State and Local Area Integrated Telephone Survey (SLAITS)
National Survey of Children with Special Health Care Needs
Pretest data collection instrument (developmental work)
Household screener & survey
NOTE:
Most CATI instructions, selection processes, complicated skip patterns, et cetera are not shown in this version of the instrument to enhance clarity for the reader.
OMB Form Approved
OMB Control Number 0920-0406
Expiration Date November 30, 2007
SLAITS
NATIONAL SURVEY OF
CHILDREN WITH SPECIAL HEALTH CARE NEEDS
Pretest data collection instrument (developmental work)
Household screener & survey
According to the Paperwork Reduction Act (PRA) of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 0920-0406. The time required to complete this information collection is estimated to average 28 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments about the accuracy of the time estimate(s) or suggestions for improving this form please write to: CDC Reports Clearance Officer, 1600 Clifton Road, MS-D74, Atlanta, GA 30333; call 404-639-4794; or send an email to omb@cdc.gov.
Data collection conducted under contract to the CDC by the National Opinion Research Center (NORC) at the University of Chicago.
[The screener and survey follow questions about the National Immunization Survey; so there is no direct survey lead in.]
S.C. = Sample Child
S3_INTRO/
S3_INTRO_
INCENT Before we continue, I'd like you to know that taking part in this research is voluntary. You may choose not to answer any questions you don’t wish to answer, or end the interview at any time. We are required by Federal law to develop and follow strict procedures to protect your information and use your answers only for statistical research. I can describe these laws if you wish. In order to review my work, my supervisor may record and listen as I ask the questions. I’d like to continue now unless you have any questions.
Continue 1 GO TO S3_EVAL_R
Respondent asks for description of law 2 GO TO S3_LAW
S3_EVAL_R/
S3_EVAL_R_
INCENT Yes, respondent agrees to recording/listening 1 GO TO S_UNDR18
No, the respondent does not agree to recording/listening 2 GO TO S_UNDR18 (THE TEXT OF S_UNDR18 IS NOT SHOWN TO ENHANCE CLARITY FOR THE READER; IT ASKS THE NUMBER OF CHILDREN WHO LIVE IN THE HOUSEHOLD WHO ARE UNDER THE AGE OF 18 YEARS)
S3_LAW/
S3_LAW_
INCENT The Public Health Service Act is Volume 42 of the US Code, Section 242k. The collection of information in this survey is authorized by Section 306 of this Act. The confidentiality of your responses is assured by Section 308d of this Act, and the Confidential Information Protection and Statistical Efficiency Act. Would you like me to read the Confidential Information Protection Provisions to you?
No GO TO S_UNDR18
Yes GO TO S3_CONF
S3_CONF The information you provide will be used for statistical purposes only. In accordance with the Confidential Information Protection Provisions of Title V, Subtitle A, Public Law 107-347 and other applicable Federal laws, your responses will be kept confidential and will not be disclosed in identifiable form to anyone other than employees or agents. By law, every employee of the National Center for Health Statistics, the National Center for Immunization and Respiratory Disease, and its agent, the National Opinion Research Center who works on this survey has taken an oath and is subject to a jail term of up to 5 years, a fine of up to $250,000, or both, if he or she willingly discloses ANY identifiable information about you or your household members. GO TO S_UNDR18
THE SAMPLED CHILD (OR CHILDREN) IS/ARE RANDOMLY SELECTED HERE –THIS INFORMATION IS NOT SHOWN TO ENHANCE CLARITY FOR THE READER.
SC1_INTRO The next questions are about any kind of health problems, concerns, or conditions that may affect your (‘child’/‘children’)'s physical health, behavior, learning, growth, or physical development. Some of these health problems may affect your (‘child’/‘children’)'s abilities and activities at school or at play. Some of these problems affect the kind or amount of services your (‘child’/‘children’)'s may need or use.
CSHCN1 (‘Does (S.C.)’/‘Does your child’/ ‘Do any of your children’) currently need or use medicine prescribed by a doctor, other than vitamins?
(1) YES
(0) NO [SKIP TO CSHCN2]
(6) DON’T KNOW [SKIP TO CSHCN2]
(7) REFUSED [SKIP TO CSHCN2]
READ IF NECESSARY: This applies to ANY medications prescribed by a doctor. Do not include over-the-counter medications such as cold or headache medications, or any vitamins, minerals, or supplements that can be purchased without a prescription.
THESE QUESTIONS REFER ONLY TO A CURRENT CONDITION. THE RESPONDENT SHOULD ONLY REPLY WITH “YES” IF THE CHILD CURRENTLY HAS A SPECIAL HEALTH CARE NEED.
CSHCN1_A Is (AGEID)'s need for prescription medicine because of ANY medical, behavioral, or other health condition?
(1) YES
(0) NO [SKIP TO CSHCN2]
(6) DON’T KNOW [SKIP TO CSHCN2]
(7) REFUSED [SKIP TO CSHCN2]
CSHCN1_B Is this a condition that has lasted or is expected to last 12 months or longer?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
CSHCN2 (‘Does (S.C.)’/ ‘Does your child’/ ‘Do any of your children’) need or use more medical care, mental health, or educational services than is usual for most children of the same age?
(1) YES
(0) NO (SKIP TO CSHCN3)
(6) DON’T KNOW (SKIP TO CSHCN3)
(7) REFUSED (SKIP TO CSHCN3)
READ IF NECESSARY: The child requires more medical care, the use of more mental health services, or the use of more educational services than most children the same age. THESE QUESTIONS REFER ONLY TO A CURRENT CONDITION. THE RESPONDENT SHOULD ONLY REPLY WITH “YES” IF THE CHILD CURRENTLY HAS A SPECIAL HEALTH CARE NEED.
CSHCN2_A Is (AGEID)'s need for medical care, mental health or educational services because of ANY medical, behavioral, or other health condition?
(1) YES
(0) NO [SKIP TO CSHCN3]
(6) DON’T KNOW [SKIP TO CSHCN3]
(7) REFUSED [SKIP TO CSHCN3]
CSHCN2_B Is this a condition that has lasted or is expected to last 12 months or longer?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
CSHCN3 (‘Is (S.C.)’/ ‘Is your child’/ ‘Are any of your children’) limited or prevented in any way in (his/ her/their) ability to do the things most children of the same age can do?
(1) YES
(0) NO [SKIP TO CSHCN4]
(6) DON’T KNOW [SKIP TO CSHCN4]
(7) REFUSED [SKIP TO CSHCN4]
READ IF NECESSARY: A child is limited or prevented when there are things the child can’t do as much or can’t do at all that most children the same age can. THESE QUESTIONS REFER ONLY TO A CURRENT CONDITION. THE RESPONDENT SHOULD ONLY REPLY WITH “YES” IF THE CHILD CURRENTLY HAS A SPECIAL HEALTH CARE NEED.
CSHCN3_A Is (AGEID)'s limitation in abilities because of ANY medical, behavioral, or other health condition?
(1) YES
(0) NO [SKIP TO CSHCN4]
(6) DON’T KNOW [SKIP TO CSHCN4]
(7) REFUSED [SKIP TO CSHCN4]
CSHCN3_B Is this a condition that has lasted or is expected to last 12 months or longer?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
CSHCN4 (‘Does (S.C.)’/ ‘Does your child’/ ‘Do any of your children’) need or get special therapy, such as physical, occupational, or speech therapy?
(1) YES
(0) NO [SKIP TO CSHCN5]
(6) DON’T KNOW [SKIP TO CSHCN5]
(7) REFUSED [SKIP TO CSHCN5]
READ IF NECESSARY: Special therapy includes physical, occupational, or speech therapy. This is centered on physical needs, and things like psychological therapy are not included here. THESE QUESTIONS REFER ONLY TO A CURRENT CONDITION. THE RESPONDENT SHOULD ONLY REPLY WITH “YES” IF THE CHILD CURRENTLY HAS A SPECIAL HEALTH CARE NEED.
CSHCN4_A Is (AGEID)'s need for special therapy because of ANY medical, behavioral, or other health condition?
(1) YES
(0) NO [SKIP TO CSHCN5]
(6) DON’T KNOW [SKIP TO CSHCN5]
(7) REFUSED [SKIP TO CSHCN5]
CSHCN4_B Is this a condition that has lasted or is expected to last 12 months or longer?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
CSHCN5 (‘Does (S.C.)’/‘Does your child’/ ‘Do any of your children’) have any kind of emotional, developmental, or behavioral problem for which ('he/she needs'/ 'they need') treatment or counseling?
(1) YES
(0) NO [SKIP TO C2START1]
(6) DON’T KNOW [SKIP TO C2START1]
(7) REFUSED [SKIP TO C2START1]
READ IF NECESSARY: These are remedies, therapy, or guidance a child may receive for his/her emotional, developmental, or behavioral problem. THESE QUESTIONS REFER ONLY TO A CURRENT CONDITION. THE RESPONDENT SHOULD ONLY REPLY WITH “YES” IF THE CHILD CURRENTLY HAS A SPECIAL HEALTH CARE NEED.
CSHCN5_A Has (AGEID)'s emotional, developmental or behavioral problem lasted or is it expected to last 12
months or longer?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
THE NS-CSHCN SCREENER ENDS HERE.
THE CHILD (CHILDREN) IS/ARE CLASSIFIED AS EITHER A CSHCN OR NON-CSHCN (CWTYPE = N OR S) DEPENDING ON THE ANSWERS TO THE SCREENER QUESTIONS.
CW10Q01 FILL WITH NIS DATA IF AVAILABLE
FIRST CHILD - Is (S.C.) of Hispanic or Latino origin?
[THE REST OF THE CHILDREN-IF APPLICABLE] And how about (S.C.)?
(1)YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
CW10Q02 FILL WITH NIS DATA IF AVAILABLE
[FIRST CHILD] Now, I'm going to read a list of categories. Please choose one or more of the
following categories to describe (S.C.)’s race. Is (S.C.) White, Black or African American, American Indian, Alaska Native, Asian, Native Hawaiian or other Pacific Islander?
[THE REST OF CHILDREN-IF APPLICABLE] And how about (S.C.)?
[MARK ALL THAT APPLY]
C1002X01 WHITE (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C1002X02 BLACK/ AFRICAN AMERICAN (1) YES (0) NO (6) DON’T KNOW (7) REF
C1002X03 AMERICAN INDIAN (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C1002X04 ALASKA NATIVE (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C1002X05 ASIAN (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C1002X06 NATIVE HAWAIIAN (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C1002X07 PACIFIC ISLANDER (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C1002X08 OTHER (SPECIFY) (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
End Loop
HELP SCREEN: Be sure to read the entire question as written (including all response categories).
Race information is collected by self-identification. It is “whatever race you consider yourself to be.” Do not try to explain or define any of the groups. Multiple races may be selected.
CW10Q02A ENTER OTHER DESCENT
CW10Q04 What is the highest level of school that anyone in the household has completed or the highest degree anyone in the household has received?
(1) 8th Grade or Less
(2) 9th-12th Grade
(3) High School Graduate or GED
(4) Some College (Less than 4 Years)
(5) College Graduate (4+ Years)
(6) DON’T KNOW
(7) REFUSED
C2Q05 What is the primary language spoken in your home?
(1) English
(2) Spanish
(3) Any other language
(6) DON’T KNOW
(7) REFUSED
C2Q04 FILL WITH NIS DATA IF AVAILABLE
What is your relationship to (S.C.)?
(1) Mother (BIOLOGICAL, STEP, FOSTER, ADOPTIVE)
(2) Father (BIOLOGICAL, STEP, FOSTER, ADOPTIVE)
(3) Sister OR BROTHER (BIOLOGICAL/STEP/FOSTER/HALF/ADOPTIVE)
(4) IN-LAW OF ANY TYPE
(5) Aunt/ UNCLE
(6) GRANDPARENT
(7) OTHER FAMILY MEMBER
(8) FEMALE GUARDIAN
(9) MALE GUARDIAN
(10) GODPARENT OR OTHER FRIEND
(96) Don’t Know
(97) REFUSED
C3QINTRO [IF CWTYPE = N, SKIP TO S3Q01, ELSE ASK C3QINTRO]
Earlier, you told me that (S.C.)
IF CSHCN1_B = 1, ADD “needs prescription drugs....”
IF CSHCN2_B = 1, ADD “needs medical care, mental health, or education services....”
IF CSHCN3_B = 1, ADD “is limited or prevented in (his/her) ability to do things....”
IF CSHCN4_B = 1, ADD “needs special therapy....”
IF CSHCN5_A = 1, ADD “needs treatment or counseling....”
If CSHCN1_B, CSHCN2_B, CSHCN3_B, or CSHCN4_B = 1, then continue: “...because of medical, behavioral, or other health conditions.”
IFCSHCN1_B = 2, CSHCN2_B = 2, CSHCN3_B = 2, CSHCN4_B = 2, AND CSHCN5_A = 1, then continue: “because of emotional, developmental, or behavioral problems.”
C3Q02 [During the past 12 months/Since (his/her) birth], how often have (S.C.)’s (medical, behavioral, or other health conditions / emotional, developmental, or behavioral problems) affected (his/her) ability to do things other children (his/her) age do? Would you say:
(1) Never (SKIP TO C3Q11)
(2) Sometimes
(3) Usually
(4) Always
(6) DON’T KNOW (SKIP TO C3Q11)
(7) REFUSED (SKIP TO C3Q11)
READ IF NECESSARY: This question asks how often your child's abilities are affected by his/her health. It does not ask about the severity, intensity, or magnitude of the effect.
ADDITIONAL INFO: FOR EXAMPLE, IF A CHILD'S ASTHMA WAS SEVERE BUT THE ATTACKS WERE RARE, THIS QUESTION WOULD BE ANSWERED WITH "SOMETIMES." IF THE CONDITION IS EPISODIC, RESPONDENTS SHOULD THINK ABOUT HOW OFTEN THE CONDITION HAS AFFECTED THE CHILD'S ABILITIES DURING THE PAST ENTIRE 12 MONTHS.
C3Q03 Do (S.C.)’s (medical, behavioral, or other health conditions/emotional, developmental, or behavioral problems) affect (his/her) ability to do things a great deal, some, or very little?
(1) A great deal
(2) Some
(3) Very little
(6) DON’T KNOW
(7) REFUSED
READ IF NECESSARY: You told me your child's health affects his/her ability to do things. When this occurs, how much are your child's abilities affected?
ADDITIONAL INFO: FOR EXAMPLE, IF A CHILD'S ASTHMA WAS SEVERE BUT THE ATTACKS WERE RARE, THIS QUESTION WOULD BE ANSWERED WITH "A GREAT DEAL." IF THE CONDITION IS EPISODIC, RESPONDENTS SHOULD THINK ABOUT HOW SEVERE THE IMPACT HAS BEEN WHEN THE EPISODES OCCURRED OVER THE PAST 12 MONTHS.
C3Q11 Which of the following statements best describes (S.C.)’s health care needs? - (S.C.)’s health care needs change all the time, - (S.C.)’s health care needs change only once in a while, or -(S.C.)’s health care needs are usually stable?
(1) Child’s health care needs change all the time
(2) Child’s health care needs change only once in a while
(3) Child’s health care needs are usually stable
(4) NONE OF THE ABOVE
(6) DON’T KNOW
(7) REFUSED
S3Q01 The next questions are about ways (S.C.) might experience difficulties due to (his/her) health. Without glasses or contact lenses, would you say (he/she) experiences any difficulty seeing?
(1) YES
(0) NO [SKIP TO S3Q02]
(6) DON’T KNOW [SKIP TO S3Q02]
(7) REFUSED [SKIP TO S3Q02]
S3Q01A Does (S.C.) wear glasses or contact lenses?
