Attachment 5: 2011 NSCH Telephone Interview Questionnaire
The following public burden estimate statement will be available as a CATI screen:
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 27 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 NORC at the University of Chicago.
Form approved
OMB No. 0920-0406
Exp. Date 04/30/11
All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
2011 National Survey of Children’s Health
(January 21, 2011)
Section 1: Initial Demographics 5
Section 2: Health and Functional Status 7
Subdomain 1: General health status 7
Subdomain 2: Presence of a special health care need 8
Subdomain 3: Common chronic conditions 10
Section 3: Health Insurance Coverage 16
Subdomain 1: Current coverage and past year coverage 16
Subdomain 2: Adequacy of health insurance 17
Subdomain 3: Expenses and Barriers to Care 17
Section 4: Health Care Access and Utilization 18
Subdomain 1: Usual place for care 18
Subdomain 2: Utilization of services 19
Subdomain 3: Use of developmental services 21
Subdomain 2: Care coordination 23
Subdomain 3: Provider communication 24
Subdomain 4: Compassionate, culturally effective, family-centered care 25
Section 6: Early Childhood (0-5 years) 26
Subdomain 1: Parent’s Evaluation of Developmental Status 26
Subdomain 2: Developmental screening 27
Section 7: Middle Childhood and Adolescence (6-17 years) 31
Subdomain 1: School enrollment 31
Subdomain 2: After-school activities and parental involvement 32
Subdomain 3: Sleep and exercise 33
Subdomain 5: Media consumption 34
Subdomain 6: Bullying and emotional difficulties 35
Section 8: Family Functioning 36
Subdomain 1: Family activities 36
Subdomain 2: Parent/child relationship 36
Subdomain 1: Household composition 38
Subdomain 2: Age and marital status of adults in household 41
Subdomain 3: General health status 44
Subdomain 5: Adverse family experiences 45
Subdomain 6: Presence of adult mentor 45
Section 10: Neighborhood and Community Characteristics 46
Subdomain 1: Neighborhood amenities 46
Subdomain 2: Neighborhood condition 46
Subdomain 3: Social capital 46
Subdomain 4: Perceived safety 46
Section 11: Additional Demographics 47
Subdomain 1: Race and ethnicity of child 47
Subdomain 2: Education of parents 48
Subdomain 3: Birthplace of child and parents 49
Subdomain 4: Residential mobility 51
Subdomain 5: Employment and income 52
Subdomain 6: Program participation 56
Section 12: Additional Health Insurance Questions 57
Subdomain 1: Reasons for Uninsurance 57
Subdomain 2: History with Medicaid 58
Subdomain 3: History with CHIP 60
Subdomain 4: Interest in Enrolling in Medicaid/CHIP 62
Subdomain 5: Parents’ Coverage and Availability of Employer-Sponsored Insurance 65
Section 13: Locating Information 71
Subdomain 1: Telephone line information 71
SCQ02 IF S_NUMB=0 or SUC=3,5 or 6 or no ELIG_1-9 =1, SKIP TO SCQ05. IF SAMPLE_USE_CODE=4 AND NOT NIS OR TEEN ELIGIBLE, SKIP TO SCQ05. ELSE IF NIS INTERVIEW WAS CONDUCTED BUT [S.C.] WAS NOT NIS-ELIGIBLE, SKIP TO SCQ03. IF SAMPLE_USE_CODE=4 AND NIS OR TEEN DONE, BUT [S.C.] WAS NOT NIS OR TEEN-ELIGIBLE, SKIP TO SCQO3.
IF S_UNDR18 = 01, SAY: “Next, I have some other questions about the health and health care of [S.C.]. As before, you may choose not to answer any questions you don’t wish to answer, or end the interview at any time with no impact on the benefits you may receive. [IF NSCH INCENTIVE CASE DISPLAY: In appreciation for your time, we will send you [$NSCH_INCENT].] This part of the survey will take about half an hour. I’d like to continue now unless you have any questions.”
IF S_UNDR18 > 01, SAY: “I appreciate your answers about the immunizations of [NIS-ELIGIBLE CHILDREN, IF SAMPLE_USE_CODE=4 AND TEEN INTERVIEW COMPLETE FILL WITH TEEN SC, ELSE FILL WITH NIS-ELIGIBLE CHILDREN]. The next questions are about the health and health care of [S.C.]. As before, you may choose not to answer any questions you don’t wish to answer, or end the interview at any time with no impact on the benefits you may receive. [IF NSCH INCENTIVE CASE DISPLAY: In appreciation for your time, we will send you [$NSCH_INCENT].] This part of the survey will take about half an hour. I’d like to continue now unless you have any questions.”
(1) CONTINUE [SKIP TO K1Q01]
SCQ03 I appreciate your answers about the immunizations of [IF SAMPLE_USE_CODE = 2 then fill with NIS-ELIGIBLE CHILDREN, IF SAMPLE_USE_CODE=4 AND NIS DONE BUT NO TEEN THEN FILL WITH NIS-ELIGIBLE CHILDREN, IF SAMPLE_USE_CODE=4 AND TEEN INTERVIEW DONE THEN FILL WITH ST]. The next questions are about the health and health care of [S.C.]. We need to talk to a parent or guardian who lives in this household who knows about the health and health care of [S.C.]. Who would that be?
MYSELF / SOMEONE ELSE [SKIP TO SCQ06 IF SOMEONE ELSE]
SCQ04 As before, you may choose not to answer any questions you don’t wish to answer, or end the interview at any time with no impact on the benefits you may receive. [IF NSCH INCENTIVE CASE DISPLAY: In appreciation for your time, we will send you [$NSCH_INCENT].] This part of the survey will take about half an hour. I’d like to continue now unless you have any questions.
(1) CONTINUE [SKIP TO K1Q01]
SCQ05 Most of this survey will be about the health and health care of [S.C.]. We need to talk to a parent or guardian who lives in this household who knows about the health and health care of [S.C.]. Who would that be?
MYSELF / SOMEONE ELSE [SKIP TO S3_NSCH_LTR IF MYSELF]
SCQ06 May I speak with that person now?
YES / NO [IF NO, SCHEDULE APPOINTMENT: POR is SCQ05]
NEW_RESP Hello, my name is ________________. I'm calling on behalf of the Centers for Disease Control and Prevention. We are doing a nationwide survey about the health of children and teenagers, and I was told that you were the person to talk with about the health and health care of [S.C.].
(1) CONTINUE
S3_NSCH_LTR IF NO ADVANCE LETTER SENT, THEN SKIP TO SL_INTRO.
A letter describing this survey may have been sent to your home recently. Do you remember seeing the letter?
YES / NO / DK / RF
SL_INTRO Before we continue, I’d like you to know that taking part in this research is voluntary. You may choose not to answer any questions you don’t wish to answer, or end the interview at any time with no impact on the benefits you may receive. We are required by Federal law to develop and follow strict procedures to protect the confidentiality of your information and use your answers only for statistical research. I can describe these laws if you wish. [IF NSCH INCENTIVE CASE DISPLAY: In appreciation for your time, we will send you [$NSCH_INCENT].] The survey will take about half an hour. 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.
READ IF NECESSARY: 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 by the Confidential Information Protection and Statistical Efficiency Act. Would you like me to read the Confidential Information Protection provisions to you?
IF RESPONDENT WOULD LIKE TO HEAR PROVISIONS, READ: 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 Diseases, 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.
(1) CONTINUE, RECORDING ACCEPTABLE
(0) CONTINUE, DO NOT RECORD
K1Q01_INTRO
[SKIP TO K1Q01 IF NAME OF S.C. ALREADY GATHERED NAME_1-NAME_9 OR NIS INTERVIEW]
I can continue to refer to your child as (your N month/year old) for the rest of the interview, or if you prefer, you could give me a first name or initials.
(01) CONTINUE TO USE AGE REFERENCE [GO TO K1Q01]
(02) USE NAME [GO TO SELECTION1_NAME_A]
SELECTION1_NAME_A
ENTER NAME/INITIALS: ____________ [GO TO K1Q01]
K1Q01 Is [SC] male or female?
MALE / FEMALE / DK / RF
K1Q02 What is your relationship to [SC]?
PARENT
(1) MOTHER (BIOLOGICAL, STEP, FOSTER, ADOPTIVE)
(2) FATHER (BIOLOGICAL, STEP, FOSTER, ADOPTIVE)
OLDER RELATIVES OR GUARDIANS
(11) GRANDMOTHER
(12) GRANDFATHER
(13) AUNT
(14) UNCLE
(15) FEMALE GUARDIAN
(16) MALE GUARDIAN
OTHER RELATIVES
(17) SISTER (BIOLOGICAL, STEP, FOSTER, HALF, ADOPTIVE)
(18) BROTHER (BIOLOGICAL, STEP, FOSTER, HALF, ADOPTIVE)
(19) COUSIN
(20) IN-LAW OF ANY TYPE
(22) OTHER RELATIVE / FAMILY MEMBER
OTHER NON-RELATIVES
(23) PARENT’S BOYFRIEND / MALE PARTNER
(24) PARENT’S GIRLFRIEND / FEMALE PARTNER
(25) PARENT’S PARTNER, but SEX REFUSED
(26) OTHER NON-RELATIVE OR FRIEND
(77) DON’T KNOW
(99) REFUSED
K1Q03 What is the primary language spoken in your home?
(1) ENGLISH
(2) SPANISH
(3) ARABIC
(4) CHINESE
(5) FRENCH
(6) ITALIAN
(7) JAPANESE
(8) KOREAN
(9) POLISH
(10) RUSSIAN
(11) TAGALOG
(12) VIETNAMESE
(13) ANY OTHER LANGUAGE
(77) DON’T KNOW
(99) REFUSED
K2Q01 In general, how would you describe [SC]’s health? Would you say [his/her] health is excellent, very good, good, fair, or poor?
EXCELLENT / VERY GOOD / GOOD / FAIR / POOR / DK / RF
NOTE: TEXT BELOW MUST BE ACCESSIBLE TO ALL RESPONDENTS. BECAUSE K2Q01 IS ASKED OF ALL CASES, THE TEXT BELOW WILL APPEAR AS HELP TEXT.
INTERVIEWER INSTRUCTION: IF RESPONDENT REQUESTS INFORMATION ON THE OMB CONTROL NUMBER, OR WOULD LIKE CONTACT INFORMATION TO PROVIDE COMMENTS ABOUT THE ACCURACY OF THE TIME ESTIMATE OR SUGGESTIONS ABOUT IMPROVING THE SURVEY, READ THE TEXT BELOW AS NECESSARY:
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 27 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 NORC at the University of Chicago.
IF AGE < 12 MONTHS, SKIP TO K2Q02.
K2Q01_D How would you describe the condition of [SC]’s teeth: excellent, very good, good, fair, or poor?
EXCELLENT / VERY GOOD / GOOD / FAIR / POOR / NO NATURAL TEETH / DK / RF
K2Q02 How tall is [SC] now?
___ FEET / ___ INCHES / ___ CENTIMETERS / DK / RF
K2Q03 How much does [SC] weigh now?
___ POUNDS / ___ KILOGRAMS / DK / RF
K2Q04 What was [SC]’s birth weight?
___ POUNDS / ___ OUNCES / ___ GRAMS / DK / RF
K2Q05 Was [SC] born premature, that is, more than 3 weeks before [his/her] due date?
YES / NO / DK / RF
HELP SCREEN: Most pregnancies last about 40 weeks. A premature birth is when a baby is born more than three weeks before the due date.
K2Q10_INTRO The next questions are about any kind of health problems, concerns, or conditions that may affect [SC]’s behavior, learning, growth, or physical development.
K2Q10 Does [SC] currently need or use medicine prescribed by a doctor, other than vitamins?
READ IF NECESSARY: This only applies to medications prescribed by a doctor. Over-the-counter medications such as cold or headache medication, or other vitamins, minerals, or supplements purchased without a prescription are not included.
(1) YES [SKIP TO K2Q11]
(0) NO [SKIP TO K2Q13]
(6) DON’T KNOW [SKIP TO K2Q13]
(7) REFUSED [SKIP TO K2Q13]
K2Q11 Is [his/her] need for prescription medicine because of ANY medical, behavioral, or other health condition?
(1) YES [SKIP TO K2Q12]
(0) NO [SKIP TO K2Q13]
(6) DON’T KNOW [SKIP TO K2Q13]
(7) REFUSED [SKIP TO K2Q13]
K2Q12 Is this a condition that has lasted or is expected to last 12 months or longer?
YES / NO / DK / RF
K2Q13 Does [SC] need or use more medical care, mental health, or educational services than is usual for most children of the same age?
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.
(1) YES [SKIP TO K2Q14]
(0) NO [SKIP TO K2Q16]
(6) DON’T KNOW [SKIP TO K2Q16]
(7) REFUSED [SKIP TO K2Q16]
K2Q14 Is [his/her] need for medical care, mental health or educational services because of ANY medical, behavioral, or other health condition?
(1) YES [SKIP TO K2Q15]
(0) NO [SKIP TO K2Q16]
(6) DON’T KNOW [SKIP TO K2Q16]
(7) REFUSED [SKIP TO K2Q16]
K2Q15 Is this a condition that has lasted or is expected to last 12 months or longer?
YES / NO / DK / RF
K2Q16 Is [SC] limited or prevented in any way in [his/her] ability to do the things most children of the same age can do?
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.
(1) YES [SKIP TO K2Q17]
(0) NO [SKIP TO K2Q19]
(6) DON’T KNOW [SKIP TO K2Q19]
(7) REFUSED [SKIP TO K2Q19]
K2Q17 Is [his/her] limitation in abilities because of ANY medical, behavioral, or other health condition?
(1) YES [SKIP TO K2Q18]
(0) NO [SKIP TO K2Q19]
(6) DON’T KNOW [SKIP TO K2Q19]
(7) REFUSED [SKIP TO K2Q19]
K2Q18 Is this a condition that has lasted or is expected to last 12 months or longer?
YES / NO / DK / RF
K2Q19 Does [SC] need or get special therapy, such as physical, occupational, or speech therapy?
READ IF NECESSARY: Special therapy includes physical, occupational, or speech therapy. Do not include psychological therapy.
(1) YES [SKIP TO K2Q20]
(0) NO [SKIP TO K2Q22]
(6) DON’T KNOW [SKIP TO K2Q22]
(7) REFUSED [SKIP TO K2Q22]
K2Q20 Is [his/her] need for special therapy because of ANY medical, behavioral, or other health condition?
(1) YES [SKIP TO K2Q21]
(0) NO [SKIP TO K2Q22]
(6) DON’T KNOW [SKIP TO K2Q22]
(7) REFUSED [SKIP TO K2Q22]
K2Q21 Is this a condition that has lasted or is expected to last 12 months or longer?
YES / NO / DK / RF
K2Q22 Does [SC] have any kind of emotional, developmental, or behavioral problem for which [he/she] needs treatment or counseling?
READ IF NECESSARY: These are remedies, therapy, or guidance a child may receive for his/her emotional, developmental, or behavioral problem.
(1) YES [SKIP TO K2Q23]
(0) NO [SKIP TO CATI INSTRUCTION BELOW]
(6) DON’T KNOW [SKIP TO CATI INSTRUCTION BELOW]
(7) REFUSED [SKIP TO CATI INSTRUCTION BELOW]
K2Q23 Has [his/her] emotional, developmental or behavioral problem lasted or is it expected to last 12 months or longer?
