Not Assigned Child Mental Health Services

Page 1 of 3

2007 NHIS Questionnaire - Sample Child

Child Mental Health Services

Document Version Date: 12-Jul-06

Question ID: CMS.010_00.000 Instrument Variable Name: SEEDIFF QuestionnaireFileName: Sample Child

QuestionText: Did you ever see or talk to any health care provider or school staff/personnel about difficulties [fill1: SC name] has with

emotions, concentration, behavior or being able to get along with others?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: Sample children GE 4

SkipInstructions: <1> [goto MRVSEE] <2,R,D> [goto MEDDIFF]

Question ID: CMS.020_00.000 Instrument Variable Name: MRVSEE QuestionnaireFileName: Sample Child

QuestionText: (book) C9

When was the MOST RECENT conversation or visit?

1 In the past 6 months

2 7 to 12 months ago

3 More than 12 months ago

7 Refused

9 Don't know

UniverseText: Sample children GE 4 who have seen or talked to health care provider/school/staff/personnel about child's difficulties

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

Question ID: CMS.030_00.000 Instrument Variable Name: MEDDIFF QuestionnaireFileName: Sample Child

QuestionText: Was [fill1: SC name] ever prescribed medication for difficulties with [fill2: his/her] emotions, concentration, behavior or

being able to get along with others?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: Sample children GE 4

SkipInstructions: <1> [goto MRVMED] <2,R,D> [goto TRETDIFF]

Page 2 of 3

2007 NHIS Questionnaire - Sample Child

Child Mental Health Services

Document Version Date: 12-Jul-06

Question ID: CMS.040_00.000 Instrument Variable Name: MRVMED QuestionnaireFileName: Sample Child

QuestionText: (book) C9

When was the MOST RECENT medication prescribed for these difficulties?

1 In the past 6 months

2 7 to 12 months ago

3 More than 12 months ago

7 Refused

9 Don't know

UniverseText: Sample children GE 4 who have had medication prescribed for difficulties with emotion, concentration, behavior, or

getting along with others

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

Question ID: CMS.050_00.000 Instrument Variable Name: MEDWHY QuestionnaireFileName: Sample Child

QuestionText: Was this medication prescribed for difficulties with concentration, hyperactivity, or impulsivity?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: Sample children GE 4 who have had medication prescribed for difficulties with emotion, concentration, behavior, or

getting along with others

SkipInstructions: <1,2,R,D> [goto TRETDIFF]

Question ID: CMS.060_00.000 Instrument Variable Name: TRETDIFF QuestionnaireFileName: Sample Child

QuestionText: Has [Fill1: SC name] EVER received ANY treatment or help, [Fill2: other than medication,] for difficulties with emotions,

concentration, behavior or being able to get along with others?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: Sample children GE 4

SkipInstructions: <1> [goto MRVTRET] <2,R,D> [goto next section]

Page 3 of 3

2007 NHIS Questionnaire - Sample Child

Child Mental Health Services

Document Version Date: 12-Jul-06

Question ID: CMS.070_00.000 Instrument Variable Name: MRVTRET QuestionnaireFileName: Sample Child

QuestionText: (book) C9

When was the MOST RECENT help or treatment received?

1 In the past 6 months

2 7 to 12 months ago

3 More than 12 months ago

7 Refused

9 Don't know

UniverseText: Sample children GE 4 who have received treatment or help for difficulties with emotions, concentration, behavior, or

getting along with others

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

Question ID: CMS.080_00.000 Instrument Variable Name: TRETWHER QuestionnaireFileName: Sample Child

QuestionText: (book) C10

Was any of this treatment or help received from any of the following?

*Enter all that apply, separate with commas.

1 A pediatric or general medical care practice

2 A mental health private practice

3 A mental health clinic or center

4 The child's school

5 Other

7 Refused

9 Don't know

UniverseText: Sample children GE 4 who have received treatment or help for difficulties with emotions, concentration, behavior, or

getting along with others

SkipInstructions: <1-5,R,D> [goto next section]