(1) YES
(0) NO [SKIP TO S3Q02]
(6) DON’T KNOW [SKIP TO S3Q02]
(7) REFUSED [SKIP TO S3Q02]
S3Q01B Does (S.C.) have any difficulty seeing even when wearing glasses or contact lenses?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S3Q02 Without hearing aids, would you say (he/she) experiences any difficulty hearing?
(1) YES
(0) NO [SKIP TO S3Q03]
(6) DON’T KNOW [SKIP TO S3Q03]
(7) REFUSED [SKIP TO S3Q03]
S3Q02A Does (S.C.) use a hearing aid?
(1) YES
(0) NO [SKIP TO S3Q03]
(6) DON’T KNOW [SKIP TO S3Q03]
(7) REFUSED [SKIP TO S3Q03]
S3Q02B Does (S.C.) have any difficulty hearing even when using a hearing aid?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S3Q03 Would you say (he/she) experiences any difficulty with breathing or other respiratory problems, such as wheezing or shortness of breath?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S3Q04 (READ IF NECESSARY: Would you say (he/she) experiences any difficulty with) Swallowing, digesting food, or metabolism?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S3Q05 (READ IF NECESSARY: Would you say (he/she) experiences any difficulty with)
Blood circulation?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S3Q06 (READ IF NECESSARY: Would you say (he/she) experiences any difficulty with)
Repeated or chronic physical pain, including headaches?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S3Q07 [IF S.C. IS YOUNGER THAN 36 MONTHS, SKIP TO S3Q08]
Compared to other (S.C. AGE)-year-old children, would you say (he/she) experiences any difficulty taking care of (himself/herself), for example, doing things like eating, dressing and bathing?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S3Q08 IF SC AGE=0 MONTHS, THEN "Compared to other newborns would you say (he/she) experiences any difficulty with coordination or moving around, such as….?"
IF SC AGE>0 MONTHS, THEN "Compared to other (SC AGE)-year-old children would you say (he/she) experiences any difficulty with coordination or moving around, such as..."
(IF S.C. <10 MONTHS OLD, SAY: “crawling or moving arms or legs?”
IF S.C 10 – 23 MONTHS OLD, SAY: “walking or crawling?”
IF S.C 24+ MONTHS OLD, SAY: “walking or running?”)
(1) YES
(0) NO
(6)DON’T KNOW
(7)REFUSED
S3Q09 IF SC AGE=0 MONTHS, THEN "Compared to other newborns would you say (he/she) experiences any difficulty using (his/her) hands such as such as….?"
IF SC AGE>0 MONTHS, THEN "Compared other (SC AGE)-year-old children would you say (he/she) experiences any difficulty using (his/her) hands such as such as..."
(IF S.C. 0-7 MONTHS, SAY: “ grabbing small objects?”
IF S.C. 8-23 MONTHS, SAY: “ holding a cup or eating finger foods?”
IF S.C. 24+ MONTHS, SAY: “using scissors, a pencil, or a fork?”)
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S3Q10 [IF S.C. IS YOUNGER THAN 12 MONTHS, SKIP TO S3Q12]
(READ IF NECESSARY: Compared to other (S.C. AGE)-year-old children, would you say (he/she) experiences any difficulty)
Learning, understanding, or paying attention?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S3Q11 (READ IF NECESSARY: Compared to other (S.C. AGE)-year-old children, would you say (he/she) experiences any difficulty)
Speaking, communicating, or being understood?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S3Q12 [IF S.C. IS YOUNGER THAN 18 MONTHS, SKIP TO S3Q14]
(READ IF NECESSARY: Compared to other (S.C. AGE)-year-old children, would you say (he/she) experiences any difficulty)
With feeling anxious or depressed?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S3Q13 (READ IF NECESSARY: Compared to other (S.C. AGE)-year-old children, would you say (he/she) experiences any difficulty)
With behavior problems, such as acting-out, fighting, bullying, or arguing?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S3Q14 [IF S.C. IS YOUNGER THAN 36 MONTHS, SKIP TO INSTRUCTIONS BEFORE C3Q10]
(READ IF NECESSARY: Compared to other (S.C. AGE)-year-old children, would you say (he/she) experiences any difficulty)
Making and keeping friends?
(1) YES
(0) NO
(6)DON’T KNOW
(7)REFUSED
IF (S3Q01 = 2, 6, 7 or S3Q01B = 2, 6, 7), (S3Q02 = 2, 6, 7 or S3Q02B = 2, 6, 7), AND ALL S3Q03 THROUGH S3Q14 = 2, 6, 7, SKIP TO S3Q15
C3Q10 Overall, how would you rate the severity of the difficulties caused by (S.C.)’s health problems? Would you say minor, moderate, or severe?
(1) MINOR
(2) MODERATE
(3) SEVERE
(6) Don’t know
(7) Refused
HELP SCREEN: IF THE PARENT IS HAVING TROUBLE RATING THE OVERALL SEVERITY BECAUSE THE CHILD HAS MORE THAN ONE DIFFICULTY, THE PARENT SHOULD RATE THE MOST SEVERE DIFFICULTY RATHER THAN TRYING TO AVERAGE SEVERITY ACROSS ALL OF THE DIFFICULTIES.
ALL SKIP TO S3Q16
S3Q15 [IF REFERENT SAMPLE AND CWTYPE = ‘N’, SKIP TO S3Q16]
You reported that (S.C.) does not experience any difficulty in any of the areas just mentioned. In your opinion, would you say this is because (S.C.)’s health problems are being treated and are under control?
(1) YES [SKIP TO S3Q16]
NO [SKIP TO S3Q15A]
(6) DON’T KNOW [SKIP TO S3Q16]
(7) REFUSED [SKIP TO S3Q16]
S3Q15A Why is it that (S.C.)’s health problems do not currently cause (him/her) difficulty?
_______________________[250 CHARACTERS MAX]
[NOTE TO INTERVIEWERS: DO NOT RECORD ONLY THE DIAGNOSIS OR CONDITION. IF THE RESPONDENT GIVES ONLY THE DIAGNOSIS OR CONDITION, ASK: “Why doesn’t that problem cause any difficulty in the areas just mentioned?”]
S3Q16 To the best of your knowledge, does (S.C.) currently have any of the following: Asthma?
(1) YES
(0) NO
(6) DK
(7) REF
S3Q17 (READ IF NECESSARY: To the best of your knowledge, does (S.C.) currently have) Attention Deficit Disorder or Attention Deficit Hyperactive Disorder, that is, ADD or ADHD?
(1) YES
(0) NO
(6) DK
(7) REF
S3Q18 (READ IF NECESSARY: To the best of your knowledge, does (S.C.) currently have) Autism or Autism Spectrum Disorder, that is, ASD?
(1) YES
(0) NO
(6) DK
(7) REF
S3Q19 (READ IF NECESSARY: To the best of your knowledge, does (S.C.) currently have) Down Syndrome?
(1) YES
(0) NO
(6) DK
(7) REF
S3Q20 (READ IF NECESSARY: To the best of your knowledge, does (S.C.) currently have) Mental retardation or developmental delay?
(1) YES
(0) NO
(6) DK
(7) REF
S3Q21 (READ IF NECESSARY: To the best of your knowledge, does (S.C.) currently have) Depression, anxiety, an eating disorder, or other emotional problems?
(1) YES
(0) NO
(6) DK
(7) REF
S3Q22 (READ IF NECESSARY: To the best of your knowledge, does (S.C.) currently have) Diabetes?
(1) YES [SKIP TO S3Q22A]
(0) NO [SKIP TO S3Q23]
(6) DK [SKIP TO S3Q23]
(7) REF [SKIP TO S3Q23]
S3Q22A Does (S.C.) use insulin?
(1) YES
(0) NO
(6) DK
(7) REF
S3Q23 To the best of your knowledge, does (S.C.) currently have a heart problem, including congenital heart disease?
(1) YES
(0) NO
(6) DK
(7) REF
S3Q25 (READ IF NECESSARY: To the best of your knowledge, does (S.C.) currently have) Blood problems such as anemia or sickle cell disease? Please do not include Sickle Cell Trait.
(1) YES
(0) NO
(6) DK
(7) REF
S3Q26 (READ IF NECESSARY: To the best of your knowledge, does (S.C.) currently have) Cystic Fibrosis?
(1) YES
(0) NO
(6) DK
(7) REF
S3Q27 (READ IF NECESSARY: To the best of your knowledge, does (S.C.) currently have) Cerebral Palsy?
(1) YES
(0) NO
(6) DK
(7) REF
S3Q28 (READ IF NECESSARY: To the best of your knowledge, does (S.C.) currently have) Muscular Dystrophy?
(1) YES
(0) NO
(6) DK
(7) REF
S3Q29 (READ IF NECESSARY: To the best of your knowledge, does (S.C.) currently have) Epilepsy or other seizure disorder?
(1) YES
(0) NO
(6) DK
(7) REF
S3Q30 (READ IF NECESSARY: To the best of your knowledge, does (S.C.) currently have) Migraine or frequent headaches?
(1) YES
(0) NO
(6) DK
(7) REF
S3Q32 (READ IF NECESSARY: To the best of your knowledge, does (S.C.) currently have) Arthritis or other joint problems?
(1) YES
(0) NO
(6) DK
(7) REF
S3Q31 (READ IF NECESSARY: To the best of your knowledge, does (S.C.) currently have) Allergies?
(1) YES
(0) NO [SKIP TO C3Q14]
(6) DK [SKIP TO C3Q14]
(7) REF [SKIP TO C3Q14]
S3Q31_A:
(READ IF NECESSARY: To the best of your knowledge)
Are
any of these food allergies?
(1)
YES
(0)
NO
(6)
DK
(7)
REF
C3Q14 [IF AGE FROM C2Q01 OR C2Q02 < 60 MONTHS (5 YEARS), SKIP TO C6Q00]
During the past 12 months, that is since (FILL, TODAY – 12 MONTHS), about how many days did (S.C.) miss school because of illness or injury?
[NOTE: A SCHOOL YEAR IS 240 DAYS]
(Date Format for FILL: MONTH NAME/YEAR. Example if this were executed today: "…, that is since February 2004, about how many days…")
______________NUMBER OF DAYS
(000) NONE
(994) DID NOT GO TO SCHOOL
(995) HOME SCHOOLED
(996) DON’T KNOW
(997) REFUSED
C6Q00 [‘During the past 12 months’/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] ‘Since (his/her) birth’], how many times did (S.C.) visit a hospital emergency room?
READ IF NECESSARY: This includes emergency room visits that resulted in a hospital admission.
ENTER NUMBER OF VISITS
______________NUMBER OF VISITS
(000) NO VISITS IN PAST 12 MONTHS
(996) DON’T KNOW
(997) REFUSED
C6Q01 [During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth], how many times did (S.C.) visit a doctor or other health care provider? Do not include (IF C6Q00 > 0 AND < 777 THEN FILL: “visits to hospital emergency rooms or”) times when (S.C.) was hospitalized overnight.
ENTER NUMBER OF VISITS
______________NUMBER OF VISITS
(000) NO VISITS IN PAST 12 MONTHS
(996) DON’T KNOW (SKIP TO NAME_SEC4)
(997) REFUSED (SKIP TO NAME_SEC4)
(IF C6Q01 > 000 AND < 030, SKIP TO C4Q0A)
C6Q01_A I have (ANSWER FROM C6Q01) visits. Is that correct?
(1) YES
(0) NO [SKIP BACK TO C6Q01]
Section 4. ACCESS TO CARE: UTILIZATION AND UNMET NEEDS
C4Q0A Is there a place that (S.C.) USUALLY goes when (he/she) is sick or you need advice about
(his/her) health?
(1) YES
(2) THERE IS NO PLACE [SKIP TO C4Q0D]
(3) THERE IS MORE THAN ONE PLACE
(6) DON’T KNOW [SKIP TO C4Q0D]
(7) REFUSED [SKIP TO C4Q0D]
C4Q0B IF C4Q0A = 01, SAY “What kind of place is it?”
IF C4Q0A = 03, SAY “What kind of place does (S.C.) go to most often?”
Is it a doctor’s office, emergency room, hospital outpatient department, clinic, or some other place?
(1) Doctor’s office [SKIP TO C4Q0D]
(2) HOSPITAL emergency room [SKIP TO C4Q0D]
(3) Hospital outpatient department [SKIP TO C4Q0D]
(4) Clinic OR HEALTH CENTER [SKIP TO C4Q0D]
(5) SCHOOL (NURSE’S OFFICE, ATHLETIC TRAINER’S OFFICE, ETC) [SKIP TO C4Q0D]
(6) fRIEND/RELATIVE [SKIP TO C4Q0D]
(7) mEXICO/OTHER LOCATIONS OUT OF US [SKIP TO C4Q0D]
(8) Some other place [SKIP TO C4Q0C]
(9) DOES NOT GO TO ONE PLACE MOST OFTEN [SKIP TO C4Q0D]
(96) DON’T KNOW [FILL 7 IN C4Q0A AND SKIP TO C4Q0D]
(97) REFUSED [FILL 9 IN C4Q0A AND SKIP TO C4Q0D]
C4Q0C READ IF NECESSARY
IF C4Q0A = 01, SAY “What kind of place is it?”
IF C4Q0A = 3, SAY “What kind of place does (S.C.) go to most often?”
Record verbatim response________
C4Q0D Is there a place that (S.C.) USUALLY goes when (he/she) needs routine preventive care, such as a physical examination or well-child check-up?
(1) YES
(2) THERE IS NO PLACE [SKIP TO C4Q02A]
(3) THERE IS MORE THAN ONE PLACE
(6) DON’T KNOW [SKIP TO C4Q02A]
(7) REFUSED [SKIP TO C4Q02A]
READ IF NECESSARY: Clinical preventive care includes check-ups, immunizations, health screening tests, and discussions about how to keep your child healthy.
C4Q01 [IF C4Q0A = 02, 7, 9, OR IF C4Q0B = 9, 7, 9, THEN GO TO C4Q02]
[IF C4Q0B = 06, 07, 08, 7, 9 FILL WITH “place”]
Is the [place selected in C4Q0B] that (S.C.) goes to when (he/she) is sick the same place (S.C.) usually goes for routine preventive care?
(1) Yes [Skip to c4q02A]
(0) No
(6) Don’t Know [Skip to c4q02A]
(7) Refused [Skip to c4q02A]
C4Q02 IF C4Q0D = 01 OR MISSING, SAY “What kind of place does (S.C.) USUALLY go to when (he/she) needs routine preventive care?”
IF C4Q0D = 03, SAY “What kind of place does (S.C.) go to most often when (he/she) needs routine preventive care?”
(1) Doctor’s office
(2) HOSPITAL emergency room
(3) Hospital outpatient department
(4) Clinic OR HEALTH CENTER
(5) SCHOOL (NURSE’S OFFICE, ATHLETIC TRAINER’S OFFICE, ETC)
(6) FRIEND/RELATIVE
(7) MEXICO/OTHER LOCATIONS OUT OF US
(8) Some other place [SKIP TO C4Q02_01]
(9) DOES NOT GO TO ONE PLACE MOST OFTEN
(96) Don’t Know
(97) Refused
FOR ALL EXCEPT (08), GO TO C4Q02A
C4Q02_01 READ
IF NECESSARY
IF C4Q0D = 1, SAY “What kind of place is it?”
IF C4Q0D = 3, SAY “What kind of place does (S.C.) go to most often?”