YES / NO / DK / RF
CATI INSTRUCTION (SECTION 2, SUBDOMAIN 2): CREATE CATI SYSTEM FLAG (CSHCN) INDICATING WHETHER THE CHILD HAS A SPECIAL HEALTH CARE NEED. THIS FLAG SHOULD BE POSITIVE (CSHCN = 1) IF K2Q12 = 1, K2Q15 = 1, K2Q18 = 1, K2Q21 = 1, OR K2Q23 = 1.
IF SC < 36 MONTHS, SKIP TO K2Q31_INTRO.
K2Q30A Has a doctor, health care provider, teacher, or school official ever told you [SC] had a learning disability?
(1) YES [SKIP TO K2Q30B]
(0) NO [SKIP TO K2Q31_INTRO]
(6) DON’T KNOW [SKIP TO K2Q31_INTRO]
(7) REFUSED [SKIP TO K2Q31_INTRO]
K2Q30B Does [SC] currently have a learning disability?
(1) YES [SKIP TO K2Q30C]
(0) NO [SKIP TO K2Q31_INTRO]
(6) DON’T KNOW [SKIP TO K2Q31_INTRO]
(7) REFUSED [SKIP TO K2Q31_INTRO]
K2Q30C Would you describe [his/her] learning disability as mild, moderate, or severe?
MILD / MODERATE / SEVERE / DK / RF
K2Q31_INTRO Now I am going to read you a list of conditions. For each condition, please tell me if a doctor or other health care provider ever told you that [SC] had the condition, even if [he/she] does not have the condition now.
INTERVIEWER INSTRUCTION: If the respondent has never heard of the medical condition or does not know what the condition is, then a doctor or other health care provider probably has not told the respondent that the SC.has the condition. If a doctor or other health care provider has not told the respondent that the SC has the condition, but the respondent insists that the SC.has the condition, we still need to code the answer as “no.”
IF AGE_NSCH < 24 MONTHS SKIP TO K2Q40A.
(READ IF NECESSARY: Has a doctor or other health care provider ever told you that [SC] had…)
K2Q31A Attention Deficit Disorder or Attention-Deficit/Hyperactivity Disorder, that is, ADD or ADHD?
K2Q32A Depression?
K2Q33A Anxiety problems?
K2Q34A Behavioral or conduct problems, such as oppositional defiant disorder or conduct disorder?
K2Q35A Autism, Asperger's Disorder, pervasive developmental disorder, or other autism spectrum disorder?
K2Q36A Any developmental delay?
K2Q60A Intellectual disability or mental retardation?
K2Q61A Cerebral palsy?
K2Q37A Speech or other language problems?
K2Q38A Tourette Syndrome?
K2Q40A Asthma?
K2Q41A Diabetes?
K2Q42A Epilepsy or seizure disorder?
K2Q43A Hearing problems?
K2Q44A Vision problems that cannot be corrected with standard glasses or contact lenses?
K2Q45A Bone, joint, or muscle problems?
K2Q46A A brain injury or concussion?
YES/NO/DK/RF FOR EACH ITEM
BEGIN LOOP TO BE ASKED FOR EACH CONDITION IDENTIFIED BY PARENT. USE THE FOLLOWING TEXT FOR CONDITION FILLS:
[ADD or ADHD] [developmental delay]
[depression] [intellectual disability or mental retardation]
[anxiety problems] [cerebral palsy]
[behavioral or conduct problems] [speech or other language problems]
[autism or ASD] [Tourette Syndrome]
NEW4Q_ SKIP TO K2Q_B IF CONDITION IS DEPRESSION OR ANXIETY PROBLEMS.
How old was [SC] when you were first told by a doctor or other health care provider that [he/she] had [CONDITION]?
RECORD AGE IN YEARS OR MONTHS / DK / RF
SKIP TO K2Q_B IF CONDITION IS NOT AUTISM OR ASD.
K2Q35D. What type of doctor or other health care provider first told you that [SC] had autism or ASD?
PEDIATRICIAN OR OTHER GENERAL PEDIATRIC HEALTH CARE PROVIDER (SUCH AS NURSE PRACTITIONER OR PHYSICIAN’S ASSISTANT IN PEDIATRIC CLINIC)
ANOTHER TYPE OF GENERAL HEALTH CARE PROVIDER (SUCH AS FAMILY PRACTICE DOCTOR OR NURSE PRACTITIONER OR PHYSICIAN’S ASSISTANT IN GENERAL PRACTICE)
A SPECIALIST PEDIATRICIAN SUCH AS A DEVELOPMENTAL PEDIATRICIAN
SCHOOL PSYCHOLOGIST / COUNSELOR
OTHER PSYCHOLOGIST (NON-SCHOOL)
PSYCHIATRIST (MEDICAL DOCTOR)
NEUROLOGIST
SCHOOL NURSE
PHYSICAL, OCCUPATIONAL, SPEECH, OR OTHER THERAPIST
A SPECIALIST DOCTOR (OTHER THAN A DEVELOPMENTAL PEDIATRICIAN, PSYCHIATRIST, OR NEUROLOGIST)
OTHER [RECORD VERBATIM RESPONSE]
WASN’T TOLD BY A DOCTOR OR OTHER HEALTH CARE PROFESSIONAL
(96) DON’T KNOW
(97) REFUSED
K2Q__B Does [SC] currently have [CONDITION]?
YES / NO / DK / RF
END OF LOOP IF K2Q_B = DK/RF.
END OF LOOP IF K2Q_B = NO AND CONDITION IS NOT AUTISM.
SKIP TO K2Q35E IF K2Q_B = NO AND CONDITION IS AUTISM.
SKIP TO K2Q61C IF CONDITION IS CEREBRAL PALSY.
K2Q__C Would you describe [his/her] [CONDITION] as mild, moderate, or severe?
MILD / MODERATE / SEVERE / DK / RF
END OF LOOP IF CONDITION IS NOT ADD/ADHD
K2Q31D Is [SC] currently taking medication for ADD or ADHD?
YES / NO / DK / RF
END OF LOOP. RETURN TO NEW4Q_ FOR EACH ADDITIONAL CONDITION.
K2Q61C How would you describe his/her usual ability to walk?
(1) WALKS WITHOUT A CANE, CRUTCHES, OR A WALKER
(2) WALKS WITH A CANE, CRUTCHES, OR A WALKER
(3) LIMITED OR NO WALKING
(4) DK
(5) REF
READ IF NECESSARY: Some children use more than one method. For example, a child may walk with a cane, crutches, or a walker at home but do limited or no walking outdoors. For children who use more than one method, please ask the respondent to indicate what the child usually does in the setting where [he/she] spends the most time in a typical weekday. This could be the child’s home, school, or other community setting. Whether or not a child wears braces should not be considered in determining [his/her] usual ability to walk. Children at all three levels of walking ability can wear braces.
END OF LOOP. RETURN TO NEW4Q_ FOR EACH ADDITIONAL CONDITION.
K2Q35E. To the best of your knowledge, did [SC] ever have autism or ASD?
YES/NO/DK/RF [SKIP TO #15 IF NO. END LOOP IF DK/RF]
K2Q35F_INTRO. I am going to read a list of reasons why [SC] may no longer have autism or ASD. For each reason, please tell me if it applies to [SC].
K2Q35F_1. Treatment helped the condition go away
K2Q35F_2. The condition seemed to go away on its own
K2Q35F_3. The behaviors or symptoms changed
K2Q35F_4. A doctor or health care provider changed the diagnosis
YES/NO/DK/RF FOR EACH ITEM
K2Q35G. Are there any other reasons why you think [SC] may no longer have autism or ASD?
YES/NO/DK/RF [END LOOP IF NO/DK/RF. RECORD VERBATIM RESPONSE IF YES, THEN END LOOP.]
K2Q35H_INTRO. I am going to read a list of reasons why a doctor, health care provider, or school professional may have told you that [SC] had a condition that (he/she) never had. For each reason, please tell me if it applies to [SC].
K2Q35H_1. With more information, the diagnosis was changed
K2Q35H_2. The diagnosis was given so that [SC] could receive needed services
K2Q35H_3. You disagree with the doctor or other health provider about his or her opinion that [SC] had autism or ASD.
YES/NO/DK/RF FOR EACH ITEM
K2Q35J. Are there any other reasons why a doctor or other health care provider may have told you that [SC] had autism or ASD when (he/she) never had it?
YES/NO/DK/RF [END LOOP IF NO/DK/RF. RECORD VERBATIM RESPONSE IF YES, THEN END LOOP.]
END OF LOOP. RETURN TO NEW4Q_ FOR EACH ADDITIONAL CONDITION.
BEGIN LOOP TO BE ASKED FOR EACH CONDITION IDENTIFIED BY PARENT. USE THE FOLLOWING TEXT FOR CONDITION FILLS:
[asthma] [vision problems]
[diabetes] [bone, joint, or muscle problems]
[epilepsy or seizure disorder] [brain injury]
[hearing problems]
K2Q44A_1 SKIP TO K2Q_B IF CONDITION IS NOT VISION PROBLEMS.
How old was [SC] when you were first told by a doctor or other health care provider that [he/she] had vision problems that cannot be corrected with standard glasses or contact lenses?
RECORD AGE IN YEARS OR MONTHS / DK / RF
K2Q__B Does [SC] currently have [CONDITION]?
YES / NO / DK / RF [END OF LOOP IF NO/DK/RF]
K2Q__C Would you describe [his/her] [CONDITION] as mild, moderate, or severe?
MILD / MODERATE / SEVERE / DK / RF
END OF LOOP. RETURN TO K2Q__B FOR EACH ADDITIONAL CONDITION.
K3Q01_INTRO The next questions are about health insurance.
K3Q01 Does [SC] have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicaid?
YES / NO / DK / RF [SKIP TO K3Q04 IF NO]
K3Q02 IF K3Q01 = 1 THEN FILL “Is that coverage”. ELSE, fill “Is [he/she] insured by…]
[Is that coverage/Is [he/she] insured by] Medicaid or the Children’s Health Insurance Program, CHIP? [IF VIRGIN ISLANDS CASE, DISPLAY "In this area," ELSE DISPLAY "In this state,"], the program is sometimes called [FILL MEDICAID NAME, CHIP NAME].
READ IF NECESSARY: CHIP is a type of state-sponsored health insurance coverage that a child may have. The name of the plan varies from state-to-state.
YES / NO / DK / RF [SKIP TO K3Q04 IF K3Q01 IS DK/RF AND K3Q02 IS NO/DK/RF]
K3Q03 [During the past 12 months / Since (his/her) birth], was there any time when [he/she] was not covered by ANY health insurance?
YES / NO / DK / RF [ALL SKIP TO K3Q20]
K3Q04 [During the past 12 months / Since (his/her) birth], was there any time when [he/she] had health care coverage?
YES / NO / DK / RF [ALL SKIP TO K3Q25]
K3Q20 [IF K3Q01 OR K3Q02 OR K3Q03 ASKED AND NOT FILLED FROM NIS OR TEEN, then display: "The next questions are about [S.C.]'s health insurance or health care plans."] Does [SC]’s health insurance offer benefits or cover services that meet [his/her] needs? Would you say:
NEVER / SOMETIMES / USUALLY / ALWAYS / DK / RF
K3Q22 Does [SC]’s health insurance allow (him/her) to see the health care providers [he/she] needs?
Would you say:
NEVER / SOMETIMES / USUALLY / ALWAYS / DK / RF
K3Q21A Not including health insurance premiums or costs that are covered by insurance, do you pay any money for [SC]’s health care?
READ IF NECESSARY: Include out-of-pocket payments for all types of health-related needs such as co-payments, dental or vision care, medications, and any kind of therapy.
YES / NO / DK / RF [SKIP TO K3Q25 IF NO/DK/RF]
K3Q21B How often are these costs reasonable? Would you say never, sometimes, usually, always?
NEVER / SOMETIMES / USUALLY / ALWAYS / NO OUT OF POCKET COSTS / DK / RF
INTERVIEWER INSTRUCTION: 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: How often are those costs reasonable?
K3Q25 In the past 12 months did your family have problems paying or were unable to pay any of (SC’s) medical bills? Include bills for doctors, dentists, hospitals, therapists, medication, equipment, or home care.
YES / NO / NO EXPENSES / DK / RF
C4Q04. [During the past 12 months / [WHEN SC IS YOUNGER THAN 12 MONTHS] Since (his/her) birth], how often have you been frustrated in your efforts to obtain health care services for (SC)? Would you say never, sometimes, usually, or always?
NEVER / SOMETIMES / USUALLY / ALWAYS / DK / RF
K4Q01 Is there a place that [SC] USUALLY goes when [he/she] is sick or you need advice about [his/her] health?
(1) YES
(2) NO [SKIP TO K4Q04]
(3) THERE IS MORE THAN ONE PLACE
(6) DON’T KNOW [SKIP TO K4Q04]
(7) REFUSED [SKIP TO K4Q04]
K4Q02 IF K4Q01 = 1, SAY “What kind of place is it?”
IF K4Q01 = 3, SAY “What kind of place does [SC] go to most often?”
Is it a doctor’s office, emergency room, hospital outpatient department, clinic, or some other place?
(1) Doctor’s office
(2) HOSPITAL emergency room
(3) Hospital outpatient department
(4) Clinic OR HEALTH CENTER
(5) retail store clinic or “minute clinic”
(6) SCHOOL (NURSE, ATHLETIC TRAINER, ETC)
(7) fRIEND/RELATIVE
(8) mEXICO/OTHER LOCATIONS OUT OF US
(9) Some other place [RECORD VERBATIM RESPONSE]
(10) DOES NOT GO TO ONE PLACE MOST OFTEN
(96) DON’T KNOW
(97) REFUSED
K3Q03 READ IF NECESSARY: ( IF K4Q01 = 1, READ “What kind of place is it?”; IF K4Q01 = 3, READ: “What kind of place does [S.C.] go to most often?”)
RECORD VERBATIM RESPONSE
K4Q04 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 [SC]’s personal doctor or nurse?
YES, ONE PERSON / YES, MORE THAN ONE PERSON / NO / DK / RF
S4Q01 [During the past 12 months/Since (his/her) birth], did [SC] see a doctor, nurse, or other health care professional for any kind of medical care, including sick-child care, well-child check-ups, physical exams, and hospitalizations?
YES / NO / DK / RF [SKIP TO K4Q30 IF NO/DK/RF]
K4Q20 [During the past 12 months/Since (his/her) birth], how many times did [SC] see a doctor, nurse, or other health care provider for preventive medical care such as a physical exam or well-child checkup?
RECORD NUMBER OF TIMES / DK / RF
K4Q30 [During the past 12 months/Since (his/her) birth], did [SC] see a dentist for any kind of dental care, including check-ups, dental cleanings, x-rays, or filling cavities?
YES / NO / DK / RF [SKIP TO K4Q39 IF NO/DK/RF]
K4Q21 [During the past 12 months/Since (his/her) birth], how many times did [SC] see a dentist for preventive dental care, such as check-ups and dental cleanings?
RECORD NUMBER OF TIMES / DK / RF
K4Q39 IF AGE < 12 MONTHS, SKIP TO K4Q24.
[During the past 12 months/Since (his/her) birth], did [SC] have a toothache, decayed teeth, or unfilled cavities?
YES / NO / DK / RF
IF AGE < 24 MONTHS, SKIP TO K4Q24.
K4Q22 Mental health professionals include psychiatrists, psychologists, psychiatric nurses, and clinical social workers. During the past 12 months, has [SC] received any treatment or counseling from a mental health professional?
