Name: CMHMF_4 QuestionnaireFileName: Sample Child

QuestionText: (book) C7

* Read if necessary.

I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,

SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS.

[fill2: He/She...]

...gets along better with adults than with other [fill3: children/youth].

1 Not true

2 Somewhat true

3 Certainly true

7 Refused

9 Don't know

UniverseText: Sample children GE 4

SkipInstructions: <1-3,D,R> [goto CMHMF_5]

Question ID: CMB.020_05.000 Instrument Variable Name: CMHMF_5 QuestionnaireFileName: Sample Child

QuestionText: (book) C7

* Read if necessary.

I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,

SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS.

[fill2: He/She...]

...has good attention span, sees chores or homework through to the end.

1 Not true

2 Somewhat true

3 Certainly true

7 Refused

9 Don't know

UniverseText: Sample children GE 4

SkipInstructions: <1-3,D,R> [goto CMHDIFF]

Page 4 of 4

2007 NHIS Questionnaire - Sample Child

Child Mental Health Brief Questionnaire

Document Version Date: 12-Jul-06

Question ID: CMB.030_00.000 Instrument Variable Name: CMHDIFF QuestionnaireFileName: Sample Child

QuestionText: (book) C8

Overall, do you think that [fill1: SC name] has difficulties in any of the following areas: emotions, concentration, behavior,

or being able to get along with other people?

1 No

2 Yes, minor difficulties

3 Yes, definite difficulties

4 Yes, severe difficulties

7 Refused

9 Don't know

UniverseText: Sample children GE 4

SkipInstructions: <1-4,R,D> [goto SEEDIFF]