Record verbatim response________
C4Q02A A personal doctor or nurse is a health professional who knows your child well and is familiar with your child’s health history. This can be a general doctor, a pediatrician, a specialist doctor, a nurse practitioner, or a physician’s assistant. Do you have one or more persons you think of as (S.C.)’s personal doctor or nurse?
(1) Yes, one person
(2) yes, more than one person
(3) No [Skip to C4Q03]
(6) Don’t Know [Skip to C4Q03]
(7) Refused [Skip to C4Q03]
C4Q02B IF C4Q02A = 01 THEN READ: “Is this person a general doctor, pediatrician, specialist, nurse practitioner, or physician’s assistant?” [MARK ALL THAT APPLY]
IF C4Q02A = 02 THEN READ: “Are those people general doctors, pediatricians, specialists, nurse practitioners, or physician assistants?” [MARK ALL THAT APPLY]
C4Q02BX01 General doctor (general practice, family or internal medicine) (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C4Q02BX02 Pediatrician (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C4Q02BX03 Specialist (FOR EXAMPLE; surgeons, heart doctors, psychiatrists, ob/gyn) (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C4Q02BX04 Nurse Practitioner (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C4Q02BX05 Physician’s Assistant
(1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C4Q02BX06 MOTHER/FRIEND/RELATIVE
(1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C4Q02BX07 OTHER [SKIP TO C4Q02B_01]
(1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C4Q02B_01 READ IF NECESSARY
What type of health professional is this person?
Record verbatim response________
C4Q03 People often delay or do not get needed health care. By health care I mean medical care as well as other kinds of care like dental care, mental health services, physical, occupational, or speech therapies, and special education services. [During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth], have you delayed or gone without needed health care for (S.C.)?
(1) Yes
(0) No [Skip to c4q05]
(6) Don’t Know [Skip to c4q05]
(7) Refused [Skip to c4q05]
READ IF NECESSARY: When a parent attempts to treat a child by themselves but then takes the child to a doctor, this should not be considered a delay in health care.
AN example of that would be a child with a cough or a sore throat WHO WAS GIVEN COUGH SYRUP AT HOME, BUT THAT DID NOT HELP OR WORK.
C4Q04_A There are many reasons people delay or do not get needed health care. I am going to read a list of reasons. For each, please tell me – yes or no – if this was a reason you delayed or did not get needed health care.
Did you delay or not get health care for (S.C.) because you couldn’t get through to the health care provider’s office on the telephone?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
C4Q04_B (READ IF NECESSARY: Did you delay or not get health care for (S.C.) because) You couldn’t get an appointment for (S.C.) soon enough?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
C4Q04_C (READ IF NECESSARY: Did you delay or not get health care for (S.C.) because) The clinic or doctor’s office was not open when you could get there?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
C4Q04_D (READ IF NECESSARY: Did you delay or not get health care for (S.C.) because) Transportation was a problem?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
C4Q04_E (READ IF NECESSARY: Did you delay or not get health care for (S.C.) because) You didn’t have enough money to pay the health care provider?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
C4Q04_F (READ IF NECESSARY: Did you delay or not get health care for (S.C.) because) The type of care (S.C.) needed was not available in your area?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
C4Q04_G (READ IF NECESSARY: Did you delay or not get health care for (S.C.) because) The health care provider did not have the skills (S.C.) needed?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
c4q04_h (READ IF NECESSARY: Did you delay or not get health care for (S.C.) because) The type of care was not covered by your health plan?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
c4q04_I (READ IF NECESSARY: Did you delay or not get health care for (S.C.) because) You could not get approval from your health plan or doctor?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
C4Q04_J (READ IF NECESSARY: Did you delay or not get health care for (S.C.) because) Once you get there, (S.C.) has to wait too long to see the health care provider?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
C4Q04_ K (READ IF NECESSARY: Did you delay or not get health care for (S.C.) because) You have language, communication, or cultural problems with the health care provider?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
C4Q04_L (READ IF NECESSARY: Did you delay or not get health care for (S.C.) because) Going to appointments conflicts with other responsibilities at home or at work?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
C4Q05 (4.5)
(CATI: THIS SERIES SHOULD BE ASKED HORIZONTALLY ACROSS THE TABLE. IN OTHER WORDS, IF THEY ANSWER YES TO SOMETHING IN COLUMN 01, THEY SHOULD IMMEDIATELY BE ASKED THE QUESTIONS IN COLUMN 2, 3, 4, 5 AS APPLICABLE)
IF C4Q03 = 1, THEN ADD THE FOLLOWING TRANSITION: “There are many different services that children sometimes need.”
ALL RECEIVE THE FOLLOWING INTRODUCTION: [During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth], was there any time when (S.C.) needed any of the following services: |
Did (S.C.) receive all the {fill each ‘Yes' item from first column} that {he/she} needed? |
Why did (S.C.) not get the {fill each yes item from first column} {he/she} needed? (CHECK ALL THAT APPLY. READ RESPONSES ONLY IF NECESSARY) |
|
Did (S.C.) get any {fill each yes item from first column} [during the past 12 months/ since (his/her) birth]? |
C4Q05_X01 (READ IF NECESSARY: During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when (S.C.) needed) Routine preventive care, such as a physical examination or well child check-up? (1) YES (0) NO [SKIP TO C4Q05_X02] (6) DK [SKIP TO C4Q05_X02] (7) REF [SKIP TO C4Q05_X02]
note: C4Q05_X01a is avariable that is not used. |
C4Q05X01A Did (S.C.) receive all the [routine preventive care] that {he/she} needed?
(1)Yes [SKIP TO C4Q05_X02] (0) No (6) DK [SKIP TO C4Q05_X02] (7) Ref [SKIP TO C4Q05_X02] |
C40501BX01-X16 Why did (S.C.) not get the routine preventive care {he/she} needed?
(1) Yes (0) NO (6) Dk (7) REF
1 Cost too much 2 NO INSURANCE 3 Health plan problem 4 Can’t find PROVIDER who accepts child’s insurance 5 Not available in area/transport problems 6 Not convenient times/could not get appointment 7 PROVIDER did not know how to treat or provide care 8 Dissatisfaction with PROVIDER 9 Did not know where to go for treatment 10 Child refused to go 11 Treatment is ongoing 12 Vaccine shortage 13 No referral 14 Lack of resources at school 15 DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT 16 Other (SKIP TO C4Q0501OE)
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C4Q0501OE
READ IF NECESSARY (Why did (S.C.) not get the {routine preventive care} {he/she} needed ?)
Record Verbatim response________
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C4Q05X01C Did (S.C.) get any routine preventive care [during the past 12 months/[WHEN S.C. IS YOUNGER THAN 12 MONTHS: since his/her birth]? (1) YES (0) NO (6) DK (7) REF
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C4Q05_X02 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when (S.C.) needed) Care from a specialty doctor?
(1) YES (0) NO [SKIP TO C4Q05_X03] (6) DK [SKIP TO C4Q05_X03] (7) REF [SKIP TO C4Q05_X03]
READ IF NECESSARY: Specialty doctors focus on one part of your child’s health. These include cardiologists, pulmonologists, ear, nose and throat doctors, surgeons, etc. Do not include dentists or psychiatrists. Needs for care from dentists and psychiatrists are asked in other questions.
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C4Q05X02A Did (S.C.) receive all the Care from a specialty doctor that {he/she} needed?
(1)Yes [SKIP TO C4Q05X02AA] (0) No (6) DK [SKIP TO C4Q05_X03] (7) Ref [SKIP TO C4Q05_X03]
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C40502BX01-X16 Why did (S.C.) not get the Care from a specialty doctor {he/she} needed?
For each below: (1) Yes (0) NO (6) Dk (7) REF
1 Cost too much 2 NO INSURANCE 3 Health plan problem 4 Can’t find PROVIDER who accepts child’s insurance 5 Not available in area/transport problems 6 Not convenient times/could not get appointment 7 PROVIDER did not know how to treat or provide care 8 Dissatisfaction with PROVIDER 9 Did not know where to go for treatment 10 Child refused to go 11 Treatment is ongoing 12 Vaccine shortage 13 No referral 14 Lack of resources at school 15 DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT 16 Other ( (SKIP TO C4Q0502OE)
|
C4Q0502OE READ IF NECESSARY (Why did (S.C.) not get the {care from a specialty doctor} {he/she} needed ?)
Record verbatim response_________ |
C4Q05X02C Did (S.C.) get any care from a specialty doctor [during the past 12 months/ since (his/her) birth]? (1) YES [SKIP TO C4Q05X02AA] (0) NO (6) DK (7) REF [SKIP TO C4Q05_X03]
C4Q05X02AA
[IF C4Q05X02A = 01 OR C4Q0502C = 01 THEN ASK]: How many different specialty doctors did (S.C.) see [during the past 12 months/ since (his/her) birth]?
6 - DON’T KNOW 7 - REFUSED |
C4Q05_X031 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when (S.C.) needed) Preventive dental care, such as check-ups and dental cleanings?
(1) YES (0) NO [SKIP TO C4Q05_X032] (6) DK [SKIP TO C4Q05_X032] (7) REF [SKIP TO C4Q05_X032] |
C4Q05X031A Did (S.C.) receive all the [PREVENTIVE DENTAL CARE] that {he/she} needed?
(1)Yes [SKIP TO C4Q05_X032] (0) No (6) DK [SKIP TO C4Q05_X032] (7) Ref [SKIP TO C4Q05_X032]
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C405031BX01-X16 Why did (S.C.) not get the [PREVENTIVE DENTAL CARE] {he/she} needed?
For each below: (1) Yes (0) NO (6) Dk (7) REF
01 Cost too much 02 NO INSURANCE 03 Health plan problem 04 Can’t find PROVIDER who accepts child’s insurance 05 Not available in area/transport problems 06 Not convenient times/could not get appointment 07 PROVIDER did not know how to treat or provide care 08 Dissatisfaction with PROVIDER 09 Did not know where to go for treatment 10 Child refused to go 11 Treatment is ongoing 12 Vaccine shortage 13 No referral 14 Lack of resources at school 15 DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT 16 Other (SKIP TO C4Q05031OE) |
C4Q05031OE
READ IF NECESSARY (Why did (S.C.) not get the { PREVENTIVE DENTAL CARE } {he/she} needed ?)
Record verbatim response_________ |
C4Q05X031C Did (S.C.) get any preventive dental care [during the past 12 months/ since (his/her) birth]? (1) YES (0) NO (6) DK (7) REF |
C4Q05_X032 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when (S.C.) needed) Any other dental care?
(1) YES (0) NO [SKIP TO C4Q05_X04] (6) DK [SKIP TO C4Q05_X04] (7) REF [SKIP TO C4Q05_X04] |
C4Q05X032A Did (S.C.) receive all the [OTHER DENTAL CARE] that {he/she} needed?
(1)Yes [SKIP TO C4Q05_X04] (0) No (6) DK [SKIP TO C4Q05_X04] (7) Ref [SKIP TO C4Q05_X04] |
C405032BX01-X16 Why did (S.C.) not get the [OTHER DENTAL CARE] {he/she} needed?
For each below: (1) Yes (0) NO (6) Dk (7) REF
01 Cost too much 02 NO INSURANCE 03 Health plan problem 04 Can’t find PROVIDER who accepts child’s insurance 05 Not available in area/transport problems 06 Not convenient times/could not get appointment 07 PROVIDER did not know how to treat or provide care 08 Dissatisfaction with PROVIDER 09 Did not know where to go for treatment 10 Child refused to go 11 Treatment is ongoing 12 Vaccine shortage 13 No referral 14 Lack of resources at school 15 DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT 16 Other (SKIP TO C4Q05032OE)
|
C4Q05032OE
READ IF NECESSARY (Why did (S.C.) not get the { OTHER DENTAL CARE } {he/she} needed ?)
Record verbatim response_________ |
C4Q05X032C Did (S.C.) get any non-preventive dental care [during the past 12 months/ since (his/her) birth]? (1) YES (0) NO (6) DK (7) REF |
C4Q05_X04 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when (S.C.) needed) Prescription medications?
(1) YES (0) NO [SKIP TO C4Q05_X05] (6) DK [SKIP TO C4Q05_X05] (7) REF [SKIP TO C4Q05_X05]
|
C4Q05X04A Did (S.C.) receive all the [Prescription medications] that {he/she} needed?
(1)Yes [SKIP TO C4Q05_X05] (0) No (6) DK [SKIP TO C4Q05_X05] (7) Ref [SKIP TO C4Q05_X05] |
C40504BX01-X16 Why did (S.C.) not get the [Prescription medications] {he/she} needed?
For each below: (1) Yes (0) NO (6) Dk (7) REF
01 Cost too much 02 NO INSURANCE 03 Health plan problem 04 Can’t find PROVIDER who accepts child’s insurance 05 Not available in area/transport problems 06 Not convenient times/could not get appointment 07 PROVIDER did not know how to treat or provide care 08 Dissatisfaction with PROVIDER 09 Did not know where to go for treatment 10 Child refused to go 11 Treatment is ongoing 12 Vaccine shortage 13 No referral 14 Lack of resources at school 15 DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT 16 Other (SKIP TO C4Q0504OE)
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C4Q0504OE
READ IF NECESSARY (Why did (S.C.) not get the [Prescription medications] {he/she} needed?
Record verbatim response_________ |
C4Q05X04C Did (S.C.) get any prescription medications [during the past 12 months/ since (his/her) birth]? (1) YES (0) NO (6) DK (7) REF |
C4Q05_X05 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when (S.C.) needed) Physical, occupational or speech therapy?
(1) YES (0) NO [SKIP TO C4Q05_X06] (6) DK [SKIP TO C4Q05_X06] (7) REF [SKIP TO C4Q05_X06] |
C4Q05X05A Did (S.C.) receive all the [therapy] that {he/she} needed?
(1)Yes [SKIP TO C4Q05_X06] (0) No (6) DK [SKIP TO C4Q05_X06] (7) Ref [SKIP TO C4Q05_X06] |
C40505BX01-X16 Why did (S.C.) not get the [therapy] {he/she} needed?
For each below: (1) Yes (0) NO (6) Dk (7) REF
01 Cost too much 02 NO INSURANCE 03 Health plan problem 04 Can’t find PROVIDER who accepts child’s insurance 05 Not available in area/transport problems 06 Not convenient times/could not get appointment 07 PROVIDER did not know how to treat or provide care 08 Dissatisfaction with PROVIDER 09 Did not know where to go for treatment 10 Child refused to go 11 Treatment is ongoing 12 Vaccine shortage 13 No referral 14 Lack of resources at school 15 DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT 16 Other (SKIP TO C4Q0505OE)
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C4Q0505OE
READ IF NECESSARY (Why did (S.C.) not get the [therapy] {he/she} needed?
Record verbatim response_________ |
C4Q05X05C Did (S.C.) get any physical, occupational, or speech therapy [during the past 12 months/ since (his/her) birth]? (1) YES (0) NO (6) DK (7) REF |
C4Q05_X06 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when (S.C.) needed) Mental health care or counseling?
(1) YES (0) NO [SKIP TO C4Q05_X07] (6) DK [SKIP TO C4Q05_X07] (7) REF [SKIP TO C4Q05_X07] |
C4Q05X06A Did (S.C.) receive all the [Mental health care or counseling] that {he/she} needed?
(1)Yes [SKIP TO C4Q05_X07] (0) No (6) DK [SKIP TO C4Q05_X07] (7) Ref [SKIP TO C4Q05_X07] |
C40506BX01-X16 Why did (S.C.) not get the [Mental health care or counseling] {he/she} needed?