YES / NO / DK / RF
IF K2Q31D = 1, SKIP TO K4Q24.
K4Q23 During the past 12 months, has [SC] taken any medication because of difficulties with [his/her] emotions, concentration, or behavior?
YES / NO / DK / RF
K4Q24 Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and others who specialize in one area of health care. [During the past 12 months/Since (his/her) birth], did [SC] see a specialist [IF K4Q22 = 1, THEN INSERT: other than a mental health professional]?
YES / NO / DK / RF [SKIP TO K4Q26 IF YES]
K4Q25 [During the past 12 months/Since (his/her) birth], did you or a doctor think that [he/she] needed to see a specialist?
YES / NO / DK / RF [SKIP TO K4Q31 IF NO/DK/RF]
K4Q26 [During the past 12 months/Since (his/her) birth], how much of a problem, if any, was it to get the care from the specialists that [SC] needed? Would you say it was a big problem, a small problem, or not a problem?
BIG PROBLEM / SMALL PROBLEM / NOT A PROBLEM / DK / RF
K4Q31 IF AGE < 5 YEARS, READ: Has [SC] ever had (his/her) vision tested with pictures, shapes, or letters?
IF AGE 5+ YEARS, READ: During the past 2 years, that is, since [FILL INTDATE – 48 MONTHS], has [SC] had (his/her) vision tested with pictures, shapes, or letters?
YES / NO / DK / RF [SKIP TO K4Q27 IF NO/DK/RF]
K4Q32 What kind of place or places did [SC] have (his/her) vision tested? Was it an eye doctor’s office, a general doctor’s office, clinic, school, or some other place? [Mark all that apply]
(1) EYE DOCTOR OR EYE SPECIALIST (OPHTHALMOLOGIST, OPTOMETRIST) OFFICE
(2) PEDIATRICIAN OR OTHER GENERAL DOCTOR’S OFFICE
(3) CLINIC OR HEALTH CENTER
(4) SCHOOL
(5) OTHER [RECORD VERBATIM RESPONSE]
(6) DK
(7) RF
K4Q27 Sometimes people have difficulty getting health care when they need it. By health care, I mean medical care as well as other kinds of care like dental care, vision care, and mental health services. [During the past 12 months/Since (his/her) birth], was there any time when [SC] needed health care but it was delayed or not received?
YES / NO / DK / RF [SKIP TO K4Q35 IF NO/DK/RF]
K4Q28 What type of care was delayed or not received? Was it medical care, dental care, vision care, mental health services, or something else? [Mark all that apply]
(1) MEDICAL CARE
(2) DENTAL CARE
(3) VISION CARE
(4) MENTAL HEALTH SERVICES
(5) SOMETHING ELSE
(6) DON’T KNOW
(7) REFUSED
K4Q35 ASK K4Q35 ONLY IF AGE=0-3 YEARS
Some new parents are helped by programs that send nurses, healthcare workers, social workers, or other professionals to their home to help prepare for the new baby or take care of the baby or mother. Between the time [you were / [his/her] mother was] pregnant with [SC] and up until the present day, did someone from such a program visit your home?
YES / NO / DK / RF
IF YES, GO TO K4Q35A; ELSE GO TO K4Q36
K4Q35A How many different professionals came to your home?
_______ ENTER VALUE
K4Q35B_INTRO
Parents, especially new parents, often have concerns about their children and families. Please tell me if [the professional / any of the professionals] who visited your home talked about any of the following:
[Your/[S.C.]’s mother’s) emotional well-being?
Smoking or alcohol use in your home?
How to build a close relationship with [S.C.]?
How to use toys, playtime, and story time to help [S.C.] learn, grow, and develop?
How to make sure that [S.C.] is safe and does not get hurt?
How to get the health care that (SC) needs?
Other services that might help your family, such as public assistance, transportation, or job training?
SKIP TO NEXT SECTION IF CHILD HAS NEVER BEEN DIAGNOSED WITH ASD OR DEV DELAY.
K4Q36 Earlier you told me that you had been told by a doctor or other health care provider that [SC] had (a condition / conditions) that affected [his/her] learning or development. Has [SC] ever received therapy services to meet (his/her) developmental needs, such as Early Intervention, occupational therapy, speech therapy, or behavioral therapy?
YES / NO / DK / RF
INTERVIEWER INSTRUCTION: If a parent asks which conditions are being referred to, you may read this list: [LIST]
CATI PROGRAMMER INSTRUCTION: NEW23 is only to be asked if child has been diagnosed autism/ASD and/or developmental delay. However, in list, include all conditions that had a YES to “ever told” from: ADHD, behavioral/conduct problems, autism/ASD, developmental delay, Tourette Syndrome, cerebral palsy, intellectual disability, speech or other language problems. Use number of conditions in this list to determine whether to fill “condition” or “conditions.”
K4Q37 How old was [SC] when [he/she] began receiving services?
RECORD AGE / DK / RF
K4Q38 Is [SC] currently receiving therapy services?
YES / NO / DK / RF
K5Q10 [During the past 12 months / Since (his/her) birth], did [SC] need a referral to see any doctors or receive any services?
YES / NO / DK / RF [SKIP TO K5Q20 IF NO/DK/RF]
K5Q11 Was getting referrals a big problem, a small problem, or not a problem?
BIG PROBLEM / SMALL PROBLEM / NOT A PROBLEM / DK / RF
SUM UP THE NUMBER OF SERVICES FROM SECTION 4, SUBDOMAIN 2 AND ASSIGN TO VARIABLE NUMB_SERVICES.
IF NUMB_SERVICES = 0 AND AGE ≤ 5 YEARS, THEN SKIP TO K6Q01.
IF NUMB_SERVICES = 0 AND AGE ≥ 6 YEARS, THEN SKIP TO K7Q01.
IF NUMB_SERVICES = 1, THEN SKIP TO K5Q31.
K5Q20 Does anyone help you arrange or coordinate [SC]’s care among the different doctors or services that [he/she] uses?
YES / NO / DK / RF
READ IF NECESSARY: By “arrange or coordinate,” I mean: Is there anyone who helps you make sure that [SC] 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?
READ IF NECESSARY: Anyone means anyone.
K5Q21 [During the past 12 months / Since (his/her) birth], have you felt that you could have used extra help arranging or coordinating [SC]’s care among the different health care providers or services?
YES / NO / DK / RF [SKIP TO K5Q30 IF NO/DK/RF]
K5Q22 [During the past 12 months / Since (his/her) birth], how often did you get as much help as you wanted with arranging or coordinating [SC]’s care? Would you say never, sometimes, or usually?
NEVER / SOMETIMES / USUALLY / DK / RF
K5Q30 Overall, are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied with the communication among [SC]’s doctors and other health care providers?
VERY SATISFIED / SOMEWHAT SATISFIED / SOMEWHAT DISSATISFIED /
VERY DISSATISFIED / NO COMMUNICATION NEEDED OR WANTED / DK / RF
K5Q31 Do [SC]’s doctors or other health care providers need to communicate with [his/her]
[IF AGE < 36 MONTHS, INSERT: child care providers or early intervention program?]
[IF AGE ≥ 36 MONTHS AND < 72 MONTHS, INSERT: child care providers, school, or special education program?]
[IF AGE ≥72 MONTHS AND CHILD DOES NOT HAVE SPECIAL HEALTH CARE NEEDS, INSERT: school or special education program?]
[IF AGE ≥ 72 MONTHS AND < 144 MONTHS AND CHILD DOES HAVE SPECIAL HEALTH CARE NEEDS, INSERT: school or special education program?]
[IF AGE ≥ 144 MONTHS AND CHILD DOES HAVE SPECIAL HEALTH CARE NEEDS, INSERT: school, special education program, or vocational education program?]
YES / NO / DK / RF [SKIP TO K5Q40 IF NO/DK/RF]
K5Q32 Overall, are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied with that communication?
VERY SATISFIED / SOMEWHAT SATISFIED / SOMEWHAT DISSATISFIED /
VERY DISSATISFIED / NO COMMUNICATION NEEDED OR WANTED / DK / RF
K5Q40 [During the past 12 months / Since (his/her) birth], how often did [SC]’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 / DK / RF
K5Q41 [During the past 12 months / Since (his/her) birth], how often did [SC]’s doctors and other health care providers listen carefully to you? Would you say never, sometimes, usually, or always?
NEVER / SOMETIMES / USUALLY / ALWAYS / DK / RF
K5Q42 When [SC] 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?
NEVER / SOMETIMES / USUALLY / ALWAYS / DK / RF
K5Q43 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. [During the past 12 months / Since (his/her) birth], how often did you get the specific information you needed from [SC]’s doctors and other health care providers? Would you say never, sometimes, usually, or always?
NEVER / SOMETIMES / USUALLY / ALWAYS / DK / RF
K5Q44 [During the past 12 months / Since (his/her) birth], how often did [SC]’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?
NEVER / SOMETIMES / USUALLY / ALWAYS / DK / RF
IF AGE ≤ 5 YEARS, THEN SKIP TO K6Q01.
IF AGE ≥ 6 YEARS, THEN SKIP TO K7Q01.
Questions K6Q01-K6Q09 are from the Parent’s Evaluation of Developmental Status (PEDS) child development screening test. The PEDS is protected by U.S.. and international copyright law. All rights are reserved by Frances Page Glascoe. Permission to use these items in the NSCH has been granted by Dr. Glascoe. Permission must be requested from the publisher (forepath.org, PO Box 23186, Washington, DC, 20026, www.forepath.org, support@forepath.org) before using these items for other purposes.
K6Q01 Do you have any concerns about [SC]’s learning, development, or behavior?
YES / NO / DK / RF
IF AGE < 4 MONTHS, SKIP TO K6Q10.
K6Q02_INTRO [IF K6Q01 = NO, READ: Although you told me you have no concerns, I need to ask a few specific questions about concerns that some parents may have. Please tell me if you are currently concerned a lot, a little, or not at all about the following.]
[ELSE, READ: The next section asks about specific concerns some parents may have. Please tell me if you are currently concerned a lot, a little, or not at all about the following.]
(READ IF NECESSARY: Are you concerned a lot, a little, or not at all about…)
K6Q02 How [SC] talks and makes speech sounds?
K6Q03 How [he/she] understands what you say?
K6Q04 How [he/she] uses [his/her] hands and fingers to do things?
K6Q05 How [he/she] uses [his/her] arms and legs?
K6Q06 How [he/she] behaves?
K6Q07 How [he/she] gets along with others?
IF AGE < 10 MONTHS, SKIP TO K6Q10.
K6Q08 How [he/she] is learning to do things for (himself/herself)?
IF AGE < 18 MONTHS, SKIP TO K6Q10.
K6Q09 How [he/she] is learning pre-school or school skills?
A LOT / A LITTLE / NOT AT ALL / DK / RF FOR EACH ITEM
K6Q10 IF NUMB_SERVICES = 0, THEN SKIP TO K6Q15.
[During the past 12 months / Since [SC]’s birth], did [SC]’s doctors or other health care providers ask if you have concerns about [his/her] learning, development, or behavior?
YES / NO / DK / RF
K6Q12 IF AGE_NSCH < 10 MONTHS, SKIP TO K6Q15.
Sometimes a child’s doctor or other health care provider will ask a parent to fill out a questionnaire at home or during their child’s visit. During the past 12 months, did a doctor or other health care provider have you fill out a questionnaire about specific concerns or observations you may have about [SC]’s development, communication, or social behaviors?
YES / NO / DK / RF [SKIP TO K6Q15 IF NO/DK/RF]
INTERVIEWER INSTRUCTION: If another person read the questionnaire to the parent and filled in the answers for the parent, then this question should be answered yes. But if a doctor or nurse just asked about concerns and did not fill out a questionnaire, then this question should be answered no.
IF AGE_NSCH = 24-71 MONTHS, SKIP TO K6Q14A.
K6Q13A Did this questionnaire ask about your concerns or observations about how [SC] talks or makes speech sounds?
YES / NO / DK / RF
K6Q13B Did this questionnaire ask about your concerns or observations about how [SC] interacts with you and others?
YES / NO / DK / RF [ALL SKIP TO K6Q15]
K6Q14A Did this questionnaire ask about your concerns or observations about words and phrases [SC] uses and understands?
YES / NO / DK / RF
K6Q14B Did this questionnaire ask about your concerns or observations about how [SC] behaves and gets along with you and others?
YES / NO / DK / RF
K6Q15 Does [SC] have any developmental problems for which [he/she] has a written intervention plan called an [IF AGE < 36 MONTHS, INSERT: Individualized Family Services Plan or an IFSP?; IF AGE ≥ 36 MONTHS, INSERT: Individualized Education Program or IEP?]
READ IF NECESSARY: Some young children have developmental delays or other problems for which they receive services from a program called Early Intervention Services or Special Education. Children receiving these services have a written intervention plan called an IFSP if the child is 3 or under, or an IEP if older than about 3 years. Services on an IFSP or an IEP might include things such as special instruction; speech language therapy; vision and hearing services; psychological services; health services; social work services; family counseling and support; transportation; service coordination or other services needed to support the child’s development.
YES / NO / DK / RF
K6Q20 The next questions are about child care. Does [SC] receive care for at least 10 hours per week from someone not related to (him/her)? This could be a day care center, preschool, Head Start program, nanny, au pair, or any other non-relative.
YES / NO / DK / RF
READ IF NECESSARY: Child care should be reported regardless of whether care is paid or unpaid, or provided by certified or uncertified providers. Occasional babysitting is not included.
Head Start is a federally-funded program to help young children from low-income families get ready for kindergarten and grade school. Children who participate are usually between three and five years old, but there are Head Start programs for even younger children.
K6Q27 [During the past 12 months / Since [S.C]’s birth], did you or anyone in the family have to quit a job, not take a job, or greatly change your job because of problems with child care for [SC]?
YES / NO / DK / RF
K6Q40 Was [SC] ever breastfed or fed breast milk?
YES / NO / DK / RF [SKIP TO NEXT SUBDOMAIN IF NO/DK/RF]
K6Q41 How old was [he/she] when [he/she] completely stopped breastfeeding or being fed breast milk?
RECORD AGE / STILL BREASTFEEDING / DK / RF
K6Q42 How old was [SC] when [he/she] was first fed formula?
RECORD AGE / AT BIRTH / NEVER BEEN FED FORMULA / DK / RF
K6Q43 This next question is about the first thing that [SC] was given other than breast milk or formula. Please include juice, cow’s milk, sugar water, baby food, or anything else that [SC] might have been given, even water. How old was [SC] when [he/she] was first fed anything other than breast milk or formula?
RECORD AGE / AT BIRTH / NEVER / DK / RF
IF AGE IS LESS THAN SIX MONTHS, SKIP TO NEXT SUBDOMAIN.
INTRO I am going to read a list of items that sometimes describe children. For each item, please tell me how often this was true for [SC] during the past month. Would you say never, rarely, sometimes, usually, or always?
K6Q70 [He/She] is affectionate and tender with you.
K6Q73 [He/She] bounces back quickly when things don’t go [his/her] way.
K7Q71 [He/She] shows interest and curiosity in learning new things.
K6Q72 [He/She] smiles and laughs a lot.
NEVER / RARELY / SOMETIMES / USUALLY / ALWAYS / DK / RF FOR EACH ITEM
K6Q65A On an average weekday, about how much time does [SC] usually spend in front of a TV watching TV programs, videos, or playing video games?