For each below: (1) Yes (0) NO (6) Dk (7) REF
01 Cost too much 02 NO INSURANCE 03 Health plan problem 04 Can’t find PROVIDER who accepts child’s insurance 05 Not available in area/transport problems 06 Not convenient times/could not get appointment 07 PROVIDER did not know how to treat or provide care 08 Dissatisfaction with PROVIDER 09 Did not know where to go for treatment 10 Child refused to go 11 Treatment is ongoing 12 Vaccine shortage 13 No referral 14 Lack of resources at school 15 DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT 16 Other (SKIP TO C4Q0506OE) |
C4Q0506OE FILL [Mental health care or counseling] READ IF NECESSARY (Why did (S.C.) not get the [Mental health care or counseling] {he/she} needed?
Record verbatim response_________ |
C4Q05X06C Did (S.C.) get any mental health care or counseling [during the past 12 months/ since (his/her) birth]? (1) YES (0) NO (6) DK (7) REF |
C4Q05_X07 [SKIP IF AGE IS LESS THAN 8 YEARS OLD] (During the past 12 months, was there any time when (S.C.) needed) Substance abuse treatment or counseling?
(1) YES (0) NO [SKIP TO C4Q05_X08] (6) DK [SKIP TO C4Q05_X08] (7) REF [SKIP TO C4Q05_X08]
Help Screen: sUBSTANCE ABUSE TREATMENT INCLUDES TREATMENT FOR ALCOHOL AND TOBACCO ABUSE. Some respondents may find this question inappropriate. If this occurs, tell the respondent: I understand this question may be more appropriate for older children, but I am required to ask and read verbatim.
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C4Q05X07A Did (S.C.) receive all the [Substance abuse treatment or counseling] that {he/she} needed?
(1)Yes [SKIP TO C4Q05_X08] (0) No (6) DK [SKIP TO C4Q05_X08] (7) Ref [SKIP TO C4Q05_X08] |
C40507BX01-X16 Why did (S.C.) not get the [Substance abuse treatment or counseling] {he/she} needed?
For each below: (1) Yes (0) NO (6) Dk (7) REF
01 Cost too much 02 NO INSURANCE 03 Health plan problem 04 Can’t find PROVIDER who accepts child’s insurance 05 Not available in area/transport problems 06 Not convenient times/could not get appointment 07 PROVIDER did not know how to treat or provide care 08 Dissatisfaction with PROVIDER 09 Did not know where to go for treatment 10 Child refused to go 11 Treatment is ongoing 12 Vaccine shortage 13 No referral 14 Lack of resources at school 15 DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT 16 Other (SKIP TO C4Q0507OE) |
C4Q0507OE
READ IF NECESSARY (Why did (S.C.) not get the [Substance abuse treatment or counseling] {he/she} needed?
Record verbatim response_________ |
C4Q05X07C Did (S.C.) get any substance abuse treatment or counseling [during the past 12 months/ since (his/her) birth]?
(1) YES (0) NO (6) DK (7) REF |
C4Q05_X08 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when (S.C.) needed) Home health care?
(1) YES (0) NO [SKIP TO C4Q05_X09] (6) DK [SKIP TO C4Q05_X09] (7) REF [SKIP TO C4Q05_X09] |
C4Q05X08A Did (S.C.) receive all the [Home health care] that {he/she} needed?
(1)Yes (0) No [SKIP TO C4Q0508C] (6) DK (7) Ref
[IF 01,6,7 THEN SKIP TO C4Q05_X09]
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|
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C4Q05X08C Did (S.C.) get any home health care [during the past 12 months/ since (his/her) birth]?
(1) YES (0) NO (6) DK (7) REF |
C4Q05_X09 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when (S.C.) needed) Eyeglasses or vision care?
(1) YES (0) NO [SKIP TO C4Q05_X10] (6) DK [SKIP TO C4Q05_X10] (7) REF [SKIP TO C4Q05_X10] |
C4Q05X09A Did (S.C.) receive all the [Eyeglasses or vision care] that {he/she} needed?
(1)Yes (0) No [SKIP TO C4Q0509C] (6) DK (7) Ref
[IF 01,6,7 THEN SKIP TO C4Q05_X10] |
|
|
C4Q05X09C Did (S.C.) get any eyeglasses or vision care [during the past 12 months/ since (his/her) birth]?
(1) YES (0) NO (6) DK (7) REF |
C4Q05_X10 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when (S.C.) needed) Hearing aids or hearing care?
(1) YES (0) NO [SKIP TO C4Q05_X11] (6) DK [SKIP TO C4Q05_X11] (7) REF [SKIP TO C4Q05_X11] |
C4Q05X10A Did (S.C.) receive all the [Hearing aids or hearing care] that {he/she} needed?
(1)Yes (0) No[SKIP TO C4Q0510C] (6) DK (7) Ref [IF 01,6,7 THEN SKIP TO C4Q05_X11] |
|
|
C4Q05X10C Did (S.C.) get any hearing aids or hearing care [during the past 12 months/ since (his/her) birth]?
(1) YES (0) NO (6) DK (7) REF |
C4Q05_X11 [SKIP IF AGE IS LESS THAN 3 YEARS OLD] (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when (S.C.) needed) Mobility aids or devices, such as canes, crutches, wheelchairs, or scooters? (1) YES (0) NO [SKIP TO C4Q05_X12] (6) DK [SKIP TO C4Q05_X12] (7) REF [SKIP TO C4Q05_X12] |
C4Q05X11A Did (S.C.) receive all the [mobility aids or devices] that {he/she} needed?
(1)Yes (0) No [SKIP TO C4Q0511C] (6) DK (7) Ref [IF 01,6,7 THEN SKIP TO C4Q05_X12] |
|
|
C4Q05X11C Did (S.C.) get any mobility aids or devices [during the past 12 months/ since (his/her) birth]?
(1) YES (0) NO (6) DK (7) REF |
C4Q05_X12 [SKIP IF AGE IS LESS THAN 3 YEARS OLD] (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when (S.C.) needed) Communication aids or devices, such as communication boards?
(1) YES (0) NO [SKIP TO C4Q05_X13] (6) DK [SKIP TO C4Q05_X13] (7) REF [SKIP TO C4Q05_X13]
|
C4Q05X12A Did (S.C.) receive all the [communication aids or devices] that {he/she} needed?
(1)Yes (0) No [SKIP TO C4Q0512C] (6) DK (7) Ref [IF 01,6,7 THEN SKIP TO C4Q05_X13] |
|
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C4Q05X12C Did (S.C.) get any communication aids or devices [during the past 12 months/ since (his/her) birth]? (1) YES (0) NO (6) DK (7) REF |
C4Q05_X13 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when (S.C.) needed) Medical supplies?
(1) YES (0) NO [SKIP TO C4Q05_X14] (6) DK [SKIP TO C4Q05_X14] (7) REF [SKIP TO C4Q05_X14] READ IF NECESSARY: Some examples of medical supplies include bandages and sponges. These are items that are disposable. This does not include prescription medication.
|
C4Q05X13A Did (S.C.) receive all the [Medical supplies] that {he/she} needed?
(1)Yes (0) No [SKIP TO C4Q0513C] (6) DK (7) Ref [IF 01,6,7 THEN SKIP TO C4Q05_X14] |
|
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C4Q05X13C Did (S.C.) get any medical supplies [during the past 12 months/ since (his/her) birth]? (1) YES (0) NO (6) DK (7) REF |
C4Q05_X14 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when (S.C.) needed) Durable medical equipment?
(1) YES (0) NO [SKIP TO C4Q06] (6) DK [SKIP TO C4Q06] (7) REF [SKIP TO C4Q06] READ IF NECESSARY: Some examples of durable medical equipment include wheelchairs, hospital beds, oxygen tanks, pressure machines, and orthotics. These are items that are not disposable. |
C4Q05X14A Did (S.C.) receive all the [Durable medical equipment] that {he/she} needed?
(1)Yes (0) No [SKIP TO C4Q0514C] (6) DK (7) Ref [IF 01,6,7 THEN SKIP TO C4Q06] |
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C4Q05X14C Did (S.C.) get any durable medical equipment [during the past 12 months/ since (his/her) birth]?
(1) YES (0) NO (6) DK (7) REF |
C4Q06 (4.6) [IF CWTYPE = ‘N’ THEN SKIP TO C3Q12]
(CATI: THIS SERIES SHOULD BE ASKED HORIZONTALLY ACROSS THE TABLE. IN OTHER WORDS, IF THEY ANSWER YES TO SOMETHING IN COLUMN 01, THEY SHOULD IMMEDIATELY BE ASKED THE QUESTIONS IN COLUMN 02, 03, 4 AS APPLICABLE)
During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when you or other family members needed any of the following services because of {S.C.’s} health: |
Did you or your family receive all the {fill with underlined words from first column} that was needed? |
Why did you or your family not get the {fill with underlined words from first column} that was needed? (CHECK ALL THAT APPLY. READ RESPONSES ONLY IF NECESSARY) |
Did you or your family get any {fill with underlined words from first column} during the past 12 months? |
C4Q06_X01 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when you or other family members needed) Respite care?
(1) YES (0) NO [SKIP TO C4Q06_X02] (6) DK [SKIP TO C4Q06_X02] (7) REF [SKIP TO C4Q06_X02]
READ IF NECESSARY: Respite care is care for the child so the family can have a break from ongoing care of the child. Respite care can be thought of as child care or babysitting by someone trained to meet any special needs the child may have. Both professional and non-professional respite care should be included. |
C4Q06X01A FILL [respite care]
(1) Yes [SKIP TO C4Q06_X02] (0) No (6) DK [SKIP TO C4Q06_X02] (7) Ref [SKIP TO C4Q06_X02] |
C40601BX01-X16 FILL [respite care]
Why did you or your family not get the {fill with underlined words from first column} that was needed? For each below: (1) Yes (0) NO (6) Dk (7) REF
01 Cost too much 02 NO INSURANCE 03 Health plan problem 04 Can’t find doctor who accepts child’s insurance 05 Not available in area/transport problems 06 Not convenient times/could not get appointment 07 Doctor did not know how to treat or provide care 08 Dissatisfaction with doctor 09 Did not know where to go for treatment 10 Child refused to go 11 Treatment is ongoing 12 Vaccine shortage 13 No referral 14 Lack of resources at school 15 DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT 16 Other [GO TO c4q0601OE]
c4q0601OE READ IF NECESSARY: Why did you or your family not get the respite care that was needed?
ENTER OTHER_______ |
C4Q06X01C Did you or your family get any respite care [during the past 12 months/ since (his/her) birth]? (1) YES (0) NO (6) DK (7) REF |
C4Q06_X02 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when you or other family members needed) Genetic counseling for advice about inherited conditions related to (SC)’s medical, behavioral, or other health conditions?
(1) YES (0) NO [SKIP TO C4Q06_X03] (6) DK [SKIP TO C4Q06_X03] (7) REF [SKIP TO C4Q06_X03] |
C4Q06X02A FILL [genetic counseling]
(1) Yes [SKIP TO C4Q06_X03] (0) No (6) DK [SKIP TO C4Q06_X03] (7) Ref [SKIP TO C4Q06_X03] |
C40602BX01-X16 FILL [genetic counseling]
Why did you or your family not get the {fill with underlined words from first column} that was needed? For each below: (1) Yes (0) NO (6) Dk (7) REF
01 Cost too much 02 NO INSURANCE 03 Health plan problem 04 Can’t find doctor who accepts child’s insurance 05 Not available in area/transport problems 06 Not convenient times/could not get appointment 07 Doctor did not know how to treat or provide care 08 Dissatisfaction with doctor 09 Did not know where to go for treatment 10 Child refused to go 11 Treatment is ongoing 12 Vaccine shortage 13 No referral 14 Lack of resources at school 15 DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT 16 Other [SKIP c4q0602OE]
c4q0602OE
READ IF NECESSARY: Why did you or your family not get the genetic counseling that was needed? ENTER OTHER_______ |
C4Q06X02C Did you or your family get any genetic counseling [during the past 12 months/ since (his/her) birth]? (1) YES (0) NO (6) DK (7) REF
|
C4Q06_X03 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, was there any time when you or other family members needed) Mental health care or counseling related to (SC)’s medical, behavioral, or other health conditions?
(1) YES (0) NO [SKIP TO C3Q12] (6) DK [SKIP TO C3Q12] (7) REF [SKIP TO C3Q12] |
C4Q06X03A FILL [mental health care or counseling]
(1) Yes [SKIP TO C3Q12] (0) No (6) DK [SKIP TO C3Q12] (7) Ref [SKIP TO C3Q12] |
C40603BX01-X16 FILL [mental health care or counseling]
Why did you or your family not get the {fill with underlined words from first column} that was needed?
For each below: (1) Yes (0) NO (6) Dk (7) REF
01 Cost too much 02 NO INSURANCE 03 Health plan problem 04 Can’t find doctor who accepts child’s insurance 05 Not available in area/transport problems 06 Not convenient times/could not get appointment 07 Doctor did not know how to treat or provide care 08 Dissatisfaction with doctor 09 Did not know where to go for treatment 10 Child refused to go 11 Treatment is ongoing 12 Vaccine shortage 13 No referral 14 Lack of resources at school 15 DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT 16 Other [SKIP c4q0603OE]
c4q0603OE READ IF NECESSARY: Why did you or your family not get the mental health care or counseling that was needed? ENTER OTHER_______
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C4Q06X03C Did you or your family get any mental health care or counseling [during the past 12 months/ since (his/her) birth]? (1) YES (0) NO (6) DK (7) REF
|
C3Q12 [IF AGE FROM C2Q01 OR C2Q02 IS 36 MONTHS (3 YEARS) OR GREATER, SKIP TO C3Q13]
Does (S.C.) receive services from a program called Early Intervention Services? Children receiving these services often have an Individualized Family Service Plan.
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
[ALL SKIP TO C5Q00]
READ IF NECESSARY: Early Intervention Services are defined as: family training, counseling, and home visits; health services; medicine; nursing; nutrition; occupational therapy; physical therapy; psychological services; service coordination services; social work services; special instruction; speech-language therapy; transportation, communication or mobility devices; and vision and hearing services.
C3Q13 Does (S.C.) receive services from a program called Special Educational Services? Children receiving these services often have an Individualized Education Plan.
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
READ IF NECESSARY: Special Education is any kind of special school, classes or tutoring.
Section 5. CARE COORDINATION
[SKIP THIS SECTION IF CARE COORDINATION WAS NOT NEEDED, ONLY ONE SERVICE WAS USED]
C5Q00 “You told me that, [in the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] since (his/her) birth], (S.C.) used [FILL WITH ALL NAMES OF SERVICES USED AS REPORTED IN SECTION 4, INCLUDING C3Q12 AND C3Q13].”
C5Q01 Did (S.C.) use any other health-related medical, educational, or social services [in the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] since (his/her) birth]?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
READ IF NECESSARY: There are many types of services children might use to improve their education, their health, or their well-being. We listed 15 of these services earlier, but there could be others that your child uses.
C5Q11 (During the past 12 months/ Since (his/her) birth), did (S.C.) need a referral to see any doctors or receive any services?
(1) Yes
(0) No [SKIP TO C5Q12]
(6) Don’t Know [SKIP TO C5Q12]
(7) Refused [SKIP TO C5Q12]
C4Q07 Was getting referrals a big problem, a small problem, or not a problem?
(1) Big problem
(2) Small problem
Not a problem
(6) Don’t Know
(7) Refused
C5Q12 Does anyone help you arrange or coordinate (S.C.)’s care among the different doctors or services that (he/she) uses? By “arrange or coordinate,” I mean: Is there anyone who helps you make sure that (S.C.) gets all the health care and services (he/she) needs, that health care providers share information, and that these services fit together and are paid for in a way that works for you?