RECORD NUMBER OF HOURS OR MINUTES / DON’T OWN / DK / RF
K6Q65B On an average weekday, about how much time does [SC] usually spend with computers, cell phones, handheld video games, and other electronic devices?
RECORD NUMBER OF HOURS OR MINUTES / DON’T OWN / DK / RF
K6Q60 During the past week, how many days did you or other family members read to [SC]?
RECORD NUMBER OF DAYS / DK / RF
READ IF NECESSARY: Reading stories includes books with words or pictures but not books read by an audio tape, record, CD, or computer.
K6Q61 During the past week, how many days did you or other family members tell stories or sing songs to [SC]?
RECORD NUMBER OF DAYS / DK / RF
K6Q63 During the past week, how many days did [SC] play with other children [his/her] age?
RECORD NUMBER OF DAYS / DK / RF
K6Q64 During the past week, how many days did you or any family member take [SC] on any kind of outing, such as to the park, library, zoo, shopping, church, restaurants, or family gatherings?
RECORD NUMBER OF DAYS / DK / RF
K7Q01 IF CURRENT MONTH IS JUNE, JULY, OR AUGUST, ASK: “During the last school year, what kind of school was [SC] enrolled in? Is it a public school, private school, or home-school?”
ELSE ASK: “What kind of school is [SC] currently enrolled in? Is it a public school, private school, or home-school?
(1) PUBLIC [SKIP TO K7Q02]
(2) PRIVATE [SKIP TO K7Q02]
(3) HOME-SCHOOLED [SKIP TO K7Q05]
(4) [SC] IS NOT ENROLLED IN SCHOOL. [SKIP TO K7Q01F]
(6) DON’T KNOW [SKIP TO K7Q02]
(7) REFUSED [SKIP TO K7Q02]
INTERVIEWER INSTRUCTION: If the child was enrolled in more than one type of school during the current or last school year, ask the type of school that the child has most recently attended.
K7Q01F At any time during the past 12 months, was [SC] enrolled in a public school, a private school, or home school?
YES / NO / DK / RF [SKIP TO K7Q05 IF NO/DK/RF]
K7Q02 During the past 12 months, that is since [FILL: CURRENT MONTH, 1 YEAR AGO], about how many days did [SC] miss school because of illness or injury?
RECORD NUMBER OF DAYS / DK / RF
INCLUDE ANSWER CHOICES FOR ENTIRE SCHOOL YEAR (180), HOME SCHOOLED (555), OR DID NOT GO TO SCHOOL (666). INCLUDE QUESTION CONFIRMING ANSWER IF NUMBER OF DAYS IS GREATER THAN 20.
SKIP TO K7Q05 IF CHILD WAS HOME SCHOOLED OR DID NOT GO TO SCHOOL.
K7Q04 During the past 12 months, how many times has [SC]’s school contacted you or another adult in your household about any problems [he/she] is having with school?
RECORD NUMBER OF TIMES / DK / RF
READ IF NECESSARY: This includes school related problems but not health related problems.
K7Q05 Since starting kindergarten, has [he/she] repeated any grades?
YES / NO / DK / RF [SKIP TO K7Q11 IF NO/DK/RF]
K7Q05_A Which grade or grades did [he/she] repeat? [Mark all that apply.]
RECORD INDIVIDUAL GRADES (K-12) / DK / RF
K7Q11 Does [SC] have a health problem, condition, or disability for which [he/she] has a written intervention plan called an Individualized Education Program or IEP?
READ IF NECESSARY: Some children have difficulty in school because of a health problem, condition, or a disability. These children may receive services from a program called Special Education and have a written intervention plan called an Individualized Education Program or IEP. Services on an IEP might include things such as special instruction; speech language therapy; vision and hearing services; psychological services; health services; social work services; family counseling and support; transportation; or other services needed to support the child’s educational performance.
YES / NO / DK / RF
K7Q30 During the past 12 months, was [SC] on a sports team or did [he/she] take sports lessons after school or on weekends?
READ IF NECESSARY: Include any teams run by your child’s school or community groups.
YES / NO / DK / RF
K7Q31 During the past 12 months, did [he/she] participate in any clubs or organizations after school or on weekends?
READ IF NECESSARY: Examples of clubs or organizations are scouts, arts, religious groups, and boys/girls clubs.
YES / NO / DK / RF
K7Q32 During the past 12 months, did [he/she] participate in any other organized activities or lessons, such as music, dance, language, or other arts?
READ IF NECESSARY: This question can include organized lessons in music, dance, foreign languages, performing arts, computers, etc.
YES / NO / DK / RF
SKIP TO K7Q34 IF K7Q30, K7Q31, AND K7Q32 ARE ALL NO/DK/RF.
K7Q33 During the past 12 months, how often did you attend events or activities that [SC] participated in? Would you say never, sometimes, usually or always?
NEVER / SOMETIMES / USUALLY / ALWAYS / DK / RF
K7Q34 Regarding [SC]’s friends, would you say that you have met all of [his/her] friends, most of [his/her] friends, some of [his/her] friends, or none of [his/her] friends?
ALL / MOST / SOME / NONE / CHILD HAS NO FRIENDS / DK / RF
IF AGE < 144 MONTHS (12 YEARS), SKIP TO K7Q40.
K7Q37 During the past 12 months, how often has [SC] been involved in any type of community service or volunteer work at school, church, or in the community? Would you say once a week or more, a few times a month, a few times a year, or never?
ONCE A WEEK OR MORE / FEW TIMES A MONTH / FEW TIMES A YEAR / NEVER / DK / RF
K7Q38 During the past week, did [SC] earn money from any work, including regular jobs as well as babysitting, cutting grass, or other occasional work?
YES / NO / DK / RF [SKIP TO K7Q40 IF NO/DK/RF]
READ IF NECESSARY: Do not include household chores.
K7Q39 During the past week, how many hours did [SC] work for pay?
RECORD NUMBER OF HOURS / DK / RF
INCLUDE CODE FOR LESS THAN ONE HOUR BUT MORE THAN ZERO.
K7Q40 During the past week, on how many nights did [SC] get enough sleep for a child [his/her] age?
RECORD NUMBER OF NIGHTS / DK / RK
READ IF NECESSARY: “Enough sleep” is whatever you define it as for this child.
K7Q41 During the past week, on how many days did [S.C.] exercise, play a sport, or participate in physical activity for at least 20 minutes that made [him/her] sweat and breathe hard?
RECORD NUMBER OF DAYS / DK / RK
READ IF NECESSARY: Include active sports such as baseball, softball, basketball, swimming, soccer, tennis, or football; riding a bike or rollerskating; walking or jogging; jumping rope; gymnastics; and active dance such as ballet.
K7Q50 On an average weekday, about how much time does [he/she] usually spend reading for pleasure?
RECORD NUMBER OF HOURS OR MINUTES / DK / RK
INCLUDE ANSWER CHOICE FOR “CHILD CAN’T READ”
READ IF NECESSARY: Time spent reading includes the time a child spends reading to themselves or being read to by another person.
K7Q60A On an average weekday, about how much time does [SC] usually spend in front of a TV watching TV programs, videos, or playing video games?
RECORD NUMBER OF HOURS OR MINUTES / DK / RK
INCLUDE ANSWER CHOICE FOR “DON’T OWN.”
K7Q60B On an average weekday, about how much time does [SC] usually spend with computers, cell phones, handheld video games, and other electronic devices, doing things other than schoolwork?
RECORD NUMBER OF HOURS OR MINUTES / DK / RK
INCLUDE ANSWER CHOICE FOR “DON’T OWN.”
SKIP TO NEXT SUBDOMAIN IF FAMILY DOES NOT OWN ELECTRONIC EQUIPMENT (K7Q60A AND K7Q60B BOTH ARE “DON’T OWN.”)
K7Q61 Do you monitor the content of what [he/she] watches on TV, plays on the computer, or does on electronic devices?
READ IF RESPONDENT ASKS WHAT “MONITOR” MEANS: We want to know if you check or pre-screen these media for topics you might not approve of, such as violence, drugs or alcohol, fighting, guns, or sexual content.
INTERVIEWER INSTRUCTION: If a respondent states that he/she uses these media together with the child (such as watching TV shows or movies together) to explain the content to the child, code this as a “yes” response.
YES / NO / DK / RF
K7Q61A Do you limit the amount of time [he/she] spends watching TV, playing on the computer, or using electronic devices?
YES / NO / DK / RF
K7Q62 Does [he/she] have a TV, computer, or access to electronic devices in [his/her] bedroom?
YES / NO / DK / RF
K7Q70_INTRO I am going to read a list of items that sometimes describe children. For each item, please tell me how often this was true for [SC] during the past month. Would you say never, rarely, sometimes, usually, or always?
K7Q70 [He/She] argues too much.
K7Q71 [He/She] bullies or is cruel or mean to others.
K7Q79 [He/She] is unhappy, sad, or depressed.
NEVER / RARELY / SOMETIMES / USUALLY / ALWAYS / DK / RF FOR EACH ITEM
K7Q84 [He/She] finishes the tasks [he/she] starts and follows through with what [he/she] says [he’ll/she’ll] do.
K7Q85 [He/She] stays calm and in control when faced with a challenge.
K7Q86 [He/She] shows interest and curiosity in learning new things.
K7Q82 [He/She] cares about doing well in school.
K7Q83 [He/She] does all required homework.
NEVER / RARELY / SOMETIMES / USUALLY / ALWAYS / DK / RF FOR EACH ITEM
K8Q12 About how often does [SC] attend a religious service?
RECORD FREQUENCY (NUMBER OF TIMES PER TIME PERIOD) / DK /RF
K8Q11 During the past week, on how many days did all the family members who live in the household eat a meal together?
RECORD NUMBER OF DAYS / DK /RF
IF AGE < 72 MONTHS (6 YEARS), SKIP TO K8Q30.
K8Q21 How well can you and [SC] share ideas or talk about things that really matter? Would you say very well, somewhat well, not very well, or not very well at all?
VERY WELL / SOMEWHAT WELL / NOT VERY WELL / NOT VERY WELL AT ALL / DK / RF
K8Q30 IF RESPONDENT IS MOTHER/FATHER, FILL “parenthood”. ELSE FILL “raising children”.
In general, how well do you feel you are coping with the day to day demands of [parenthood / raising children]? Would you say that you are coping very well, somewhat well, not very well, or not well at all?
VERY WELL / SOMEWHAT WELL / NOT VERY WELL / NOT VERY WELL AT ALL / DK / RK
K8Q31 During the past month, how often have you felt [SC] is much harder to care for than most children [his/her] age? Would you say never, rarely, sometimes, usually, or always?
NEVER / RARELY / SOMETIMES / USUALLY / ALWAYS / DK / RF
K8Q32 During the past month, how often have you felt [he/she] does things that really bother you a lot?
NEVER / RARELY / SOMETIMES / USUALLY / ALWAYS / DK / RF
K8Q34 During the past month, how often have you felt angry with [him/her]?
NEVER / RARELY / SOMETIMES / USUALLY / ALWAYS / DK / RF
K8Q35 IF RESPONDENT IS MOTHER/FATHER, FILL “parenthood”. ELSE FILL “raising children”.
Is there someone that you can turn to for day-to-day emotional help with [parenthood/raising children]?
YES / NO / DK / RF
READ IF NECESSARY: This can be any person, including your spouse.
K9Q00 Including the adults and all the children, how many people live in this household?
RECORD NUMBER OF PEOPLE.
[Answer must be greater than the number of children to proceed.]
INTERVIEWER INSTRUCTION: Each person in the household must be a current resident of the household. A current residence is defined as a place where the person is staying for more than two months at the time of the survey contact. If a person has no place where he or she usually stays, the person should be considered a current resident regardless of the length of the current stay.
Persons away from their residence for two months or less, whether traveling or in the hospital, are considered “in residence.”
Persons away from their residence for more than two months are considered “not in residence” unless the person is away at school (i.e., boarding school, military academy, prep school, etc.).
Children who only live part-time in the household because of custody issues should be included if they are staying there when contact with the household is made.
CP_K9Q10A IF K1Q02=77, 99 GO TO C10Q02A
ELSE GO TO K9Q10A
K9Q10A I have that you are [S.C.]'s [FILL FROM K1Q02]. Is that correct?
(01) YES [GO TO CP_C10Q02A]
(02) NO [GO TO CP_C10Q02A]
(77) DON'T KNOW [GO TO CP_C10Q02A]
(99) REFUSED [GO TO CP_C10Q02A]
CP_C10Q02A IF K9Q10A=02, 77, 99 THEN GO TO C10Q02A
IF K9Q10A=01 and K1Q02=01, 02 THEN GO TO C10Q02A
IF K9Q10A=01 and K1Q02=11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26 THEN GO TO C10Q02B and fill C10Q02A with C10Q02A=K1Q02 value
C10Q02A IF K1Q02=77, 99 OR K9Q10A=02, 77, 99 THEN DISPLAY:
What is your relationship to [S.C.]?
IF R RESPONDS “Mother” or “Father,” YOU MUST PROBE:: Are you [S.C.]’s biological, step, foster, or adoptive mother/father?
IF R RESPONDS “Parent's Partner,” PROBE IF NOT SURE: Are you male or female?
IF K9Q10A=01 AND K1Q02=01 THEN DISPLAY:
Are you [S.C.]’s biological, adoptive, step, or foster mother?
IF K9Q10A=01 AND K1Q02=02 THEN DISPLAY:
Are you [S.C.]’s biological, adoptive, step, or foster father?
PARENT
(1) BIOLOGICAL MOTHER
(2) STEP MOTHER
(3) FOSTER MOTHER
(4) ADOPTIVE MOTHER
(5) MOTHER, but TYPE REFUSED
(6) BIOLOGICAL FATHER
(7) STEP FATHER
(8) FOSTER FATHER
(9) ADOPTIVE FATHER
(10) FATHER, but TYPE REFUSED
OLDER RELATIVES OR GUARDIANS
(11) GRANDMOTHER
(12) GRANDFATHER
(13) AUNT
(14) UNCLE
(15) FEMALE GUARDIAN
(16) MALE GUARDIAN
OTHER RELATIVES
(17) SISTER (BIOLOGICAL, STEP, FOSTER, HALF, ADOPTIVE)
(18) BROTHER (BIOLOGICAL, STEP, FOSTER, HALF, ADOPTIVE)
(19) COUSIN
(20) IN-LAW OF ANY TYPE
(22) OTHER RELATIVE / FAMILY MEMBER
OTHER NON-RELATIVES
(23) PARENT’S BOYFRIEND / MALE PARTNER
(24) PARENT’S GIRLFRIEND / FEMALE PARTNER
(25) PARENT’S PARTNER, but SEX REFUSED
(26) OTHER NON-RELATIVE OR FRIEND
(77) DON’T KNOW
(99) REFUSED
C10Q02B IF K9Q00 = DK/RF, THEN READ:
For the other people that live in your household with you and [SC], what is their relationship to [SC]? [Mark all that apply]
IF
K9Q00 > 2, THEN READ:
In
addition to you and [SC], I have that [FILL: K9Q00 - 2] [other
person lives/other people live] in your household. What is their
relationship to [SC]? [Mark
all that apply]
IF R RESPONDS “Mother” or “Father,” YOU MUST PROBE: Is that [SC]’s biological, step, foster, or adoptive mother/father?
IF R RESPONDS “Partner,” PROBE: Is the partner male or female?