(1) Yes
(0) No [SKIP TO C5Q17]
(6) Don’t Know [SKIP TO C5Q17]
(7) Refused [SKIP TO C5Q17]
HELP SCREEN: IF RESPONDENT SAID ‘YES’ TO ANY ONE OF THE THREE CATEGORIES LISTED IN THE SECOND SENTENCE, ENTER ‘YES’ FOR THIS QUESTION.
READ IF NECESSARY: Anyone means anyone.
C5Q13 Does a doctor or someone in a doctor’s office provide this help arranging or coordinating (S.C.)’s care?
(1) Yes [SKIP TO C5Q15]
(0) No
(6) Don’t Know
(7) Refused
C5Q14 Who does provide help arranging or coordinating (S.C.)’s care? A parent, guardian, other family member, friend, nurse, therapist, social worker, hospital discharge planner, case manager, or someone else?
C5Q14X01 Parent (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q14X02 Guardian (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q14X03 Other family member (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q14X04 Friend (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q14X05 Nurse (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q14X06 Therapist (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q14X07 Social Worker (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q14X08 Hospital Discharge Planner (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q14X09 Case Manager (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q14X10 Someone else (1) Yes [SKIP to C5Q14_XOE]
(0) NO (6) DON’T KNOW
(7) REFUSED
[SKIP TO C5Q17]
C5Q14_XOE Who would that be?
ENTER RESPONSE ___________________ [30 CHARACTERS MAX]
[SKIP TO C5Q17]
C5Q15 Is there anyone else who helps arrange or coordinate (S.C.)’s care?
(1) Yes
(0) No [SKIP TO C5Q17]
(6) Don’t Know [SKIP TO C5Q17]
(7) Refused [SKIP TO C5Q17]
C5Q16 Is this person a parent, guardian, other family member, friend, nurse, therapist, social worker, hospital discharge planner, case manager, or someone else? [MARK ALL THAT APPLY]
C5Q16X01 Parent (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q16X02 Guardian (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q16X03 Other family member (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q16X04 Friend (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q16X05 Nurse (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q16X06 Therapist (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q16X07 Social Worker (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q16X08 Hospital Discharge Planner (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q16X09 Case Manager (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q16X10 Someone else [SKIP to C5Q16_XOE]
(1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C5Q16_XOE Who would that be?
ENTER RESPONSE ___________________ [30 CHARACTERS MAX]
C5Q17 (During the past 12 months/ Since (his/her) birth), have you felt that you could have used extra help arranging or coordinating (S.C.)’s care among these different health care providers or services?
(1) Yes
(0) No [SKIP TO C5Q10]
(6) Don’t Know [SKIP TO C5Q10]
(7) Refused [SKIP TO C5Q10]
C5Q09 (During the past 12 months/ Since (his/her) birth), how often did you get as much help as you wanted with arranging or coordinating (S.C.)’s care? Would you say never, sometimes, or usually?
(1) Never
(2) Sometimes
(3) Usually
(6) Don’t know
(7) Refused
C5Q10 Overall, are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied with the communication among (S.C.)’s doctors and other health care providers?
(1)Very satisfied
(2) Somewhat satisfied
(3) Somewhat dissatisfied
(4) Very dissatisfied
(5) NO COMMUNICATION NEEDED OR WANTED
(6) Don’t know
(7) Refused
C5Q05 Do (S.C.)’s doctors or other health care providers need to communicate with (his/her) school, early intervention program, child care providers, vocational education or rehabilitation program?
(1) Yes
(0) No [SKIP TO C6Q02]
(6) Don’t Know [SKIP TO C6Q02]
(7) Refused [SKIP TO C6Q02]
C5Q06 Overall, are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied with that communication?
(1) Very satisfied
(2) Somewhat satisfied
(3) Somewhat dissatisfied
(4) Very dissatisfied
(6) Don’t know
(7) Refused
Section 6A. FAMILY CENTERED CARE
C6Q02 [IF C6Q01 = 000, SKIP TO C6Q07]
(During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth), how often did (S.C.)’s doctors and other health care providers spend enough time with (him/her)? Would you say never, sometimes, usually, or always?
Never
Sometimes
Usually
Always
(6) Don’t know
(7) Refused
C6Q03 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth), how often did (S.C.)’s doctors and other health care providers listen carefully to you? Would you say never, sometimes, usually, or always?
(1)Never
(2) Sometimes
(3) Usually
(4) Always
(6) Don’t know
(7) Refused
C6Q04 When (S.C.) is seen by doctors or other health care providers, how often are they sensitive to your family’s values and customs? Would you say never, sometimes, usually, or always?
(1) Never
(2) Sometimes
(3) Usually
(4) Always
(6) DON’T know
Refused
C6Q05 Information about a child’s health or health care can include things such as the causes of any health problems, how to care for a child now, and what changes to expect in the future. [In the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth], how often did you get the specific information you needed from (S.C.)’s doctors and other health care providers? Would you say never, sometimes, usually, or always?
(1) Never
(2) Sometimes
(3) Usually
(4) Always
(6) Don’t know
(7) Refused
C6Q06 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth), how often did (S.C.)’s doctors or other health care providers help you feel like a partner in (his/her) care? Would you say never, sometimes, usually, or always?
(1) Never
(2) Sometimes
(3) Usually
(4) Always
(6) Don’t know
(7) Refused
S5Q13 CATI INSTRUCTION (S5Q13): IF C2Q05 IN (01, 7, 9) [I.E. LANGUAGE ENGLISH OR UNKNOWN] SKIP TO C6Q07. ELSE, SKIP TO S5Q13. IF S.C. >36 MONTHS, FILL [or S.C.]. ELSE, NO FILL.
An interpreter is someone who repeats what one person says in a language used by another person. (During the past 12 months\Since (S.C.)’s birth), did you (or S.C.) need an interpreter to help speak with (his/her) doctors or other health care providers?
(1) YES [SKIP TO S5Q13A]
(0) NO [SKIP TO C6Q07]
(6) DON’T KNOW [SKIP TO C6Q07]
(7) REFUSED [SKIP TO C6Q07]
S5Q13A CATI INSTRUCTION (S5Q13): IF S.C. >36 MONTHS, FILL [or S.C.]. ELSE, DO NOT FILL.
When you (or S.C.) needed an interpreter, how often were you able to get someone other than a family member to help you speak with (his/her) doctors or other health care providers? Would you say never, sometimes, usually, or always?
(1) Never
(2) Sometimes
(3) Usually
(4) Always
(6) DON’T KNOW
(7) REFUSED
Section 6B. TRANSITION ISSUES
C6Q07 [If child is less than 5 years of age, skip to C6Q0D. If child is 5-11 years of age, skip to C6Q08]
The next questions are about preparing for (S.C.)’s health care needs as (he/she) becomes an adult. Do any of (S.C.)’s doctors or other health care providers treat only children?
(1) Yes
(0) No [SKIP TO C6Q0A]
(6) Don’t Know [SKIP TO C6Q0A]
(7) Refused [SKIP TO C6Q0A]
C6Q0A_B Have they talked with you about having (S.C.) eventually see doctors or other health care providers who treat adults?
(1) Yes [SKIP TO C6Q0A]
(0) No
(6) Don’t Know [SKIP TO C6Q0A]
(7) Refused [SKIP TO C6Q0A]
[HELP SCREEN: THIS QUESTION REFERS TO DISCUSSIONS BETWEEN THE RESPONDENT AND THE DOCTORS OR OTHER HEALTH CARE PROVIDERS WHO TREAT ONLY CHILDREN.]
C6Q0A_C Would a discussion about doctors who treat adults have been helpful to you?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q0A Have (S.C.)’s doctors or other health care providers talked with you or (S.C.) about (his/her) health care needs as (he/she) becomes an adult?
(1) Yes [SKIP TO C6Q0A_E]
(0) No
(6) Don’t Know [SKIP TO C6Q0A_E]
(7) Refused [SKIP TO C6Q0A_E]
C6Q0A_D Would a discussion about (S.C)’s health care needs have been helpful?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q0A_E Eligibility for health insurance often changes as children reach adulthood. Has anyone discussed with you how to obtain or keep some type of health insurance coverage as (S.C.) becomes an adult?
(1) Yes [SKIP TO C6Q08]
(0) No
(6) Don’t Know [SKIP TO C6Q08]
(7) Refused [SKIP TO C6Q08]
HELP SCREEN: Anyone means anyone.
C6Q0A_F Would a discussion about health insurance have been helpful to you?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q08 How often do (S.C.)’s doctors or other health care providers encourage (him/her) to take responsibility for [his/her] health care needs, such as:
IF REFERENT SAMPLE AND CWTYPE = N, THEN:
[If child is 5-11 years of age, THEN READ: “learning about (his/her) health or helping with treatments and medications?”
[If child is 12+ years of age, THEN READ: “taking medication, understanding [his/her] health, or following medical advice?”
ELSE:
[If child is 5-11 years of age, THEN READ: “learning about (his/her) conditions or helping with treatments and medications?”
[If child is 12+ years of age, THEN READ: “taking medication, understanding [his/her] diagnosis, or following medical advice?”
Would you say never, sometimes, usually, or always?
(1) Never
(2) Sometimes
(3) Usually
(4) Always
(6) Don’t Know
(7) Refused
Section 6C. EASE OF SERVICE USE
C6Q0D We have been talking primarily about medical services provided by your child’s doctors. There are other types of services children may need or use because of their health. These services may be provided by (IF AGE < 36 MONTHS, SHOW: early intervention programs; ELSE SHOW: schools), child care facilities, vocational education and rehabilitation programs, and other community programs.
Thinking about (S.C.)’s health needs and all the services that (he/she) needs, have you had any difficulties trying to use these services (IF AGE = 12 MONTHS OR GREATER, SHOW: during the past 12 months; ELSE SHOW: since (his/her) birth)?
(1) Yes
(0) No [SKIP TO C6Q0C]
(6) Don’t Know [SKIP TO C6Q0C]
(7) Refused [SKIP TO C6Q0C]
IF THE PARENT SAYS THAT THE CHILD DID NOT NEED ANY SERVICES, READ: This question asks about difficulty using ANY services that your child needed because of his/her health. Did you have ANY difficulty using ANY services during the past 12 months?
C6Q0E I am going to read a list of reasons why people may have difficulty trying to use these services. For each reason, please tell me – yes or no – if this was a reason you had difficulties trying to use these services. Did you have any difficulties because:
C6Q0E_A You could not get the information you needed?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q0E_B (READ IF NECESSARY: Did you have difficulty trying to use any services because) There was too much paperwork required?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q0E_C (READ IF NECESSARY: Did you have difficulty trying to use any services because) You didn't have enough money to pay for the services?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q0E_D (READ IF NECESSARY: Did you have difficulty trying to use any services because) Transportation was a problem?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q0E_E (READ IF NECESSARY: Did you have difficulty trying to use any services because) You couldn't get services for (S.C.) when (he/she) needed them?
(1) Yes
(0) No [SKIP TO C6Q0E_F]
(6) Don’t Know [SKIP TO C6Q0E_F]
(7) Refused [SKIP TO C6Q0E_F]
C6Q0E_E1 Was this because there were long waiting lists?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q0E_F Did you have difficulty trying to use any services because there were problems in communication between service providers?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q0E_G (READ IF NECESSARY: Did you have difficulty trying to use any services because) You had language, communication, or cultural problems with the service providers?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q0E_H (READ IF NECESSARY: Did you have difficulty trying to use any services because) You could not find service providers who had the skills (S.C.) needed?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q0E_I (READ IF NECESSARY: Did you have difficulty trying to use any services because) The types of services (S.C.) needed were not available in your area?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q0E_J (READ IF NECESSARY: Did you have difficulty trying to use any services because) The types of services (S.C.) needed were available but (he/she) was not eligible?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q0E_K (READ IF NECESSARY: Did you have difficulty trying to use any services because) The types of services (S.C.) needed were available but (he/she) had used up all eligible benefits?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q0E_L (READ IF NECESSARY: Did you have difficulty trying to use any services because) You didn't have the time to figure it all out?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C6Q0C Thinking about (S.C.)’s health needs and the services (he/she) receives, how satisfied or dissatisfied are you with those services? Would you say very satisfied, somewhat satisfied, somewhat dissatisfied or very dissatisfied?
(1) Very satisfied
(2) Somewhat satisfied
(3) Somewhat dissatisfied
(4) Very dissatisfied
(6) Don’t know
(7) Refused
Section 6D. HURRICANE EVACUEES
NOTE:
This entire section is only asked of a very small number of respondents. Most respondents will skip out of this section at the first question (K1).
K_INTRO The next question is about the 2005 Gulf Coast hurricanes.
K1 In 2005, did (S.C.) leave (his/her) home for one night or longer because of Hurricane Katrina or Rita?
(1) YES [GO TO K2]
(0) NO [GO TO NAME_SEC7]
(6) DON'T KNOW [GO TO NAME_SEC7]
(7) REFUSED [GO TO NAME_SEC7]
INTERVIEWER NOTE: THE PARENT SHOULD ANSWER "YES" IF THE CHILD LEFT HOME FOR AT LEAST ONE NIGHT FOR ANY REASON RELATED TO THE HURRICANE. THIS CAN BE BEFORE THE HURRICANE OR AFTER THE HURRICANE WAS OVER. THIS MAY INCLUDE LEAVING AS A PRECAUTION, LEAVING BY ORDER OF THE AUTHORITIES, LEAVING TO ENSURE COMFORT IN THE ABSENCE OF POWER OR WATER, LEAVING TO OBTAIN OR ENSURE NECESSARY HEALTH CARE, OR ANY OTHER REASON RELATED TO THE HURRICANE.
K2 In order to leave, did (S.C.) require any special arrangements because of (his/her) health
(IF CWTYPE = ‘S’, SHOW: ‘conditions’)?
(1)
YES [GO TO K2A]
(0) NO [GO TO K3]
(6)
DON'T KNOW [GO TO K3]
(7) REFUSED [GO TO K3]
INTERVIEWER NOTE: THIS QUESTION REFERS TO ANY HEALTH CONDITIONS THAT EXISTED PRIOR TO THE HURRICANES. DO NOT INCLUDE SPECIAL ARRANGEMENTS RELATED TO INJURIES SUSTAINED DURING THE HURRICANE OR THE EVACUATION.
K2A What special arrangements were needed?
RECORD VERBATIM RESPONSE
K3 Did you have trouble finding temporary shelter for (S.C.) because of (his/her) health
(IF CWTYPE = ‘S’, SHOW: ‘conditions’)?
(1)
YES [GO TO K3A]
(0) NO [GO TO K4A]
(6)
DON'T KNOW [GO TO K4A]
(7) REFUSED [GO TO K4A]
INTERVIEWER NOTE: THIS QUESTION REFERS TO ANY HEALTH CONDITIONS THAT EXISTED PRIOR TO THE HURRICANES. DO NOT INCLUDE TROUBLE FINDING SHELTER BECAUSE OF INJURIES SUSTAINED DURING THE HURRICANE OR THE EVACUATION.
K3A. (IF CWTYPE = ‘N’ SHOW: What health condition) (IF CWTYPE = ‘S’ SHOW: Which health conditions) made it difficult to find temporary shelter?
RECORD VERBATIM RESPONSE
K4A At any point after the hurricanes, did (S.C.) move back into the same home where (he/she) lived before the hurricanes?