PARENT
(01) BIOLOGICAL MOTHER (06) BIOLOGICAL FATHER
(02) STEP MOTHER (07) STEP FATHER
(03) FOSTER MOTHER (08) FOSTER FATHER
(04) ADOPTIVE MOTHER (09) ADOPTIVE FATHER
(05) MOTHER, but TYPE REFUSED (10) FATHER, but TYPE REFUSED
OLDER RELATIVES OR GUARDIANS
(11) GRANDMOTHER (14) UNCLE
(12) GRANDFATHER (15) FEMALE GUARDIAN
(13) AUNT (16) MALE GUARDIAN
OTHER RELATIVES
(17) SISTER
(18) BROTHER
(19) COUSIN
(20) IN-LAW OF ANY TYPE
(21) [SC]’S CHILD, SON, OR DAUGHTER
(22) OTHER RELATIVE / FAMILY MEMBER
OTHER NON-RELATIVES
(23) PARENT’S BOYFRIEND / MALE PARTNER
(24) PARENT’S GIRLFRIEND / FEMALE PARTNER
(25) PARENT’S PARTNER, but SEX REFUSED
(26) OTHER NON-RELATIVE OR FRIEND
(77) DON’T KNOW
(99) REFUSED
C10Q02B_
CONF I am now going to list all the people that live in your household.
I have that [LIST OF RELATIONSHIPS ROSTERED] live in this household with [SC].
Is this a correct list of everyone living in your household?
(1) CONFIRMED - THIS LIST IS CORRECT
(2) NOT CORRECT - RETURN TO K9Q00 AND START AGAIN
C10Q02B_ Earlier you told me that there are [VALUE FROM K9Q00] people living in your household.
WARNING However, based on the relationships you just gave, I have [COUNT OF RELATIONSHIPS INCLUDING R & SC] people living in your household. Let's re-confirm your answers.
(1) RETURN TO RE-CONFIRM ANSWERS [GO TO K9Q00]
USE RARELY:
(2) ISSUE CANNOT BE RESOLVED - CONTINUE ON [GO TO C10Q02C]
SKIP TO K9Q16 IF ANY BIOLOGICAL MOTHER OR BIOLOGICAL FATHER IN HOUSEHOLD.
SKIP TO K9Q16 IF RESPONDENT IS ADOPTIVE MOTHER OR ADOPTIVE FATHER.
C10Q02C Have you legally adopted [SC]?
YES / NO / DK / RF
K9Q16 SKIP TO C10Q14 IF NO MOTHER-TYPE IN HOUSEHOLD
IF K1Q02 = 1, FILL “are you”. ELSE, FILL “is [SC]’s [MOTHER TYPE]”
How old [are you / is [SC]’s [MOTHER TYPE]]?
RECORD AGE IN YEARS / DK / RF
C10Q14 What is the age of the oldest adult living in the household?
RECORD AGE IN YEARS / DK / RF
IF HOUSEHOLD INCLUDES A MOTHER AND A FATHER, ASK C10Q10. ELSE, SKIP TO C10Q11A.
C10Q10 IF THE RESPONDENT IS THE MOTHER, THEN READ: Are you and [SC]’s [FATHER TYPE] currently married, separated, divorced, or never married?
IF THE RESPONDENT IS THE FATHER, THEN READ: Are you and [SC]’s [MOTHER TYPE] currently married, separated, divorced, or never married?
IF THE RESPONDENT IS NEITHER THE MOTHER NOR THE FATHER, THEN READ: Are [SC]’s [MOTHER TYPE] and [FATHER TYPE] currently married, separated, divorced, or never married?
MARRIED / SEPARATED / DIVORCED / NEVER MARRIED / DK / RF
SKIP TO K9Q18 IF MARRIED.
C10Q10A IF THE RESPONDENT IS THE MOTHER, THEN READ: Are you and [SC]’s [FATHER TYPE] currently living together as partners?
IF THE RESPONDENT IS THE FATHER, THEN READ: Are you and [SC]’s [MOTHER TYPE] currently living together as partners?
IF THE RESPONDENT IS NEITHER THE MOTHER NOR THE FATHER, THEN READ: Are [SC]’s [MOTHER TYPE] and [FATHER TYPE] currently living together as partners?
YES / NO / DK / RF [ALL SKIP TO K9Q18]
C10Q11A IF HOUSEHOLD INCLUDES A MOTHER BUT NOT A FATHER, ASK C10Q11A. ELSE, SKIP TO C10Q12A.
IF THE RESPONDENT IS THE MOTHER, THEN READ: Are you currently married, separated, divorced, widowed, or never married?
IF THE RESPONDENT IS NOT THE MOTHER, THEN READ: Is [SC]’s [MOTHER TYPE] currently married, separated, divorced, widowed, or never married?
MARRIED / SEPARATED / DIVORCED / WIDOWED / NEVER MARRIED / DK / RF
SKIP TO C10Q11C IF NOT MARRIED.
SKIP TO K9Q18 IF MOTHER TYPE IS FOSTER OR ADOPTIVE
C10Q11B IF RESPONDENT IS THE MOTHER (C10Q02A = 1, 2, or 5), FILL “Are you”; ELSE FILL “Is [SC]’S [MOTHER TYPE]”.
(Are you / Is [SC]’s [MOTHER TYPE]) married to [SC]’s biological father?
YES / NO / DK / RF [ALL SKIP TO K9Q18]
C10Q11C IF THE RESPONDENT IS THE MOTHER (C10Q02A = 1-5), THEN READ: Are you currently living with anyone as partners?
IF THE RESPONDENT IS NOT THE MOTHER, THEN READ: Is [SC]’s [MOTHER TYPE] currently living with anyone as partners?
YES / NO / DK / RF [ALL SKIP TO K9Q18]
C10Q12A IF HOUSEHOLD INCLUDES A FATHER BUT NOT A MOTHER, ASK C10Q12A. ELSE, SKIP TO C10Q13A.
IF THE RESPONDENT IS THE FATHER (C10Q02A= 6-10), THEN READ: Are you currently married, separated, divorced, widowed, or never married?
IF THE RESPONDENT IS NOT THE FATHER, THEN READ: Is [SC]’s [FATHER TYPE] currently married, separated, divorced, widowed, or never married?
MARRIED / SEPARATED / DIVORCED / WIDOWED / NEVER MARRIED / DK / RF
SKIP TO C10Q12C IF NOT MARRIED.
SKIP TO K9Q18 IF FATHER TYPE IS FOSTER OR ADOPTIVE
C10Q12B IF RESPONDENT IS THE FATHER (C10Q02A = 6, 7, or 10) FILL “Are you”; ELSE FILL “Is [SC]’s [FATHER TYPE]”.
(Are you / Is [SC]’s [FATHER TYPE]) married to [SC]’s biological mother?
YES / NO / DK / RF [ALL SKIP TO K9Q18]
C10Q12C IF THE RESPONDENT IS THE FATHER (C10Q02A= 6-10), THEN READ: Are you currently living with anyone as partners?
IF THE RESPONDENT IS NOT THE FATHER, THEN READ: Is [SC]’s [FATHER TYPE] currently living with anyone as partners?
YES / NO / DK / RF [ALL SKIP TO K9Q18]
C10Q13A Are you currently married, separated, divorced, widowed, or never married?
MARRIED / SEPARATED / DIVORCED / WIDOWED / NEVER MARRIED / DK / RF
SKIP TO C10Q13C IF NOT MARRIED.
C10Q13B Does your spouse currently live in the household with [SC]?
YES / NO / DK / RF [ALL SKIP TO K9Q18]
C10Q13C Are you currently living with a partner?
YES / NO / DK / RF
K9Q19 CATI INSTRUCTION (K9Q19): IF HOUSEHOLD INCLUDES A MOTHER OR FATHER OF ANY TYPE, SKIP TO K9Q18. ELSE, IF HOUSEHOLD INCLUDES NEITHER A MOTHER NOR A FATHER OF ANY TYPE, BUT INCLUDES ANY OLDER RELATIVE/GUARDIAN TYPES, THEN ASK K9Q19. ELSE, SKIP TO K9Q18.
Is [S.C.] currently in foster care? That is, are you or another adult in the household acting as a foster parent to [S.C.] under the supervision of a state or county child welfare agency?
(1) YES
(2) NO
(77) DON’T KNOW
(99) REFUSED
K9Q18 SKIP TO NEXT SUBDOMAIN IF RESPONDENT DOES NOT HAVE A SPOUSE OR PARTNER
The next question is about your relationship with [TEXTFILL]. Would you say that your relationship is completely happy, very happy, fairly happy, or not too happy?
COMPLETELY HAPPY / VERY HAPPY / FAIRLY HAPPY / NOT TOO HAPPY / DK / RF
K9Q20 SKIP TO K9Q21 IF NO MOTHER-TYPE IN HOUSEHOLD
IF K1Q02 = 1, FILL “your”. ELSE, FILL [IF C10Q02B = 1, then "mother", ELSE IF C10Q02B = 2, then "step mother," ELSEIF C10Q02B = 3, then "foster mother," ELSEIF C10Q02B =4, then "adoptive mother"].
Would you say that, in general, ([SC]’s [MOTHER TYPE]/your) health is excellent, very good, good, fair, or poor?
EXCELLENT / VERY GOOD / GOOD / FAIR / POOR / DK / RF
K9Q21 SKIP TO K9Q22 IF NO FATHER-TYPE IN HOUSEHOLD
IF K1Q02 = 2, FILL “your”. ELSE, FILL [IF C10Q02B = 5, then "father", ELSEIF C10Q02B = 6, then "step father," ELSEIF C10Q02B = 7, then "foster father," ELSEIF C10Q02B =8, then "adoptive father"].
Would you say that, in general, ([SC]’s [FATHER TYPE]/your) health is excellent, very good, good, fair, or poor?
EXCELLENT / VERY GOOD / GOOD / FAIR / POOR / DK / RF
K9Q22 SKIP TO K9Q23 IF RESPONDENT IS MOTHER OR FATHER
Would you say that, in general, your health is excellent, very good, good, fair, or poor?
EXCELLENT / VERY GOOD / GOOD / FAIR / POOR / DK / RF
K9Q23 SKIP TO K9Q24 IF NO MOTHER-TYPE IN HOUSEHOLD
IF K1Q02 = 01, FILL “your”. ELSE, FILL [MOTHER TYPE].
Would you say that, in general, ([SC]’s [MOTHER TYPE]/your) mental and emotional health is excellent, very good, good, fair, or poor?
EXCELLENT / VERY GOOD / GOOD / FAIR / POOR / DK / RF
K9Q24 SKIP TO K9Q25 IF NO FATHER-TYPE IN HOUSEHOLD
IF K1Q02 = 2, FILL “your”. ELSE, FILL [FATHER TYPE].
Would you say that, in general, ([SC]’s [FATHER TYPE]/your) mental and emotional health is excellent, very good, good, fair, or poor?
EXCELLENT / VERY GOOD / GOOD / FAIR / POOR / DK / RF
K9Q25 SKIP TO K9Q40 IF RESPONDENT IS MOTHER OR FATHER
Would you say that, in general, your mental and emotional health is excellent, very good, good, fair, or poor?
EXCELLENT / VERY GOOD / GOOD / FAIR / POOR / DK / RF
K9Q40 Does anyone living in your household use cigarettes, cigars, or pipe tobacco?
YES / NO / DK / RF [SKIP TO NEXT SUBDOMAIN IF NO/DK/RF]
K9Q41 Does anyone smoke inside [SC]’s home?
YES / NO / DK / RF
INTRO_ACE I’d like to ask you some questions about events that may have happened during [SC]’s life. These things that can happen to any family, but some people may feel uncomfortable with these questions. You can ask me to skip any question you do not want to answer.
ACE1 Since [SC] was born, how often has it been very hard to get by on your family’s income – hard to cover the basics like food or housing? Would you say very often, somewhat often, rarely, or never?
VERY OFTEN / SOMEWHAT OFTEN / RARELY / NEVER / DK / RF
ACE3 Did [SC] ever live with a parent or guardian who got divorced or separated after [SC] was born?
ACE4 Did [SC] ever live with a parent or guardian who died?
ACE5 Did [SC] ever live with a parent or guardian who served time in jail or prison after [SC] was born?
ACE6 Did [SC] ever see or hear any parents or adults in [his/her] home slap, hit, kick, punch, or beat each other up?
ACE7 Was [SC] ever the victim of violence or witness any violence in [his/her] neighborhood?
ACE8 Did [SC] ever live with anyone who was mentally ill or suicidal, or severely depressed for more than a couple of weeks?
ACE9 Did [SC] ever live with anyone who had a problem with alcohol or drugs?
YES / NO / DK / RF FOR EACH ITEM
ACE10 Was [SC] ever treated or judged unfairly because of [his/her] race or ethnic group?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO NEXT SUBDOMAIN]
ACE11 During the past year, how often was [SC] treated or judged unfairly? Would you say very often, somewhat often, rarely, or never?
VERY OFTEN / SOMEWHAT OFTEN / RARELY / NEVER / DK / RF
SKIP TO NEXT SECTION IF AGE < 6 YEARS.
K9Q96 Other than adults in your home (add “or (SC)’s parents” if a nonresident parent is identified), is there at least one other adult in (SC’s) school, neighborhood, or community who knows (SC) well and who (he/she) can rely on for advice or guidance?
YES / NO / DK / RF
INTRO Now, I have a few questions about your neighborhood and community. Please tell me if the following places and things are available to children in your neighborhood, even if [SC] does not actually use them.
K10Q11 Sidewalks or walking paths?
K10Q12 A park or playground area?
K10Q13 A recreation center, community center, or boys’ or girls’ club?
K10Q14 A library or bookmobile?
YES / NO / DK / RF FOR EACH ITEM
K10Q20 In your neighborhood, is there litter or garbage on the street or sidewalk?
K10Q22 How about poorly kept or rundown housing?
K10Q23 How about vandalism such as broken windows or graffiti?
YES / NO / DK / RF FOR EACH ITEM
INTRO Now, for the next questions, I am going to ask how much you agree or disagree with each of these statements about your neighborhood or community.
K10Q30 “People in this neighborhood help each other out.” Would you say that you definitely agree, somewhat agree, somewhat disagree, or definitely disagree with this statement?
K10Q31 “We watch out for each other’s children in this neighborhood.”
K10Q32 “There are people I can count on in this neighborhood.”
K10Q34 “If my child were outside playing and got hurt or scared, there are adults nearby who I trust to help my child.”
DEFINITELY AGREE / SOMEWHAT AGREE / SOMEWHAT DISAGREE / DEFINITELY DISAGREE / DK / RF FOR EACH ITEM
K10Q40 How often do you feel [SC] is safe in your community or neighborhood? Would you say never, sometimes, usually, or always?
NEVER / SOMETIMES / USUALLY / ALWAYS / DK / RF
SKIP TO K11Q01_INTRO IF AGE < 6 YEARS OR NOT ENROLLED OR HOME-SCHOOLED
K10Q41 How often do you feel [he/she] is safe at school?
NEVER / SOMETIMES / USUALLY / ALWAYS / DK / RF
K11Q01_INTRO
Now I have a few more general questions about [SC] and your household.
K11Q01 Is [SC] of Hispanic, Latino or Spanish origin?
YES / NO / DK / RF
READ IF NECESSARY: Hispanic or Latino includes Mexican, Mexican-American, Central American, South American or Puerto Rican, Cuban, or Other Spanish-Caribbean.