(1) YES [GO TO K4B]
(0) NO [GO TO K5]
(6) DON'T KNOW [GO TO K5]
(7) REFUSED [GO TO K5]
THIS QUESTION ASKS WHETHER THE CHILD ACTUALLY MOVED BACK INTO THE HOME. IF THE CHILD ATTEMPTED TO MOVE HOME, BUT WAS NOT ABLE TO ACTUALLY DO SO, THE ANSWER SHOULD BE RECORDED AS “NO.” IF THE CHILD MOVED HOME AFTER HURRICANE KATRINA, BUT THEN LEFT BECAUSE OF HURRICANE RITA AND HAS NOT MOVED BACK HOME, THE ANSWER SHOULD BE RECORDED AS “NO.” HOWEVER, NOTE THAT THIS QUESTION DOES NOT ASK IF THE HCILD IS CURRENTLY LIVING IN THE SAME HOME WHERE THE CHILD LIVED BEFORE THE HURRICANES. IF THE HCILD MOVED HOME FOR SEVERAL MONTHS, BUT HAS SINCE MOVED AWAY, THE ANSWER SHOULD STILL BE RECORDED AS “YES.”
K4B How many nights was (S.C.) away from home because of the hurricanes?
_____
_____ ENTER NUMBER [GO TO K4B_1]
(96) DON’T KNOW
[GO TO K7]
(97) REFUSED [GO TO K7]
K4B1
(1) NIGHT(S)
(2) WEEK(S)
(3)
MONTH(S)
[ALL GO TO K7]
INTERVIEWER NOTE: THIS QUESTION REFERS TO THE COMPLETE TIME PERIOD BETWEEN LEAVING HOME AND MOVING BACK INTO THE HOME. IF THE CHILD MOVED BACK HOME, LEFT AGAIN FOR A REASON RELATED TO THE HURRICANES, AND THEN MOVED BACK HOME AGAIN, THE PARENT SHOULD ADD UP ALL OF THE NIGHTS THAT THE CHILD WAS AWAY FROM HOME.
K5 Is (S.C.) currently living in short-term or temporary housing, such as a FEMA trailer, hotel, or the home of a family member or friend?
(1)
YES [GO TO K7]
(0) NO [GO TO K6A]
(6)
DON'T KNOW [GO TO K6A]
(7) REFUSED [GO TO K6A]
K6A Did (S.C.) live in short-term or temporary housing for one night or longer, such as an evacuation center, hotel, or the home of a family member or friend?
(1)
YES [GO TO K6B]
(0) NO [GO TO NAME_SEC7]
(6)
DON'T KNOW [GO TO NAME_SEC7]
(7) REFUSED [GO TO
NAME_SEC7]
K6B How many nights did (S.C.) live in short-term or temporary housing because of the hurricanes?
_____
_____ ENTER NUMBER [GO TO K6B1]
(96)
DON’T KNOW [GO TO K7]
(97) REFUSED [GO TO K7]
K6B1
(1) NIGHT(S)
(2) WEEK(S)
(3)
MONTH(S)
[ALL GO TO K7]
INTERVIEWER NOTE: THIS QUESTION REFERS TO THE TOTAL NUMBER OF NIGHTS SPENT IN SHORT-TERM OR TEMPORARY HOUSING. IF THE CHILD LIVED IN SHORT-TERM OR TEMPORARY HOUSING SEVERAL TIMES, THE PARENT SHOULD ADD UP ALL OF THE NIGHTS THAT THE CHILD LIVED IN SUCH HOUSING.
K7 (IF K4A = 1, READ:
During the time that (S.C.) was away from home, did (S.C.) NEED any
health care?)
(IF K5 = 1, READ: Since leaving home, has (S.C.)
NEEDED any health care?)
(IF K6A = 1, READ: When (S.C.) was
living in short-term or temporary housing, did (he/she) NEED any
health care?)
By health care, I mean care from a doctor
or nurse as well as other kinds of care like mental health services,
prescription medication, and special therapies.
(1)
YES [GO TO
K8]
(0)
NO [GO TO
K11]
(6)
DON'T KNOW [GO TO
K11]
(7)
REFUSED [GO TO
K11]
K8 (IF
K4A = 1, READ: During the time that (S.C.) was away from home, did
(S.C.) receive)
(IF K5 = 1, READ: Since leaving home, has
(S.C.) received)
(IF K6A = 1, READ: When (S.C.) was living in
short-term or temporary housing, did (he/she) receive)
ANY
of the health care that (he/she) needed?
(1) YES [GO
TO K9]
(0) NO [GO TO K11]
(6) DON'T KNOW [GO
TO K11]
(7) REFUSED [GO TO K11]
K9 (IF K4A = 1, READ: Where did (S.C.) receive this health care?)
(IF K5 = 1, READ: Where has (S.C.) received this health care?)
(IF K6A = 1, READ: Where did (S.C.) receive this health care?)
MARK ALL THAT APPLY
PROBE: Any other place?
EVACUATION CENTER (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
SPECIAL NEEDS SHELTER (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
MOBILE HEALTH UNIT (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
DOCTOR'S OFFICE (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
HOSPITAL EMERGENCY ROOM (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
HOSPITAL OUTPATIENT DEPARTMENT
(1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
CLINIC OR HEALTH CENTER (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
SCHOOL (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
OTHER, SPECIFY > GO TO K9_OTHER
(1) YES (0) NO (6) DON’T KNOW
(7)
REFUSED
ALL SKIP TO K10
K9_OTHER (READ IF NECESSARY:) What kind of place was this?
RECORD VERBATIM RESPONSE _____________________
K10 (IF K4A = 1, READ: During the time that (S.C.) was away from home, did (S.C.) receive )
(IF
K5 = 1, READ: Since leaving home, has (S.C.) received)
(IF K6A =
1, READ: When (S.C. ) was living in short-term or temporary housing,
did (he/she) receive)
ALL of the health care that
(he/she) needed?
(1)
YES [GO TO K11]
(0) NO [GO TO K11]
(6)
DON'T KNOW [GO TO K11]
(7) REFUSED [GO TO K11]
K11 (IF
K4A = 1, READ: During the time that (S.C.) was away from home, did
(S.C.) NEED)
(IF K5 = 1, READ: Since leaving home, has (S.C.)
NEEDED)
(IF K6A = 1, READ: When (S.C. ) was living in short-term
or temporary housing, did (he/she) NEED)
any durable
medical equipment, such as a ventilator, wheelchair, or other medical
device?
(1)
YES [GO TO K12]
(0) NO [GO TO NAME_SEC7]
(6)
DON'T KNOW [GO TO NAME_SEC7]
(7) REFUSED [GO TO
NAME_SEC7]
K12 (IF
K4A = 1, READ: During the time that (S.C.) was away from home, did
(S.C.) receive )
(IF K5 = 1, READ: Since leaving home, has
(S.C.) received)
(IF K6A = 1, READ: When (S.C. ) was living in
short-term or temporary housing, did (he/she) receive)
ANY
of the durable medical equipment that (he/she) needed?
(1)
YES [GO TO K13]
(0) NO [GO TO NAME_SEC7]
(6)
DON'T KNOW [GO TO NAME_SEC7]
(7) REFUSED [GO TO
NAME_SEC7]
K13 (IF
K4A = 1, READ: During the time that (S.C.) was away from home, did
(S.C.) receive )
(IF K5 = 1, READ: Since leaving home, has
(S.C.) received)
(IF K6A = 1, READ: When (S.C. ) was living in
short-term or temporary housing, did (he/she) receive)
ALL
of the durable medical equipment that (he/she) needed?
(1)
YES [GO TO NAME_SEC7]
(0) NO [GO TO
NAME_SEC7]
(6) DON'T KNOW [GO TO NAME_SEC7]
(7)
REFUSED [GO TO NAME_SEC7]
Section 7. HEALTH INSURANCE
C7Q03 [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
Now I have a few questions about health insurance and health care coverage for (S.C.). At this time, is (S.C.) covered by health insurance that is provided through an employer or union?
(1) Yes
(0) No [skip to c7q01]
(6) Don’t Know [skip to c7q01]
(7) Refused [skip to c7q01]
READ ONLY IF NECESSARY: These plans may be provided in art or fully by a current employer, a former employer, a union, or a professional organization.
IF ONLY PLAN NAME OFFERED, PROBE (READ IF NECESSARY): Is this insurance provided through an employer or union? Do not include dental, vision, school, or accident insurance.
C7Q03A [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
Does this health insurance help pay for both doctor visits and hospital stays?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C7Q01 [IF STATE = AK, CT, DC, FL, HI, IL, IN, LA, ME, MA, MN, MO, NE, NM, NY, OH, OK, RI, SC, SD, TN, VT, WI, THEN SKIP TO C7Q04]
[SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
At this time, is (S.C.) covered by any Medicaid plan? Medicaid is a health insurance program for persons with certain income levels and persons with disabilities. [FILL IF APPLICABLE: In this state, the program is sometimes called [FILL NAME FROM “TEXT FILLS” SPREADSHEET].
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
READ IF NECESSARY: Medicaid is a federal-state medical assistance program. It serves low-income people of every age. Medical bills are paid from federal, state and local tax funds. Patients usually pay no part of costs for covered medical expenses. It is run by state and local governments within federal guidelines.
C7Q02 [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
At this time, is (S.C.) covered by the State Children’s Health Insurance Program or S-CHIP? In this state, the program is sometimes called {FILL NAME FROM “TEXT FILLS” SPREADSHEET}.
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
READ IF NECESSARY: The State Children's Health Insurance Program (SCHIP), created under Title XXI of the Social Security Act, expands health coverage to uninsured children whose families earn too much for Medicaid but too little to afford private coverage.
ALL SKIP TO C7Q05
C7Q04 [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
At this time, is (S.C.) covered by any Medicaid plan or the State Children’s Health Insurance Program, which are health insurance programs for persons with certain income levels and persons with disabilities? In this state, it is sometimes called [FILL NAME FROM “TEXT FILLS” SPREADSHEET].
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
READ IF NECESSARY: Medicaid and SCHIP are federal-state medical assistance programs. They serve low-income people of every age. Medical bills are paid from federal, state and local tax funds. Patients usually pay little or no part of costs for covered medical expenses. These programs are run by state and local governments within federal guidelines.
C7Q05 [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
At this time, is (S.C.) covered by military health care, TRICARE, CHAMPUS, OR CHAMP-VA?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
READ IF NECESSARY: CHAMPUS, CHAMP-VA, and TRICARE are health care plans that are offered to persons in the military (and their dependents). TRICARE is a managed health care program for active duty and retired members of the uniformed services, their families, and survivors. CHAMPUS is a program of medical care for dependents of active or retired military personnel. CHAMP-VA is medical insurance for dependents or survivors of disabled veterans..
C7Q07 [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
IF C7Q01, C7Q02, C7Q03, C7Q04, OR C7Q05 = 01, THEN SHOW: “Besides what you have already told me about,”
Is (S.C.) covered by any other health insurance or health care plan?
[IF RESPONDENT REPORTS DENTAL, VISION, SCHOOL, OR ACCIDENT INSURANCE, MARK NO]
(1) Yes
(0) No [Skip to c7q09]
(6) Don’t Know [Skip to c7q09]
(7) Refused [Skip to c7q09]
C7Q08A [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
Does this health insurance help pay for both doctor visits and hospital stays?
(1) Yes
(0) No [Skip to c7q09]
(6) Don’t Know [Skip to c7q09]
(7) Refused [Skip to c7q09]
C7Q08B [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
Is this health insurance provided through an employer or union?
(1) Yes [SKIP TO C7Q11]
(0) No
(6) Don’t Know
(7) Refused
C7Q08C [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
Is this health insurance purchased directly from an insurance company?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C7Q09 [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
It appears that (S.C.) does not have any health insurance coverage to pay for both hospitals and doctors and other health professionals. Is that correct?
(1) Yes [Skip to c7q13]
(0) No
(6) Don’t Know [Skip to C9Q01]
(7) Refused [Skip to C9Q01]
C7Q10 [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
“Now I have a few questions about health insurance and health care coverage for (S.C.). Earlier you told me that (S.C.) is covered by Indian Health Service. Does (S.C.) have any other kind of health coverage?”/ ELSE FILL “At this time, what kind of health coverage does (S.C.) have? Any other kind?”
[MARK ALL THAT APPLY. MARK SINGLE SERVICE PLAN ONLY IF VOLUNTEERED AS TYPE OF HEALTH INSURANCE.]
C7Q10X01 Medicaid [state Name]
(1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C7Q10X02 Medicare (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C7Q10X04 SCHIP
[state name] (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C7Q10X05 Medigap (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C7Q10X06 Military (1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C7Q10X07 INDIAN HEALTH SERVICE
(1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C7Q10X08 Private INSURANCE
(1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C7Q10X09 Single service plan (dental, vision, prescriptions, etc)
(1) YES (0) NO (6) DON’T KNOW
(7) REFUSED
C7Q10X10 Other (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
IF only C7Q10X09 is selected, skip to C7Q13
C7Q10B [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
Does this health insurance help pay for both doctor visits and hospital stays?
(1) Yes
(0) No [skip to c7q13]
(6) Don’t Know [skip to c9q01]
(7) Refused [skip to c9q01]
C7Q11 [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS: Since (his/her) birth], was there any time when (S.C.) was not covered by ANY health insurance?
(1) Yes
(2) No [Skip to c8q01_a]
(3) child always covered by insrance [ skip to c8q01_a]
(6) Don’t Know [Skip to c8q01_a]
(7) Refused [Skip to c8q01_a]
C7Q12 During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth, about how many months was (S.C.) without any health insurance or coverage?
[CATI: 02 NUMERIC-CHARACTER-FIELD, RANGE 01-12, 7, 9]
_____ _____ MONTHS
(96) DON’T KNOW
(97) REFUSED
[All skip to c8q01_a]
C7Q13 [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
“Earlier you told me that (S.C.) is not covered by health insurance that pays for all types of care.” IF C7Q10X09 = 1 or c7q10b = 2, Then say: About how long has it been since (S.C.) last had health coverage that helps pay for all types of care?]
[ELSE, SAY: About how long has it been since (S.C.) last had health coverage?]
(1) 6 months or less
(2) More than 6 months, but not more than 01 year ago
(3) More than 1 year, but not more than 3 years ago (GO to C9Q01)
(4) More than 3 years (GO to C9Q01)
(5) Never (GO to C9Q01)
display response (66) if s.c. = ‘nis elig child’ and ins-8 = 2, 7, or 9]
(66) child is covered by insurance (go to c7q10 and follow NS-CSHCN logic)
(6) Don’t know (GO to C9Q01)
(7) Refused (GO to C9Q01)
C7Q14 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth), about how many months was (S.C.) without any health insurance or coverage?
[CATI: 02 NUMERIC-CHARACTER-FIELD, RANGE 01-12, 6, 7]
_____ _____ MONTHS
(6) DON’T KNOW
(7) REFUSED
C7Q15 [IF S.C. AGE=0 MONTHS, THEN GO TO C9Q01]
[IF C7Q14=12, DK, OR REF, GO TO C9Q01]
[WHEN S.C. IS YOUNGER THAN 12 months, IF C7Q14=AGE OF S.C. IN MONTHS, GO TO C9Q01]
(During the (12 - C7Q14) / [IF S.C. IS YOUNGER THAN 12 MONTHS, During (S.C. AGE IN MONTHS –C7Q14)] months) when (S.C.) DID have health coverage, what kind of health coverage did (S.C.) have? [PROBE: Any other kind?]
C7Q15X01Medicaid [STATE NAME] (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C7Q15X02 Medicare (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C7Q15X04 SCHIP [State name] (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C7Q15X05 Medigap (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C7Q15X06 Military (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C7Q15X07 INDIAN HEALTH SERVICE (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C7Q15X08 Private INSURANCE (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C7Q15X09 Single service plan (dental, vision, prescriptions, etc.)