K11Q02EX Now, I'm going to read a list of categories. Please choose one or more of the following categories to describe [SC]’s race. Is [SC] White, Black or African American, American Indian, Alaska Native, Asian, or Native Hawaiian or other Pacific Islander? [Mark all that apply]
(01) WHITE / CAUCASIAN
(02) BLACK/AFRICAN-AMERICAN
(03) AMERICAN INDIAN / NATIVE AMERICAN
(04) ALASKA NATIVE
(05) ASIAN
(06) NATIVE HAWAIIAN
(07) PACIFIC ISLANDER
(08) OTHER [RECORD VERBATIM RESPONSE]
(66) DON’T KNOW
(77) REFUSED
INTERVIEWER INSTRUCTION: 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.
SKIP TO K11Q20 IF CHILD IS NOT AMERICAN INDIAN OR ALASKA NATIVE.
K11Q03 At any time during the past 12 months, did [SC] receive services from any Indian Health Service hospital or clinic?
YES / NO / DK / RF
K11Q20 SKIP TO K11Q21 IF NO MOTHER-TYPE IN HOUSEHOLD
IF RESPONDENT IS THE MOTHER, FILL “you have”. ELSE, FILL “[SC]’s [MOTHER TYPE] has”
What is the highest grade or year of school [you have / [SC]’s [MOTHER TYPE] has] completed?
(1)
8th GRADE OR LESS
(2)
9th-12th GRADE NO DIPLOMA
(3)
HIGH SCHOOL GRADUATE OR GED COMPLETED
(4)
COMPLETED A VOCATIONAL, TRADE, OR BUSINESS SCHOOL PROGRAM
(5)
SOME COLLEGE CREDIT BUT NO DEGREE
(6)
ASSOCIATE DEGREE (AA, AS)
(7)
BACHELOR’S DEGREE (BA, BS, AB)
(8)
MASTER’S DEGREE (MA, MS, MSW, MBA)
(9)
DOCTORATE (PhD, EdD) or PROFESSIONAL DEGREE (MD, DDS, DVM, JD)
(96) DON’T KNOW
(97)
REFUSED
K11Q21 SKIP TO K11Q22 IF NO FATHER-TYPE IN HOUSEHOLD
IF K11Q20 NOT BLANK AND K1Q02 = 2, ASK: “And how about you?”
IF K11Q20 NOT BLANK AND K1Q02 NE (2), ASK: “And how about [SC]’s [FATHER TYPE]?”
IF K11Q20 IS BLANK AND K1Q02 = 2, ASK: “What is the highest grade or year of school you have completed?”
IF K11Q20 IS BLANK AND K1Q02 NE (2), ASK: “What is the highest grade or year of school [SC]’s [FATHER TYPE] has completed?”
USE SAME ANSWER CHOICES AS K11Q20
K11Q22 SKIP TO K11Q23 IF RESPONDENT IS MOTHER OR FATHER
IF K11Q20 OR K11Q21 ARE NOT BLANK, ASK: “And how about you?”
IF K11Q20 AND K11Q21 ARE BLANK, ASK: “What is the highest grade or year of school you have completed?”
USE SAME ANSWER CHOICES AS K11Q20
K11Q22A Thinking back to who you lived with when you were about 13 years old, what was the highest grade or year of school completed by your mother, father, or main guardian? If you lived with more than one parent or guardian, please tell me about the one who had the most education.
USE SAME ANSWER CHOICES AS K11Q20
K11Q30 SKIP TO K11Q31 IF NO MOTHER-TYPE IN HOUSEHOLD
IF K1Q02 = 1, FILL “you have”. ELSE, FILL “[SC]’s [MOTHER TYPE] has”
[Were you / Was [SC]’s [MOTHER TYPE]] born in the United States?
YES / NO / DK / RF
K11Q31 SKIP TO K11Q32 IF NO FATHER-TYPE IN HOUSEHOLD
IF K11Q30 NOT BLANK AND K1Q02 = 2, ASK: “And how about you?”
IF K11Q30 NOT BLANK AND K1Q02 NE (2), ASK: “And how about [SC]’s [FATHER TYPE]?”
IF K11Q30 IS BLANK AND K1Q02 = 2, ASK: “Were you born in the United States?”
IF K11Q30 IS BLANK AND K1Q02 NE (2), ASK: “Was [SC]’s [FATHER TYPE] born in the United States?”
YES / NO / DK / RF
K11Q32 SKIP TO K11Q33 IF RESPONDENT IS MOTHER OR FATHER
IF K11Q30 OR K11Q31 ARE NOT BLANK, ASK: “And how about you?”
IF K11Q30 AND K11Q31 ARE BLANK, ASK: “Were you born in the United States?”
YES / NO / DK / RF
K11Q33 And how about [SC]?
YES / NO / DK / RF
K11Q34A SKIP TO K11Q35A IF NO MOTHER-TYPE IN HOUSEHOLD
SKIP TO K11Q35A IF MOTHER-TYPE BORN IN THE US
IF K1Q02 = 01, FILL “you have”. ELSE, FILL “[SC]’s [MOTHER TYPE] has”
How long [have you / has [SC]’s [MOTHER TYPE]] been in the United States?
RECORD LENGTH OF TIME IN DAYS OR WEEKS OR MONTHS OR YEARS / DK / RF
K11Q35A SKIP TO K11Q36A IF NO FATHER-TYPE IN HOUSEHOLD
SKIP TO K11Q36A IF FATHER-TYPE BORN IN THE US
IF K11Q34A NOT BLANK AND K1Q02 = 2, ASK: “And how about you?”
IF K11Q34A NOT BLANK AND K1Q02 NE (2), ASK: “And how about [SC]’s [FATHER TYPE]?”
IF K11Q34A IS BLANK AND K1Q02 = 2, ASK: “How long have you been in the United States?”
IF K11Q34A IS BLANK AND K1Q02 NE (2), ASK: “How long has [SC]’s [FATHER TYPE] been in the United States?”
RECORD LENGTH OF TIME IN DAYS OR WEEKS OR MONTHS OR YEARS / DK / RF
K11Q36A SKIP TO K11Q37A IF RESPONDENT IS MOTHER OR FATHER
SKIP TO K11Q37A IF RESPONDENT BORN IN THE US
IF K11Q34A OR K11Q35A ARE NOT BLANK, ASK: “And how about you?”
IF K11Q34A AND K11Q35A ARE BLANK, ASK: “How long have you been in the United States?”
RECORD LENGTH OF TIME IN DAYS OR WEEKS OR MONTHS OR YEARS / DK / RF
K11Q37A SKIP TO K11Q40 IF CHILD BORN IN THE US
IF K11Q34A, K11Q35A, OR K11Q36A ARE NOT BLANK, ASK: “And how about [SC]?”
IF K11Q34A, K11Q35A, AND K11Q36A ARE BLANK, ASK: “How long has [SC] been in the United States?”
RECORD LENGTH OF TIME IN DAYS OR WEEKS OR MONTHS OR YEARS / DK / RF
K11Q38 IF ANY BIOLOGICAL MOTHER OR BIOLOGICAL FATHER IN HOUSEHOLD, SKIP TO K11Q43. IF NO BIOLOGICAL PARENT IN HOUSEHOLD AND IF ANY ADOPTIVE PARENT OR GUARDIAN IN HOUSEHOLD, ASK K11Q38. ELSE, SKIP TO K11Q43.
Was [SC] adopted from another country?
YES / NO / DK / RF [SKIP TO K11Q41 IF YES]
K11Q40 IF ANY BIOLOGICAL MOTHER OR BIOLOGICAL FATHER IN HOUSEHOLD, SKIP TO K11Q43. IF NO BIOLOGICAL PARENT IN HOUSEHOLD AND IF ANY ADOPTIVE PARENT OR GUARDIAN IN HOUSEHOLD, ASK K11Q40. ELSE, SKIP TO K11Q43.
Prior to being adopted, was [SC] in the legal custody of a state or county child welfare agency in the United States? That is, was [SC] in the U.S. foster care system?
YES / NO / DK / RF
K11Q41 Has [SC]’s adoption been finalized?
YES / NO / DK / RF
K11Q43 [IF CHILD WAS ADOPTED, INSERT: Since [he/she] was adopted,]
How many times has [SC] ever moved to a new address?
RECORD NUMBER OF MOVES / DK / RF
READ IF NECESSARY: Please include any and all times a child has changed their primary residence. Do not include temporary changes in residence such as a child visiting another residence during summer vacation or other breaks in the school year.
K11Q50 Was anyone in the household employed at least 50 weeks out of the past 52 weeks?
YES / NO / DK / RF
C10Q41 Do you own or rent your home?
(1) OWNED OR BEING BOUGHT
(2) RENTED
(3) SOME OTHER ARRANGEMENT
(77) DON’T KNOW
(99) REFUSED
K11Q51 Now I am going to ask you a few questions about your income. Please think about your total combined FAMILY income during [LAST CALENDAR YEAR] for all members of the family. Can you tell me that amount before taxes?
RECORD INCOME AMOUNT / DK / RF [SKIP TO K11Q52 IF DK/RF]
READ IF NECESSARY: Include money from jobs, child support, social security, retirement income, unemployment payments, public assistance, and so forth. Also, include income from interest, dividends, net income from business, farm, or rent, and any other money income received.
K11Q52 For the purposes of this survey, it is important to get at least a range for the total income received by all members of your household in [LAST CALENDAR YEAR]. Would you say that the total combined family income, before taxes, was above or below $20,000?
(1) MORE THAN $20,000 [SKIP TO K11Q56] (2) $20,000 [SKIP TO K11Q60] (3) LESS THAN $20,000 [SKIP TO K11Q53] (6) DON'T KNOW [SKIP TO K11Q60] (7) REFUSED [SKIP TO K11Q60]
K11Q53 Was the total combined family income more or less than $10,000?
(1) MORE THAN $10,000 [SKIP TO K11Q55] (2) $10,000 [SKIP TO K11Q60] (3) LESS THAN $10,000 [SKIP TO K11Q54] (6) DON'T KNOW [SKIP TO K11Q60] (7) REFUSED [SKIP TO K11Q60]
K11Q54 Was it more than $7,500?
(1) YES [SKIP TO K11Q59] (0) NO [SKIP TO K11Q59] (6) DON'T KNOW [SKIP TO K11Q60] (7) REFUSED [SKIP TO K11Q60]
K11Q55 Was it more than $15,000?
(1) YES [SKIP TO K11Q55A] (0) NO [SKIP TO K11Q55B] (6) DON'T KNOW [SKIP TO K11Q60] (7) REFUSED [SKIP TO K11Q60]
K11Q55A Was it more than $17,500?
(1) YES [SKIP TO K11Q59] (0) NO [SKIP TO K11Q59] (6) DON'T KNOW [SKIP TO K11Q60] (7) REFUSED [SKIP TO K11Q60]
K11Q55B Was it more than $12,500?
(1) YES [SKIP TO K11Q59] (0) NO [SKIP TO K11Q59] (6) DON'T KNOW [SKIP TO K11Q60] (7) REFUSED [SKIP TO K11Q60]
K11Q56 Was it more or less than $40,000?
(1) MORE THAN $40,000 [SKIP TO K11Q56A] (2) $40,000 [SKIP TO K11Q60] (3) LESS THAN $40,000 [SKIP TO K11Q57] (6) DON'T KNOW [SKIP TO K11Q60] (7) REFUSED [SKIP TO K11Q60]
K11Q56A More or less than $60,000?
(1) MORE THAN $60,000 [SKIP TO K11Q58] (2) $60,000 [SKIP TO K11Q60] (3) LESS THAN $60,000 [SKIP TO K11Q56B] (6) DON'T KNOW [SKIP TO K11Q60] (7) REFUSED [SKIP TO K11Q60]
K11Q56B More or less than $50,000?
(1) MORE THAN $50,000 [SKIP TO K11Q59] (2) $50,000 [SKIP TO K11Q60] (3) LESS THAN $50,000 [SKIP TO K11Q56C] (6) DON'T KNOW [SKIP TO K11Q60] (7) REFUSED [SKIP TO K11Q60]
K11Q56C More or less than $45,000?
(1) MORE THAN $45,000 [SKIP TO K11Q59]
(2) $45,000 [SKIP TO K11Q60] (3) LESS THAN $45,000 [SKIP TO K11Q59] (6) DON'T KNOW [SKIP TO K11Q60]
(7) REFUSED [SKIP TO K11Q60]
K11Q57 More or less than $30,000?
(1) MORE THAN $30,000 [SKIP TO K11Q57A] (2) $30,000 [SKIP TO K11Q60] (3) LESS THAN $30,000 [SKIP TO K11Q57B] (6) DON'T KNOW [SKIP TO K11Q60] (7) REFUSED [SKIP TO K11Q60]
K11Q57A More or less than $35,000?
(1) MORE THAN $35,000 [SKIP TO K11Q59]
(2) $35,000 [SKIP TO K11Q60] (3) LESS THAN $35,000 [SKIP TO K11Q59] (6) DON'T KNOW [SKIP TO K11Q60] (7) REFUSED [SKIP TO K11Q60]
K11Q57B More or less than $25,000?
(1) MORE THAN $25,000 [SKIP TO K11Q59]
(2) $25,000 [SKIP TO K11Q60] (3) LESS THAN $25,000 [SKIP TO K11Q59] (6) DON'T KNOW [SKIP TO K11Q60] (7) REFUSED [SKIP TO K11Q60]
K11Q58 More or less than $75,000?
(1) MORE THAN $75,000 [SKIP TO K11Q59] (2) $75,000 [SKIP TO K11Q60] (3) LESS THAN $75,000 [SKIP TO K11Q59] (6) DON'T KNOW [SKIP TO K11Q60] (7) REFUSED [SKIP TO K11Q60]
K11Q59 Was the total combined family income more or less than [$REF]?
[$REF IS BASED ON A POVERTY REFERENCE TABLE]
(1) MORE THAN [$REF]
(2) EXACTLY [$REF]
(3) LESS THAN [$REF]
(6) DON'T KNOW
(7) REFUSED
SKIP TO K11Q60 IF ANSWER IS EXACTLY/LESS THAN/DK/RF OR IF THERE WAS ONLY ONE VALUE IN THE POVERTY REFERENCE TABLE.
K11Q59A Would you say this income was MORE or LESS than [$REF]?
(1) MORE THAN [$REF] (2) EXACTLY [$REF]
(3) LESS THAN [$REF]
(6) DON'T KNOW
(7) REFUSED
CATI INSTRUCTION: Calculate household poverty level from household size and reported income, or from the income cascade.
SKIP TO NEXT SECTION IF HOUSEHOLD POVERTY LEVEL > 300%
K11Q60 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 [STATE TANF NAME]?
YES / NO / DK / RF
K11Q61 IF S_UNDR18 > 1, FILL “any child in the household”. ELSE, FILL [SC].
During the past 12 months, did [[SC]/ any child in the household] receive Food Stamps or Supplemental Nutrition Assistance Program benefits?
YES / NO / DK / RF
SKIP TO S9Q34 IF ONLY ONE CHILD IN HOUSEHOLD AND AGE < 24 MONTHS.
K11Q62 During the past 12 months, did [[SC]/any child in the household] receive free or reduced-cost breakfasts or lunches at school?
YES / NO / DK / RF
S9Q34 Does anyone who lives in the household currently receive benefits from the Women, Infants, and Children (WIC) Program?