(1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C7Q15X10 Other [SKIP TO C7Q15A] (1) YES (0) NO (6) DON’T KNOW (7) REFUSED
C7Q15A ENTER OTHER______ [CATI: 255 CHARACTER-FIELD]
IF only C7Q15X09 is selected, skip to C9Q01
C7Q15b Did this health insurance help pay for both doctor visits and hospital stays?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
ALL SKIP TO C9Q01
Section 8. ADEQUACY OF HEALTH CARE COVERAGE
C8Q01_A The next questions are about (S.C.)’s health insurance or health care plans. Does (S.C.)’s health insurance offer benefits or cover services that meet (his/her) needs? Would you say:
(1) NEVER
(2) SOMETIMES
(3) USUALLY
(4) ALWAYS
(7) Don’t know
(9) Refused
C8Q01_B Are the costs not covered by (S.C.)’s health insurance reasonable?
Would you say:
(1) NEVER
(2) SOMETIMES
(3) USUALLY
(4) ALWAYS
NO OUT OF POCKET COSTS
(6) Don’t know
(7) Refused
IF THE PARENT SEEMS CONFUSED BY HOW TO ANSWER, ASK: Do you have any out-of-pocket costs for your child's health care?
IF YES, THEN ASK: Are those costs reasonable?
C8Q01_C Does (S.C.)’s health insurance allow (him/her) to see the health care providers (he/she) needs?
Would you say:
(1) NEVER
(2) SOMETIMES
(3) USUALLY
(4) ALWAYS
(6) Don’t know
(7) Refused
Section 9. IMPACT ON THE FAMILY
C9Q01 The next question is about the amount of money paid (during the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] since (his/her) birth) for (S.C.)’s medical care. Please do not include health insurance premiums or costs that were or will be reimbursed by insurance or another source. But do include out-of-pocket payments for all types of health-related needs such as co-payments, dental or vision care, medications, special foods, adaptive clothing, durable equipment, home modifications, and any kind of therapy. (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth), would you say that the family paid more than $500, $250-$500, less than $250, or nothing for (S.C.)’s medical care?
(1) More than $500
(2) $250-$500 [skip to c9q02]
(3) Less than $250 [skip to c9q02]
(4) Nothing, $0 [skip to c9q02]
(6) Don’t know [skip to c9q02]
(7) Refused [skip to c9q02]
Help Screen: Respondent may give a range as an answer to this question. Be prepared to probe for a more accurate answer.
C9Q01_A (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since (his/her) birth), would you say that the family paid more than $5000, $1000 to $5000, or less than $1000 for (S.C.)’s medical care?
(1) More than $5000
(2) $1000-$5000
(3) Less than $1000
(6) DON’T KNOW
(7) REFUSED
C9Q02 Many families provide health care at home such as changing bandages, care of feeding or breathing equipment, and giving medication and therapies. Do you or other family members provide health care at home for (S.C.)?
(1) Yes
(0) No [Skip to c9q04]
(6) Don’t Know [Skip to c9q04]
(7) Refused [Skip to c9q04]
C9Q03 How many hours per week do you or other family members spend providing this kind of care?
(CATI: 3 NUMERIC-CHARACTER-FIELD, RANGE 000-168, 996, 997)
_____ _____ HOURS PER WEEK
(000) LESS THAN ONE HOUR
(168) AROUND THE CLOCK
(996) DON’T KNOW
(997) REFUSED
IF THE PARENT SAYS THAT THE HOURS PER WEEK VARIES GREATLY FROM WEEK TO WEEK, ASK: How many hours did you or other family members spend last week?
[IF C9Q03 < 30 OR = 168, 996, 997, SKIP TO C9Q04]
C9Q03_A I have (ANSWER FROM C9Q03) hours. Is that correct?
(1) YES
(0) NO [SKIP BACK TO C9Q03]
C9Q04 How many hours per week do you or other family members spend arranging or coordinating (S.C.)’s care? By this I mean making appointments, making sure that care providers are exchanging information, and following up on (S.C.)’s care needs.
[CATI: 3 NUMERIC-CHARACTER-FIELD, RANGE 000-168, 555, 996, 997]
_____ _____ HOURS PER WEEK
(000) LESS THAN ONE HOUR
(168) AROUND THE CLOCK
(555) NONE / DOES NOT ARRANGE OR COORDINATE CARE
(996) DON’T KNOW
(997) REFUSED
IF THE PARENT SAYS THAT THE HOURS PER WEEK VARIES GREATLY FROM WEEK TO WEEK, ASK: How many hours did you or other family members spend last week?
[IF C9Q04 < 30 or C9Q04 = 168, 555, 996, 997, SKIP TO C9Q05]
C9Q04_A I have (ANSWER FROM C9Q04) hours. Is that correct?
(1) YES
(0) NO [SKIP BACK TO C9Q04]
C9Q05 [IF CHILD HAS SPECIAL HEALTH CARE NEEDS, READ:]
Have (S.C.)’s health conditions caused financial problems for your family?
[IF CHILD DOES NOT HAVE SPECIAL HEALTH CARE NEEDS, READ:]
Has (S.C.)’s health care caused financial problems for your family?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C9Q10 Have you or other family members stopped working because of (S.C.)’s health
(IF CWTYPE = ‘S’, SHOW: ’conditions’)?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C9Q06 (IF C9Q10 = 01, THEN SHOW: Not including the family members who stopped working,) have you or other family members cut down on the hours you work because of (S.C.)’s health
(IF CWTYPE = ‘S’, SHOW: ’conditions’)?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C9Q07 Have you needed additional income to cover (S.C.)’s medical expenses?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
Section 10. FAMILY COMPOSITION
C11Q01_A [SKIP IF THIS INFORMATION IS AVAILABLE FROM THE NIS]
Now I have some questions about your household. Please tell me how many people live in this household, including all children and anyone who normally lives here even if they are not here now, like someone who is away traveling or in a hospital.
_______ persons
(6) DK
(7) Refused
IF MAIN SAMPLE AND CWTYPE = N, SKIP TO C11Q01, ELSE
IF C2Q04 = (01) Mother OR (02) Father, CONTINUE WITH S10Q00.
ELSE SKIP TO S10Q01
S10Q00 CATI INSTRUCTION (S10Q00): IF C2Q04 = 01, REMOVE RESPONSE CATEGORIES 05-08. ELSE IF C2Q04 = 02, REMOVE RESPONSE CATEGORIES 01-04.
Earlier you told me you are (S.C.)’s (mother/father). Are you (S.C.)’s biological, step, foster, or adoptive (mother/father)]?
(01) Biological mother
(02) Step mother
(03) Foster mother
(04) Adoptive mother
(05) Biological father
(06) Step father
(07) Foster father
(08) Adoptive father
(09) OTHER
(96) DON’T KNOW
(97) REFUSED
S10Q01 CATI INSTRUCTION (S10Q01): [IF C11Q01_A = S_UNDR18 + 1, THERE IS ONLY ONE PARENT IN HH AND SKIP TO C10Q03.
[IF S10Q00 BLANK FILL: Earlier you told me you are (S.C.)’s (ANSWER TO C2Q04)
IF C2Q04 = 01, FILL ‘mother’;
IF C2Q04 = 02, FILL ‘father’;
IF C2Q04 = 03, FILL ‘sibling’;
IF C2Q04 = 04, 05, 07 FILL ‘relative’;
IF C2Q04 = 06, FILL ‘grandparent’;
IF C2Q04 = 10, FILL ‘friend’;
IF C2Q04 = 08, 09, FILL ‘guardian’;
IF C2Q04 = 7, 9, DO NOT READ THE SENTENCE].
[IF C2Q04 = (01) Mother OR (02) Father, FILL “other”]
Does (S.C.) have any (other) parents, or people who act as (his/her) parents, living here?
(1) YES
(0) NO [SKIP TO C10Q03]
(6) DON’T KNOW [SKIP TO C10Q03]
(7) REFUSED [SKIP TO C10Q03]
S10Q02 What is their relationship to (S.C.)? [MARK ALL THAT APPLY]
IF R RESPONDS “Mother” or “Father” PROBE: ‘Is that (his/her) biological, step, foster, or adoptive (Mother/Father?’]
S10Q02X01 BIOLOGICAL MOTHER (1) YES (0) NO (6) DK (7) REF
S10Q02X02 STEP MOTHER (1) YES (0) NO (6) DK (7) REF
S10Q02X03 FOSTER MOTHER (1) YES (0) NO (6) DK (7) REF
S10Q02X04 ADOPTIVE MOTHER (1) YES (0) NO (6) DK (7) REF
S10Q02X05 BIOLOGICAL FATHER (1) YES (0) NO (6) DK (7) REF
S10Q02X06 STEP FATHER (1) YES (0) NO (6) DK (7) REF
S10Q02X07 FOSTER FATHER (1) YES (0) NO (6) DK (7) REF
S10Q02X08 ADOPTIVE FATHER (1) YES (0) NO (6) DK (7) REF
S10Q02X09 SISTER/BROTHER (STEP/FOSTER/HALF/ADOPTIVE)
(1) YES (0) NO (6) DK (7) REF
S10Q02X10 IN-LAW OF ANY TYPE (1) YES (0) NO (6) DK (7) REF
S10Q02X11 AUNT/ UNCLE (1) YES (0) NO (6) DK (7) REF
S10Q02X12 GRANDMOTHER (1) YES (0) NO (6) DK (7) REF
S10Q02X13 GRANDFATHER (1) YES (0) NO (6) DK (7) REF
S10Q02X14 OTHER FAMILY MEMBER
(1) YES (0) NO (6) DK (7) REF
S10Q02X15 FEMALE GUARDIAN (1) YES (0) NO (6) DK (7) REF
S10Q02X16 MALE GUARDIAN (1) YES (0) NO (6) DK (7) REF
S10Q02X17 RESPONDENT’S PARTNER OR BOY/GIRLFRIEND
(1) YES (0) NO (6) DK (7) REF
S10Q02X18 OTHER NON-RELATIVE
(1) YES (0) NO (6) DK (7) REF
S10Q02X19 TWO OR MORE OF THE SAME RELATIONSHIP TYPE
(1) YES (0) NO (6) DK (7) REF
IF NUMBER OF SELECTIONS S10Q02-INDEX > = (C11Q01_A - S_UNDR18), SKIP TO S10Q02_A
ELSE, IF S10Q02X19 = 01, SKIP TO S10Q02_T
ELSE, SKIP TO C10Q03
S10Q02_T ENTER RELATIVE OR RELATIVES_______________________________.
S10Q02_A Just to confirm, you are (S.C.)’s [IF C2Q04=1 OR 2, FILL RESPONSE FROM S10Q00, ELSE FILL FROM C2Q04], and your child's [FILL ALL RESPONSES FROM S10Q02, WITH "AND" BEFORE THE LAST RESPONSE] also live in the household?
(1) YES, CONTINUE > GO TO C10Q03
(0) NO, RETURN TO S10Q02 AND CORRECT ANSWER
C10Q03 IF S10Q00 = 04 OR 08 OR S10Q02X04 = 01 OR S10Q02X08 = 01, CONTINUE WITH C10Q03. ELSE, SKIP TO C11Q01.
The next questions will help us better understand the health needs of adopted children.
How old was (S.C.) when the adoption was finalized? By “finalized,” I mean when the court papers were signed that completed the adoption process.
C10Q03 ___ ____ VALUE (MUST BE LESS THAN OR EQUAL TO AGE OF CHILD)
(6) DON’T KNOW
(7) REFUSED
IF CHILD WAS LESS THAN 1 MONTH AT THE TIME OF ADOPTION, ENTER “0 MONTHS.
C10Q03A Months (00-12)
Years (Range 00-17)
C10Q04 Was (S.C.) adopted from another country?
IF RESPONDENT SEEMS UPSET BY THIS QUESTION, READ: We ask this question for all children with adoptive parents.
(1) YES [SKIP TO C11Q01]
(0) NO
(6) DON’T KNOW
(7) REFUSED
C10Q05 Was (S.C.) residing in foster care prior to being placed for adoption? This includes children placed by private agencies on behalf of a state or county child welfare agency.
IF THE CHILD WAS ADOPTED THROUGH A PRIVATE AGENCY AND THE PRIVATE AGENCY WAS ACTIONG IN ASSOCIATION WITH OR IN COOPERATION WITH A STATE OR COUNTY WELFARE AGENCY, THEN THIS QUESITON SHOULD BE ANSWERED "YES."
IF A FOSTER PARENT ADOPTED ONE OF THEIR OWN FOSTER CHILDREN, THEN THIS QUESTION SHOULD BE ANSWERED "YES."
IF RESPONDENT SEEMS UPSET BY THIS QUESTION, READ: We ask this question for all children with adoptive parents.
(1) YES
(02) NO
(6) DON’T KNOW
(7) REFUSED
Section 10B. INFLUENZA VACCINATION SECTION
FLU_INSTRUCTIONS IF FLU_TYPE = 1 OR 2, THEN CONTINUE;
ELSE, IF FLU_TYPE = 3, THEN FILL TIMESTAMP_SECTION10B AND GO TO SELECTION2;
ELSE, GO TO C11Q01
FLU_INTRO Now I would like to ask you a few questions about your health (IF C11Q01_A – S_UNDR18 > 1 OR IF C11Q01_A = (77, 99, OR NULL), THEN ADD: and the health of all other adults living in your household.)
S10Q10 Do you (IF C11Q01_A – S_UNDR18 > 1 OR IF C11Q01_A = (77, 99, OR NULL), THEN FILL "or any other adults" / ELSE NO FILL) have any difficulty with breathing or other respiratory problems, such as wheezing or shortness of breath?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q11 To the best of your knowledge, do you (IF C11Q01_A – S_UNDR18 > 1 OR IF C11Q01_A = (77, 99, OR NULL), THEN FILL "or any other adults" / ELSE NO FILL) currently have any of the following:
asthma?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q12 (READ IF NECESSARY: To the best of your knowledge, do you (IF C11Q01_A – S_UNDR18 > 1 OR IF C11Q01_A = (77, 99, OR NULL), THEN FILL "or any other adults" / ELSE NO FILL) currently have any of the following:)
diabetes?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q13 (READ IF NECESSARY: To the best of your knowledge, do you (IF C11Q01_A – S_UNDR18 > 1 OR IF C11Q01_A = (77, 99, OR NULL), THEN FILL "or any other adults" / ELSE NO FILL) currently have any of the following:)
a heart problem, including congenital heart disease?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q14 (READ IF NECESSARY: To the best of your knowledge, do you (IF C11Q01_A – S_UNDR18 > 1 OR IF C11Q01_A = (77, 99, OR NULL), THEN FILL "or any other adults" / ELSE NO FILL) currently have any of the following:)
blood problems such as anemia or sickle cell disease? Please do not include Sickle Cell Trait.
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q15 (READ IF NECESSARY: To the best of your knowledge, do you (IF C11Q01_A – S_UNDR18 > 1 OR IF C11Q01_A = (77, 99, OR NULL), THEN FILL "or any other adults" / ELSE NO FILL) currently have any of the following:)
kidney problems?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q16 (READ IF NECESSARY: To the best of your knowledge, do you (IF C11Q01_A – S_UNDR18 > 1 OR IF C11Q01_A = (77, 99, OR NULL), THEN FILL "or any other adults" / ELSE NO FILL) currently have any of the following:)
a weakened immune system caused by a chronic illness or by medicines taken for a chronic illness?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
READ IF NECESSARY: Illnesses such as cancer or HIV/AIDS can cause a person to have a weakened immune system. Medicines such as steroids can cause a person to have a weakened immune system.
S10Q17 Are you (IF C11Q01_A – S_UNDR18 > 1 OR IF C11Q01_A = (77, 99, OR NULL), THEN FILL "or any other adults living in your household" / ELSE NO FILL) 65 years of age or older?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q18 Do you (IF C11Q01_A – S_UNDR18 > 1 OR IF C11Q01_A = (77, 99, OR NULL), THEN FILL "or any other adults living in your household" / ELSE NO FILL) work in a health care facility, such as a medical clinic, hospital, or nursing home?
(1) YES
(0) NO [SKIP TO S10Q20]
(6) DON’T KNOW [SKIP TO S10Q20]
(7) REFUSED [SKIP TO S10Q20]
READ IF NECESSARY: This includes part-time and volunteer work.
S10Q19 Do you (IF C11Q01_A – S_UNDR18 > 1 OR IF C11Q01_A = (77, 99, OR NULL), THEN FILL "or any of these adults" / ELSE NO FILL) have direct face-to-face or hands-on contact with patients as a part of (your/their) routine work?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q20 During the past 12 months, have you had a flu shot? A flu shot is usually given in the fall and protects against influenza for the flu season.
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
READ IF NECESSARY: A flu shot is injected in the arm. Do not include an influenza vaccine sprayed in the nose.
S10Q21 During the past 12 months, have you had a flu vaccine sprayed in your nose by a doctor or other health professional? This vaccine is usually given in the fall and protects against influenza for the flu season.
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
READ IF NECESSARY: This influenza vaccine is called FluMist ®.
IF (S10Q20 = 1 OR S10Q21 = 1) AND (C11Q01_A – S_UNDR18 > 1 OR IF C11Q01_A = (77, 99, OR NULL)) THEN ASK S10Q22 / ELSE GO TO FLU_INSTRUCTIONS_2
S10Q22 Thinking about the other adults living in your household, did everyone have a flu shot or a flu nasal spray during the past 12 months?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
IF FLU_TYPE=3, THEN GO TO TIMESTAMP-SECTION_11 (SKIP INSTRUCTIONS JUST BEFORE C11Q01) /ELSE CONTINUE
FLU_INSTRUCTIONS_2: IF FLU_TYPE=1, THEN GO TO FLU1_A / IF FLU_TYPE=3, THEN GO TO TIMESTAMP-SECTION_11 (SKIP INSTRUCTIONS JUST BEFORE C11Q01) / ELSE GO TO FLU_INTRO_2
FLU_INTRO_2 Now I have just a few questions about the health of (AGEID_FLU). The computer randomly chose this child for these few remaining questions.
S10Q23 Does (AGEID_FLU) have any difficulty with breathing or other respiratory problems, such as wheezing or shortness of breath?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q24 To the best of your knowledge, does (AGEID_FLU) currently have any of the following: asthma?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q25 (READ IF NECESSARY: To the best of your knowledge, does (AGEID_FLU) currently have) diabetes?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q26 (READ IF NECESSARY: To the best of your knowledge, does (AGEID_FLU) currently have)
a heart problem, including congenital heart disease?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q27 (READ IF NECESSARY: To the best of your knowledge, does (AGEID_FLU) currently have) blood problems such as anemia or sickle cell disease? Please do not include Sickle Cell Trait.
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q28 (READ IF NECESSARY: To the best of your knowledge, does (AGEID_FLU) currently have) Cerebral Palsy?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q29 (READ IF NECESSARY: To the best of your knowledge, does (AGEID_FLU) currently have) Muscular Dystrophy?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q30 (READ IF NECESSARY: To the best of your knowledge, does (AGEID_FLU) currently have) epilepsy or other seizure disorder?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q31 (READ IF NECESSARY: To the best of your knowledge, does (AGEID_FLU) currently have)
kidney problems?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q32 (READ IF NECESSARY: To the best of your knowledge, does (AGEID_FLU) currently have)
a weakened immune system caused by a chronic illness or by medicines taken for a chronic illness?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
READ IF NECESSARY: Illnesses such as cancer or HIV/AIDS can cause a child to have a weakened immune system. Medicines such as steroids can cause a child to have a weakened immune system.
S10Q33 To the best of your knowledge, is (AGEID_FLU) required to take aspirin every day?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
IF FLU_TYPE=3, THEN GO TO FLU_INTRO / ELSE GO TO FLU1_A
SELECTION2 IF FLU_TYPE = 3 AND S_UNDR18 = 1, THEN DISPLAY “"Now I have a few more questions about the health of (AGEID_FLU). / IF FLU_TYPE=3 AND S_UNDR18>1, THEN DISPLAY "Now I have just a few questions about the health of (AGEID_FLU). The computer randomly chose this child for the interview, and we will not be asking questions about any other child from this point forward."
FLU1_A. [IF AGE_ID< 12 months, THEN "Since (his/her) birth" / ELSE "During the past 12 months"], has (AGEID_FLU) had a flu shot? A flu shot is usually given in the fall and protects against influenza for the flu season.
(1) YES
(0) NO [SKIP TO FLU2_A]
(6) DON’T KNOW [SKIP TO FLU2_A]
(7) REFUSED [SKIP TO FLU2_A]
READ IF NECESSARY: A flu shot is injected in the arm. Do not include an influenza vaccine sprayed in the nose.
FLU1_B. During what month and year did (S.C./ AGEID_FLU) receive (his/her) most recent flu shot?
ENTER DATE _________
MM/YYYY
(01-12) Month
(05-06) Year
(96) DON’T KNOW
(97) REFUSED
FLU1_C. Was this the first time that (S.C./ AGEID_FLU) has ever received a flu shot?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
FLU2_A. During the past 12 months, has (S.C./ AGEID_FLU) had a flu vaccine sprayed in (his/her) nose by a doctor or other health professional? This vaccine is usually given in the fall and protects against influenza for the flu season.
(1) YES
(0) NO [SKIP TO CATI INSTRUCTION 3]
(6) DON’T KNOW [SKIP TO CATI INSTRUCTION 3]
(7) REFUSED [SKIP TO CATI INSTRUCTION 3]
READ IF NECESSARY: This influenza vaccine is called FluMist ®.
FLU2_B. During what month and year did (S.C./ AGEID_FLU) receive (his/her) most recent flu nasal spray?
ENTER DATE _________
MM/YYYY
(01-12) Month
(05-06) Year
(96) DON’T KNOW
(97) REFUSED
FLU2_C. Was this the first time that (S.C./AGEID) has ever received a flu nasal spray?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
FLU_INSTRUCTIONS_3: IF FLU1_A = 2 AND FLU2_A = 2 AND 'SC2N_FLU CHILD’S AGE' >= 6 MONTHS, THEN SKIP TO FLU3 / ELSE, GO TO FLU4.
FLU3. What is the MAIN reason (S.C./AGEID) did not receive a flu vaccination during the most recent flu season? (DO NOT READ ANSWER CHOICES BELOW. SELECT CATEGORY THAT BEST MATCHES RESPONSE.)
(01) Need: Child was too young to receive vaccine
(02) Need: Doctor did not recommend vaccination
(03) Need: Child had the flu already this flu season
(04) Need: Flu is not that serious
(05) Need: Child does not need vaccination
(06) Need: Did not know that child should be vaccinated
(07) Concern about vaccine: Side effects/can cause flu
(08) Concern about vaccine: Does not work
(09) Access: Flu vaccination costs too much
(10) Access: Inconvenient to get vaccinated / transportation / communication problems
(11) Access: Plan to get child vaccinated later this flu season
(12) Vaccine shortage: Saving vaccine for people who need it more
(13) Vaccine shortage: Tried to find vaccine, but it was not available
(14) Vaccine shortage: Not eligible to receive vaccine
(15) Some other reason [SKIP TO FLU3_OTH]
(96) DON’T KNOW/NOT SURE (Probe: “What was the main reason?”)
(97) REFUSED
FLU3_OTH. READ IF NECESSARY: What is the main reason (S.C./AGEID) did not receive a flu vaccination?
RECORD VERBATIM RESPONSE: ________________________________________
FLU4. [IF DOB FOR AGEID_FLU CHILD COLLECTED AT S3_3M/D/Y, THEN FILL MM/DD/YYYY AND CONTINUE / ELSE ASK]
Doctor recommendations regarding flu immunization vary by exact age. Would you please tell me the date of birth of (AGEID_FLU)?
IF RESPONDENT IS NOT COMFORTABLE GIVING THE FULL BIRTH DATE, PROBE FOR ONLY MONTH AND YEAR
ENTER 77/77/7777 FOR DK AND 99/99/9999 FOR REFUSED
ENTER DATE: ___ / ___ / ___
77/77/7777 DON’T KNOW
99/99/9999 REFUSED
FLU_INSTRUCTIONS_4: IF FLU_TYPE=2, THEN GO TO TIMESTAMP-SECTION_11 (SKIP INSTRUCTIONS JUST BEFORE C11Q01) / IF FLU_TYPE=3, THEN GO TO S10Q23 / ELSE GO TO S10Q34
S10Q34 To the best of your knowledge, does (S.C.) currently have a weakened immune system caused by a chronic illness or by medicines taken for a chronic illness?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
READ IF NECESSARY: Illnesses such as cancer or HIV/AIDS can cause a child to have a weakened immune system. Medicines such as steroids can cause a child to have a weakened immune system.
S10Q35 To the best of your knowledge, is (S.C.) required to take aspirin every day?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
S10Q36 To the best of your knowledge, does (S.C.) currently have kidney problems?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
ALL SKIP TO SECTION 11.
Section 11. INCOME
[SKIP APPROPRIATE VARIABLES IN THIS SECTION IF THE INFORMATION IS AVAILABLE FROM THE NIS]
C11Q01 What was the total combined income of your household in [CATI: FILL LAST CALENDAR YEAR], including income from all sources such as wages, salaries, unemployment payments, public assistance, Social Security or retirement benefits, help from relatives and so forth? Can you tell me that amount before taxes?
RECORD INCOME $___________________
(999999996) DON’T KNOW [SKIP TO W9Q02]
(999999997) REFUSED [SKIP TO W9Q02]
HELP SCREEN: RESPONDENT MAY GIVE A RANGE AS AN ANSWER TO THIS QUESTION. BE PREPARED TO PROBE FOR A MORE ACCURATE ANSWER.
C11CONF (NIS VARIABLE - CINC)
Just to confirm that I entered it correctly, your income was (AMOUNT FROM C11Q01). Is that correct?
(1) YES [SKIP TO C11Q12]
(0) NO [SKIP BACK TO C11Q01]
IF RESPONDENTS REFUSE TO ANSWER THE ‘TOTAL COMBINED HOUSEHOLD INCOME’ QUESTION, THEY ARE ROUTED THROUGH A SERIES OF INCOME QUESTIONS (NOT SHOWN) TO OBTAIN AT LEAST A RANGE FOR THE TOTAL INCOME RECEIVED BY ALL MEMBERS OF THE HOUSEHOLD. RESPONDENTS CAN REFUSE TO ANSWER ALL INCOME RANGE-RELATED QUESTIONS AS WELL.
C11Q12 [IF MAIN SAMPLE AND CWTYPE=N, SKIP TO C11Q11]
Does (S.C.) receive SSI, that is, Supplemental Security Income?
(1) YES
(0) NO [SKIP TO C11Q11]
(6) DON'T KNOW [SKIP TO C11Q11]
(7) REFUSED [SKIP TO C11Q11]
C11Q13 Is this for a disability (he/she) has?
(1) Yes
(0) No
(6) Don’t Know
(7) Refused
C11Q11 ASK ONLY IN HH WITH INCOME UNDER 200% POVERTY, BASED ON RESULTS FROM TABLE, ELSE SKIP TO C11Q14
At any time during the past 12 months, even for one month, did anyone in this household receive any cash assistance from a state or county welfare program, such as [fill state name program]?
(1) YES
(0) NO
(6) DON’T KNOW
(7) REFUSED
Section 11A. TELEPHONE LINE
AND HOUSEHOLD INFORMATION
[SKIP THESE VARIABLES IF THE INFORMATION IS AVAILABLE FROM THE NIS]
C11Q14 Do you have more than one telephone number in your household? Do not include cell phone or numbers that are only used by a computer or fax machine.
READ IF NECESSARY: I’d like to know about the telephone numbers, not telephone extensions, that ring to this household.
COUNT BUSINESS TELEPHONE NUMBERS THAT RING TO THE HOUSEHOLD IF THEY ARE USED OCCASIONALLY FOR HOME USE.
(1) Yes
(0) No [SKIP TO C11Q20]
(6) Don’t Know [SKIP TO C11Q20]
(7) Refused [SKIP TO C11Q20]
C11Q14_A How many telephone numbers are residential numbers?
THIS QUESTION IS ASKING FOR THE TOTAL NUMBER OF HOME TELEPHONE NUMBERS (INCLUDING THE NUMBER WE CALLED).
(1) ONE
(2) TWO
(3) THREE OR MORE
(6) Don’t Know
(7) Refused
C11Q20 During the past 12 months, has your household been without telephone service for 1 week or more? Please do not include cellular phones in your answer. Do not include interruptions of phone service due to weather or natural disasters.
(1) Yes
(0) No [SKIP TO C11Q22]
(6) Don’t Know [SKIP TO C11Q22]
(7) Refused [SKIP TO C11Q22]
C11Q21_A For how long was your household without telephone service in the past 12 months?
HELP SCREEN: IF ONE WEEK OR LESS, ENTER 00 FOR THE NUMBER, ENTER 7 FOR DON’T KNOW AND 9 FOR REFUSED.
ENTER NUMBER ___ ___ ___
(996) DON’T KNOW
(997) REFUSED
C11Q21_B ENTER PERIOD
(1) DAYS
(2) WEEK(S)
(3) MONTH(S)
C11Q22 Please tell me your zip code.
_____ _____ _____ ____ _____ (00001-99998)
(99996) Don’t know
(99997) Refused
C11Q22_CONF [IF C11Q22 FILLED FROM THE NIS, THEN "Earlier you told me your zip code is" / IF C11Q22 ASKED, THEN "I entered"] [FILL C11Q22], is that correct?
YES [GO TO LOC_STATE]
NO [GO TO C11Q22]
LOC_CONF We have your zip code, [FILL C11Q22], listed in [FILL C11Q22_STATE]. Do you live in this state?
(1) YES [GO TO CWEND]
(2) NO [GO TO LOC_STATE]
(3) WRONG ZIP CODE [GO TO C11Q22]
(6) DK [GO TO LOC_STATE]
REF [GO TO CWEND]
IF A RESPONDENT HAS DIFFICULTY REPORTING DECIDING BETWEEN MULTIPLE STATES, ASK: “Where is your primary residence? That is, where do you live most of the time?”
LOC_STATE What state do you live in?
______________(DROP DOWN MENU OF STATE NAMES) [THIS DOES NOT CHANGE ‘STATE’ FROM THE SAMPLE PRE-FILL TABLE]
CWEND Those are all the questions I have. You may be re-contacted in the future to participate in related studies. If you are contacted to participate in future surveys, you have the right to refuse. I'd like to thank you again on behalf of the Centers for Disease Control and Prevention for the time and effort you've spent answering these questions. If you have any questions about this survey, you may call my supervisor toll-free at 1-866-999-3340. If you have questions about your rights as a survey participant, you may call the chairman of the Research Ethics Review Board, toll-free, at 1‑800‑223‑8118. Thank you again.
| File Type | application/msword |
| File Title | Attachment 3: |
| Author | Kathy O'Connor |
| Last Modified By | cww6 |
| File Modified | 2007-10-18 |
| File Created | 2007-10-18 |