YES / NO / NEVER HEARD OF WIC / DK / RF
SKIP TO NEXT SECTION IF CHILD IS INSURED (K3Q01 = YES), IF INSURANCE STATUS IS UNKNOWN (K3Q01 IS DK/RF AND K3Q02 IS NO/DK/RF), OR IF INCOME IS 400% OF FPL OR GREATER.
INTERVIEWER TRAINING NOTE: Throughout this section, the lists of answer choices should not be read to the respondent. Individual answer choices may be repeated back to the respondent if confirming the respondent’s answer. It is important that a concerted effort is made to find the appropriate answer for each question. Too many “Other” responses will make it difficult to analyze the data.
INTERVIEWER NOTE: PLEASE USE “OTHER” RESPONSE OPTIONS RARELY IN THIS SECTION. PROMPT RESPONDENT TO FIND AN APPROPRIATE ANSWER FOR EACH QUESTION. YOU MAY REPEAT RESPONSE OPTIONS BACK TO RESPONDENT IF YOU ARE CONFIRMING THE RESPONDENT’S ANSWER.
K12Q01. Earlier, you told me that [SC] does not have health insurance. What is the main reason [SC] does not have health insurance now?
COSTS TOO MUCH
HEALTH INSURANCE NOT WORTH THE MONEY IT COSTS
NO ONE IN FAMILY CURRENTLY EMPLOYED / JOB WAS LOST
CAN’T GET INSURANCE THROUGH EMPLOYER
CHANGING JOBS OR INSURANCE POLICIES
MOVING BETWEEN STATES OR REGIONS
INSURANCE COMPANY REFUSED TO COVER / PREEXISTING CONDITION
INSURANCE COMPANY TERMINATED COVERAGE / RULE VIOLATION
INCOME TOO HIGH FOR PUBLIC PROGRAM
AGE / CHILD IS TOO OLD OR TOO YOUNG TO BE ELIGIBLE
CANNOT MEET RESIDENCY/CITIZENSHIP REQUIREMENTS, LACK OF SSN
INELIGIBLE DUE TO OTHER PROGRAM REQUIREMENT
DID NOT REAPPLY WHEN COVERAGE ENDED
ISSUES WITH THE APPLICATION OR PAPERWORK
HAVE APPLIED – NOW JUST WAITING
INTEND TO APPLY BUT JUST HAVEN’T DONE SO
DON'T KNOW HOW TO GET INSURANCE
CHILD DOES NOT NEED INSURANCE / DOES NOT GET SICK
OTHER PARENT’S RESPONSIBILITY, LACK OF LEGAL CUSTODY
OTHER [RECORD VERBATIM RESPONSE]
(96) DON’T KNOW
REFUSED
K12Q02. About how long has it been since [SC] last had any kind of health insurance?
SIX MONTHS OR LESS
MORE THAN 6 MONTHS, BUT NOT MORE THAN 1 YEAR AGO
MORE THAN 1 YEAR, BUT NOT MORE THAN 3 YEARS AGO
MORE THAN 3 YEARS
NEVER [SKIP TO K12Q11]
DON’T KNOW
REFUSED
K12Q03. Has [SC] ever been covered by health insurance that was provided through an employer or union?
YES / NO / DK / RF
K12Q04. Has [SC] ever been covered by health insurance that was purchased directly from an insurance company?
YES / NO / DK / RF
K12Q11. Before today, had you ever heard of Medicaid [or STATE MEDICAID NAME]?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO K12Q21.]
K12Q12. Has [SC] ever been enrolled in Medicaid [or STATE MEDICAID NAME]?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO K12Q15.]
K12Q13. When was the last time that [SC] was enrolled in Medicaid [or STATE MEDICAID NAME]?
RECORD DATE OR LENGTH OF TIME (IN MONTHS OR YEARS) / DK / RF
K12Q14. What is the main reason that [SC]’s enrollment ended?
COST TOO MUCH
FORGOT TO PAY THE PREMIUM
MOVING BETWEEN STATES OR REGIONS
INSURANCE TERMINATED BY INSURER / RULE VIOLATION
CHILD BECAME TOO OLD TO BE ELIGIBLE
FINANCIAL SITUATION CHANGED / NO LONGER QUALIFIED FOR MEDICAID
CHILD OBTAINED OTHER INSURANCE: CHIP / OTHER PUBLIC
CHILD OBTAINED OTHER INSURANCE: EMPLOYER / UNION / PRIVATE
DID NOT REAPPLY WHEN COVERAGE ENDED
ISSUES WITH PAPERWORK
DID NOT LIKE THE DOCTORS / MEDICAL STAFF / CLINICS / QUALITY OF CARE WHERE CHILD RECEIVED SERVICES
SERVICES PROVIDED NOT CONVENIENTLY LOCATED OR NOT AVAILABLE WHEN NEEDED
COULD NOT FIND DOCTORS WHO WOULD ACCEPT MEDICAID
CHILD DOES NOT NEED INSURANCE / DOES NOT GET SICK
OTHER [RECORD VERBATIM RESPONSE]
(96) DON’T KNOW
(97) REFUSED
SKIP TO NEXT SUBDOMAIN.
K12Q15. Have you ever applied for Medicaid [or STATE MEDICAID NAME] for [SC]?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO K12Q21.]
K12Q16. When was the last time that you applied?
RECORD DATE OR LENGTH OF TIME (IN MONTHS OR YEARS) / DK / RF
K12Q17. What is the main reason that you were unable to enroll [SC] in Medicaid [or STATE NAME]?
EARNED TOO MUCH MONEY
ASSETS/RESOURCES TOO HIGH
CHILD WAS TOO OLD
CHILD NEEDED TO BE UNINSURED FOR LONGER PERIOD OF TIME TO QUALIFY
CHILD DID NOT MEET RESIDENCY OR CITIZENSHIP REQUIREMENTS
CHILD WAS ALREADY INSURED BY OTHER INSURANCE
DID NOT PROVIDE ALL PAPERWORK / DOCUMENTS NEEDED
CHILD QUALIFIED FOR CHIP INSTEAD OF MEDICAID
APPLICATION RECENTLY SUBMITTED / NOW JUST WAITING
OTHER [RECORD VERBATIM RESPONSE]
(96) DON’T KNOW
(97) REFUSED
SKIP TO NEXT SUBDOMAIN (K12Q30) IF STATE USES THE SAME OR SUBSTANTIALLY THE SAME NAME FOR THEIR MEDICAID AND CHIP PROGRAMS.
K12Q21. Before today, had you ever heard of [STATE CHIP NAME]?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO K12Q30.]
K12Q22. Has [SC] ever been enrolled in [STATE CHIP NAME]?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO K12Q25]
K12Q23. When was the last time that [SC] was enrolled in [STATE CHIP NAME]?
RECORD DATE OR LENGTH OF TIME (IN MONTHS OR YEARS) / DK / RF
K12Q24. What is the main reason that [SC]’s enrollment ended?
COST TOO MUCH
FORGOT TO PAY THE PREMIUM
MOVING BETWEEN STATES OR REGIONS
INSURANCE TERMINATED BY INSURER / RULE VIOLATION
CHILD BECAME TOO OLD TO BE ELIGIBLE
FINANCIAL SITUATION CHANGED / NO LONGER QUALIFIED FOR CHIP
CHILD OBTAINED OTHER INSURANCE: MEDICAID / OTHER PUBLIC
CHILD OBTAINED OTHER INSURANCE: EMPLOYER / UNION / PRIVATE
DID NOT REAPPLY WHEN COVERAGE ENDED
ISSUES WITH PAPERWORK
DID NOT LIKE THE DOCTORS / MEDICAL STAFF / CLINICS / QUALITY OF CARE WHERE CHILD RECEIVED SERVICES
SERVICES PROVIDED NOT CONVENIENTLY LOCATED OR NOT AVAILABLE WHEN NEEDED
COULD NOT FIND DOCTORS WHO WOULD ACCEPT CHIP
CHILD DOES NOT NEED INSURANCE / DOES NOT GET SICK
OTHER [RECORD VERBATIM RESPONSE]
(96) DON’T KNOW
(97) REFUSED
SKIP TO NEXT SUBDOMAIN.
K12Q25. Have you ever applied for [STATE CHIP NAME] for [SC]?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO NEXT SUBDOMAIN.]
K12Q26. When was the last time that you applied?
RECORD DATE OR LENGTH OF TIME (IN MONTHS OR YEARS) / DK / RF
K12Q27. What is the main reason that you were unable to enroll [SC] in [STATE CHIP NAME]?
EARNED TOO MUCH MONEY
ASSETS/RESOURCES TOO HIGH
CHILD WAS TOO OLD
CHILD NEEDED TO BE UNINSURED FOR LONGER PERIOD OF TIME TO QUALIFY
CHILD DID NOT MEET RESIDENCY OR CITIZENSHIP REQUIREMENTS
CHILD WAS ALREADY INSURED BY OTHER INSURANCE
DID NOT PROVIDE ALL PAPERWORK / DOCUMENTS NEEDED
CHILD QUALIFIED FOR MEDICAID INSTEAD OF CHIP
APPLICATION RECENTLY SUBMITTED / NOW JUST WAITING
OTHER [RECORD VERBATIM RESPONSE]
(96) DON’T KNOW
(97) REFUSED
SKIP TO NEXT SUBDOMAIN (K12Q40) IF K12Q11 = NO/DK/RF AND K12Q21 = NO/DK/RF/MISSING.
FOR PROGRAM FILLS IN THIS SUBDOMAIN,
IF K12Q11 = YES AND K12Q21 = NO/DK/RF/MISSING, USE: Medicaid [or STATE MEDICAID NAME]
IF K12Q11 = NO/DK/RF AND K12Q21 = YES, USE: [STATE CHIP NAME]
IF K12Q11 = YES AND K12Q21 = YES, USE: Medicaid [or STATE MEDICAID NAME] or [CHIP NAME]
K12Q30. If you wanted to get more information about [PROGRAM], do you know where to go to get that information?
YES / NO / DK / RF
K12Q31. If you wanted to enroll [SC] in [PROGRAM], do you know how to do that?
YES / NO / DK / RF
K12Q32. SKIP TO K12Q33 IF RESPONDENT HAS NEVER HEARD OF MEDICAID (#11 = NO/DK/RF).
IF CHILD HAS EVER BEEN ENROLLED IN MEDICAID (#12 = YES), THEN ASK: Based on what you know about Medicaid or [STATE MEDICAID NAME], how easy or difficult do you think it is to re-enroll? Would you say very easy, somewhat easy, somewhat difficult, or very difficult?
OTHERWISE ASK: Based on what you know about Medicaid or [STATE MEDICAID NAME], how easy or difficult do you think it is to complete an application? Would you say very easy, somewhat easy, somewhat difficult, or very difficult?
VERY EASY / SOMEWHAT EASY / SOMEWHAT DIFF / VERY DIFF / DK / RF
K12Q33. SKIP TO #34 IF RESPONDENT HAS NEVER HEARD OF CHIP OR IF STATE USES THE SAME OR SUBSTANTIALLY THE SAME NAME FOR THEIR MEDICAID AND CHIP PROGRAMS (#21 = NO/DK/RF).
IF CHILD HAS EVER BEEN ENROLLED IN CHIP (#22 = YES), THEN ASK: Based on what you know about [STATE CHIP NAME], how easy or difficult do you think it is to re-enroll? Would you say very easy, somewhat easy, somewhat difficult, or very difficult?
OTHERWISE ASK: Based on what you know about [STATE CHIP NAME], how easy or difficult do you think it is to complete an application? Would you say very easy, somewhat easy, somewhat difficult, or very difficult?
VERY EASY / SOMEWHAT EASY / SOMEWHAT DIFF / VERY DIFF / DK / RF
K12Q34. Based on what you know about [PROGRAM], do you think [SC] is eligible now?
YES / NO / DK / RF
K12Q35. If you were told that [SC] was eligible for [PROGRAM], would you want to enroll [him/her]?
YES / NO / DK / RF
IF #35 = NO, THEN SKIP TO #36.
IF #35 = YES AND #34 = YES, THEN SKIP TO #37.
IF #35 = YES AND #34 = NO, THEN SKIP TO #38.
IF #35 = DK/RF OR IF (#35 = YES AND #34 = DK/RF), THEN SKIP TO NEXT SUBDOMAIN (K12Q40).
K12Q36. What is the main reason you would NOT want to enroll [SC]?
COSTS TOO MUCH
APPLICATION PROCESS TOO DIFFICULT, TAKES TOO MUCH TIME
DON’T WANT TO MEET PROGRAM APPLICATION REQUIREMENTS
DON’T LIKE PEOPLE AT APPLICATION OFFICE
WORRIES ABOUT CITIZENSHIP
DON’T ACCEPT WELFARE, DON’T WANT TO BE IN PUBLIC PROGRAM
HEARD BAD THINGS ABOUT PROGRAM
DO NOT LIKE THE DOCTORS / MEDICAL STAFF / CLINICS WHERE CHILD WOULD RECEIVE SERVICES
SERVICES PROVIDED NOT CONVENIENTLY LOCATED OR NOT AVAILABLE WHEN NEEDED
CHILD DOES NOT NEED INSURANCE / DOES NOT GET SICK
EXPECT TO HAVE INSURANCE FROM ANOTHER SOURCE SOON
OTHER [RECORD VERBATIM RESPONSE]
(96) DON’T KNOW
(97) REFUSED
SKIP TO NEXT SUBDOMAIN (K12Q40).
K12Q37. What is the main reason [SC] is not enrolled in [PROGRAM]?
COSTS TOO MUCH
MOVING BETWEEN STATES OR REGIONS
INELIGIBLE DUE TO INCOME TOO HIGH FOR PUBLIC PROGRAM
INELIGIBLE DUE TO AGE
INELIGIBLE DUE TO RESIDENCY, CITIZENSHIP, OR LACK OF SSN
INELIGIBLE DUE TO OTHER PROGRAM REQUIREMENT
DON’T HAVE THE NECESSARY DOCUMENTS
APPLICATION PROCESS TOO DIFFICULT, TAKES TOO MUCH TIME
DON’T WANT TO MEET PROGRAM APPLICATION REQUIREMENTS
WORRIES ABOUT CITIZENSHIP
HAVE APPLIED – NOW JUST WAITING
INTEND TO APPLY BUT JUST HAVEN’T DONE SO
DON'T KNOW WHERE OR HOW TO APPLY
CHILD DOES NOT NEED INSURANCE / DOES NOT GET SICK
OTHER [RECORD VERBATIM RESPONSE]
(96) DON’T KNOW
REFUSED
SKIP TO NEXT SUBDOMAIN (K12Q40).
K12Q38. What is the main reason that you think [SC] is not eligible for [PROGRAM]?
EARN TOO MUCH MONEY
ASSETS/RESOURCES TOO HIGH
CHILD IS TOO OLD
CHILD NEEDS TO BE UNINSURED FOR LONGER PERIOD OF TIME TO QUALIFY
CHILD DOES NOT MEET RESIDENCY OR CITIZENSHIP REQUIREMENTS
CHILD IS ALREADY INSURED BY OTHER INSURANCE
CANNOT OR WILL NOT PROVIDE ALL PAPERWORK / DOCUMENTS NEEDED
OTHER [RECORD VERBATIM RESPONSE]
(96) DON’T KNOW
(97) REFUSED
SKIP TO NEXT SUBDOMAIN (K12Q40).
K12Q40. SKIP TO K12Q50 IF NO MOTHER-TYPE IN HOUSEHOLD
IF K1Q02 = 1, FILL do you. ELSE, FILL does SC’s [MOTHER TYPE].
At this time, [do you / does SC’s MOTHER TYPE] have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicaid or Medicare?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO #42]
K12Q41. Is that health insurance provided through [your/her] current employer, former employer, union, or some other source?
(1) HER CURRENT EMPLOYER [SKIP TO #43.]
(2) HER FORMER EMPLOYER
(3) HER UNION [SKIP TO #43.]
(4) SOME OTHER SOURCE
(6) DK
(7) RF
INTERVIEWER NOTE: If the respondent reports that insurance is provided through multiple sources, ask which source provides primary coverage for both doctor visits and hospital stays.
K12Q42. At this time, [are you/is SC’s MOTHER TYPE’s] eligible for health insurance through [your/her] current employer or union?
(1) YES, HER CURRENT EMPLOYER
(2) YES, HER UNION
(3) YES, BOTH
(4) NO [SKIP TO #50]
(6) DK
(7) RF [SKIP TO #50]
INTERVIEWER NOTE: If the respondent reports not being employed, record answer as NO.
K12Q43. IF
K12Q41 OR K12Q42 = 1, FILL WITH “employer”
IF K12Q41
= 3 OR K12Q42 = 2, FILL WITH “union”
IF K12Q42 = 3 or 6, FILL WITH “employer or union”
Does this [employer/union/employer or union] offer health insurance that could help pay for doctor visits and hospital stays for [SC]?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO #46]
K12Q44. If [SC] was covered by insurance provided through this [employer/union/employer or union], would this [employer/union/employer or union] pay for all, some, or none of (his/her) health insurance premium?
ALL / SOME / NONE / DK / RF
K12Q45. What is the main reason that [SC] is not covered by insurance provided through this [employer/union/employer or union]?
COST IS TOO HIGH
TRADED HEALTH INSURANCE FOR HIGHER PAY
INSURER REFUSED TO COVER / PREEXISTING CONDITION
CHILD NOT ELIGIBLE DUE TO TYPE OF JOB
CHILD NOT ELIGIBLE DUE TO NUMBER OF HOURS WORKED
CHILD NOT ELIGIBLE DUE TO LENGTH OF TIME AT JOB
CHILD NOT ELIGIBLE FOR SOME OTHER REASON
HAVE APPLIED – NOW JUST WAITING
INTEND TO APPLY BUT JUST HAVEN’T DONE SO
DON'T KNOW WHERE OR HOW TO APPLY
APPLICATION PROCESS TOO DIFFICULT, TAKES TOO MUCH TIME
HEARD BAD THINGS ABOUT INSURANCE PROGRAM
DO NOT LIKE DOCTORS / MEDICAL STAFF / CLINIC IN HEALTH PLAN
SERVICES PROVIDED NOT CONVENIENTLY LOCATED OR NOT AVAILABLE WHEN NEEDED
DOES NOT NEED INSURANCE / DOES NOT GET SICK
EXPECT TO HAVE INSURANCE FROM ANOTHER SOURCE SOON
OTHER [RECORD VERBATIM RESPONSE]
(96) DON’T KNOW
(97) REFUSED
K12Q46. IF K12Q41 = 3 OR K12Q42 = 2, SKIP TO K12Q50.
Think about all locations where [your/ SC’s MOTHER TYPE’s] employer operates. Would you say that the total number of persons who work for this employer is above or below 100?
MORE THAN 100 / EXACTLY 100 / LESS THAN 100 / NOT EMPLOYED / DK / RF
K12Q47. ASK K12Q47 ONLY IF ANSWER TO K12Q46 IS “LESS THAN 100.” OTHERWISE, SKIP TO K12Q50.
Is the total number of persons who work for [your/her] employer above or below 50?
MORE THAN 50 / EXACTLY 50 / LESS THAN 50 / DK / RF
K12Q50. SKIP TO K12Q60 IF NO FATHER-TYPE IN HOUSEHOLD
IF K1Q02 = 2, FILL do you. ELSE, FILL does SC’s [FATHER TYPE].
At this time, [do you / does SC’s FATHER TYPE] have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicaid or Medicare?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO #52]
K12Q51. Is that health insurance provided through [your/his] current employer, former employer, union, or some other source?
(1) CURRENT EMPLOYER [SKIP TO #53.]
(2) FORMER EMPLOYER
(3) UNION [SKIP TO #53.]
(4) SOME OTHER SOURCE
(6) DK
(7) RF
INTERVIEWER NOTE: If the respondent reports that insurance is provided through multiple sources, ask which source provides primary coverage for both doctor visits and hospital stays.
K12Q52. At this time, [are you/is SC’s FATHER TYPE’s] eligible for health insurance through [your/his] current employer or union?
(1) YES, CURRENT EMPLOYER
(2) YES, UNION
(3) YES, BOTH
(4) NO [SKIP TO K12Q60]
(6) DK
(7) RF [SKIP TO K12Q60]
INTERVIEWER NOTE: If the respondent reports not being employed, record answer as NO.
K12Q53. IF
K12Q51 OR K12Q52 = 1, FILL WITH “employer”
IF K12Q51
= 3 OR K12Q52 = 2, FILL WITH “union”
IF K12Q52 = 3 or 6, FILL WITH “employer or union”
Does this [employer/union/employer or union] offer health insurance that could help pay for doctor visits and hospital stays for [SC]?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO #56]
K12Q54. If [SC] was covered by insurance provided through this [employer/union/employer or union], would this [employer/union/employer or union] pay for all, some, or none of (his/her) health insurance premium??
ALL / SOME / NONE / DK / RF
K12Q55. What is the main reason that [SC] is not covered by insurance provided through this [employer/union/employer or union]?
COST IS TOO HIGH
TRADED HEALTH INSURANCE FOR HIGHER PAY
INSURER REFUSED TO COVER / PREEXISTING CONDITION
CHILD NOT ELIGIBLE DUE TO TYPE OF JOB
CHILD NOT ELIGIBLE DUE TO NUMBER OF HOURS WORKED
CHILD NOT ELIGIBLE DUE TO LENGTH OF TIME AT JOB
CHILD NOT ELIGIBLE FOR SOME OTHER REASON
HAVE APPLIED – NOW JUST WAITING
INTEND TO APPLY BUT JUST HAVEN’T DONE SO
DON'T KNOW WHERE OR HOW TO APPLY
APPLICATION PROCESS TOO DIFFICULT, TAKES TOO MUCH TIME
HEARD BAD THINGS ABOUT INSURANCE PROGRAM
DO NOT LIKE DOCTORS / MEDICAL STAFF / CLINIC IN HEALTH PLAN
SERVICES PROVIDED NOT CONVENIENTLY LOCATED OR NOT AVAILABLE WHEN NEEDED
DOES NOT NEED INSURANCE / DOES NOT GET SICK
EXPECT TO HAVE INSURANCE FROM ANOTHER SOURCE SOON
OTHER [RECORD VERBATIM RESPONSE]
(96) DON’T KNOW
(97) REFUSED
K12Q56. IF K12Q51 = 3 OR K12Q52 = 2, SKIP TO K12Q60.
Think about all locations where [your/ SC’s FATHER TYPE’s] employer operates. Would you say that the total number of persons who work for this employer is above or below 100?
MORE THAN 100 / EXACTLY 100 / LESS THAN 100 / NOT EMPLOYED / DK / RF
K12Q57. ASK K12Q57 ONLY IF ANSWER TO K12Q56 IS “LESS THAN 100.” OTHERWISE, SKIP TO K12Q60.
Is the total number of persons who work for [your/his] employer above or below 50?
MORE THAN 50 / EXACTLY 50 / LESS THAN 50 / DK / RF
K12Q60. SKIP TO CPC11Q14 IF RESPONDENT IS MOTHER OR FATHER. QUESTIONS ABOUT THE RESPONDENT’S INSURANCE ARE ONLY ASKED HERE IF THE RESPONDENT HAS NOT ALREADY ANSWERED FOR HIMSELF/HERSELF IN K12Q40 OR K12Q50.
At this time, do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicaid or Medicare?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO #62]
K12Q61. Is that health insurance provided through your current employer, former employer, union, or some other source?
(1) CURRENT EMPLOYER [SKIP TO #63.]
(2) FORMER EMPLOYER
(3) UNION [SKIP TO #63.]
(4) SOME OTHER SOURCE
(77) DK
(99) RF
INTERVIEWER NOTE: If the respondent reports that insurance is provided through multiple sources, ask which source provides primary coverage for both doctor visits and hospital stays.
K12Q62. At this time, are you eligible for health insurance through your current employer or union?
(1) YES, CURRENT EMPLOYER
(2) YES, UNION
(3) YES, BOTH
(4) NO [SKIP TO NEXT SECTION]
(6) DK
(7) RF [SKIP TO NEXT SECTION]
INTERVIEWER NOTE: If the respondent reports not being employed, record answer as NO.
K12Q63. IF
K12Q61 OR K12Q62 = 1, FILL WITH “employer”
IF K12Q61
= 3 OR K12Q62 = 2, FILL WITH “union”
IF K12Q62 = 3 or 6, FILL WITH “employer or union”
Does this [employer/union/employer or union] offer health insurance that could help pay for doctor visits and hospital stays for [SC]?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO #66]
K12Q64. If [SC] was covered by insurance provided through this [employer/union/employer or union], would this [employer/union/employer or union] pay for all, some, or none of (his/her) health insurance premium?
ALL / SOME / NONE / DK / RF
K12Q65. What is the main reason that [SC] is not covered by insurance provided through this [employer/union/employer or union]?
COST IS TOO HIGH
TRADED HEALTH INSURANCE FOR HIGHER PAY
INSURER REFUSED TO COVER / PREEXISTING CONDITION
CHILD NOT ELIGIBLE DUE TO TYPE OF JOB
CHILD NOT ELIGIBLE DUE TO NUMBER OF HOURS WORKED
CHILD NOT ELIGIBLE DUE TO LENGTH OF TIME AT JOB
CHILD NOT ELIGIBLE FOR SOME OTHER REASON
HAVE APPLIED – NOW JUST WAITING
INTEND TO APPLY BUT JUST HAVEN’T DONE SO
DON'T KNOW WHERE OR HOW TO APPLY
APPLICATION PROCESS TOO DIFFICULT, TAKES TOO MUCH TIME
HEARD BAD THINGS ABOUT INSURANCE PROGRAM
DO NOT LIKE DOCTORS / MEDICAL STAFF / CLINIC IN HEALTH PLAN
SERVICES PROVIDED NOT CONVENIENTLY LOCATED OR NOT AVAILABLE WHEN NEEDED
DOES NOT NEED INSURANCE / DOES NOT GET SICK
EXPECT TO HAVE INSURANCE FROM ANOTHER SOURCE SOON
OTHER [RECORD VERBATIM RESPONSE]
(96) DON’T KNOW
(97) REFUSED
K12Q66. IF K12Q61 = 3 OR K12Q62 = 2, SKIP TO NEXT SECTION.
Think about all locations where your employer operates. Would you say that the total number of persons who work for this employer is above or below 100?
MORE THAN 100 / EXACTLY 100 / LESS THAN 100 / NOT EMPLOYED / DK / RF
K12Q67. ASK K12Q67 ONLY IF K12Q66=3 OTHERWISE, SKIP TO NEXT SECTION.
Is the total number of persons who work for your employer above or below 50?
MORE THAN 50 / EXACTLY 50 / LESS THAN 50 / DK / RF
C11Q15_CELL The next few questions are about the telephones in your household.
In total, how many working cell phones do you and your household members have available for personal use? Please do not count cell phones that are used exclusively for business purposes [IF RDD_NCCELL_CELL=2,3 then display: “and please include the number we called.”]
NONE / ONE / TWO / THREE OR MORE / DK / RF [IF NONE, SKIP TO C11Q20]
C11Q15_CELL_USUALLY
How many of these cell phones do the adults in this household usually use? [IF CELL PHONE DIALED, DISPLAY: “Please include the number we called.”]
[IF CELL PHONE DIALED, then display: "INTERVIEWER NOTE: THE NUMBER WE CALLED IS ASSUMED TO BE USUALLY USED, SO THE ANSWER MUST BE AT LEAST ONE.”]
NONE / ONE / TWO / THREE OR MORE / DK / RF
C11Q16 Of all the telephone calls that you and your household receive, are nearly all received on cell phones, nearly all received on regular phones, or some received on cell phones and some received on regular phones?
(1) NEARLY ALL RECEIVED ON CELL PHONES
(2) NEARLY ALL RECEIVED ON REGULAR PHONES
(3) SOME RECEIVED ON CELL PHONES AND SOME RECEIVED ON REGULAR PHONES
(7) DON’T KNOW
(9) REFUSED
C11_AWAY Would you mind telling me if I reached you today away from home or at home?
INTERVIEWER NOTE: IF THE RESPONDENT WAS AWAY FROM HOME DURING ANY PART OF THE CALL, THEN CODE AS AWAY FROM HOME.
(1) AWAY FROM HOME
(2) AT HOME
(77) DON'T KNOW
(99) REFUSED
C11Q20 Not including cellular telephones, has your family been without telephone service for 1 week or more during the past 12 months?
YES / NO / DK / RF
CPV_ISLAND IF IAP=95 THEN GO TO V_ISLAND, ELSE GO TO C11Q22.
V_ISLAND IF NIS COMPLETE FILL FROM C_ISLAND.
IF TEEN COMPLETE FROM TIS_C_ISLAND.
On what island do you live?
(1) SAINT CROIX [GO TO CP_ADDRESS]
(2) SAINT THOMAS [GO TO CP_ADDRESS]
(3) SAINT JOHN [GO TO CP_ADDRESS]
(4) WATER ISLAND [GO TO CP_ADDRESS]
(5) DON’T LIVE IN VIRGIN ISLANDS [GO TO C11Q22]
(77) DON’T KNOW [GO TO C11Q22]
(99) REFUSED [GO TO C11Q22]
C11Q22 (NIS VARIABLE – C19A)
Please tell me your zip code.
[CATI: 5 NUMERIC-CHARACTER-FIELD, RANGE 00001-99998]
_____ _____ _____ ____ _____ (00001-99998)
(77777) Don’t know
(99999) Refused
C11Q22_CONF [IF C11Q22 FILLED FROM C19A or TIS_C19A, 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_STATE What state do you live in?
______________(DROP DOWN MENU OF STATE NAMES) [THIS DOES NOT CHANGE ‘STATE’ FROM THE SAMPLE PRE-FILL TABLE]
LOCATE_TRANSITION We may want to contact you in the future to ask questions about the health and health care of [SC]. By participating in future surveys, you will help us better understand the health and health care needs of children and adolescents in your state and the nation.
LOCATE_NUMBER Is there another number where we can reach you if this number isn't working for some reason?
INTERVIEWER INSTRUCTION: IF THE RESPONDENT SAYS NO, PROBE THE RESPONDENT FURTHER BY SAYING: "An alternate number can be a work or cell phone number, or even a number for a relative who you keep in touch with."
READ AS NECESSARY: We will only call you back to participate in future surveys about the health or health care of [S.C.], and will not sell or disclose your telephone number to any other party. If we do not contact you in the future, you can choose whether or not to participate at that time.
YES / NO / DK / RF [SKIP TO LOCATE_ADDRESS IF NO/DK/RF.]
NUMBER_GIVEN ENTER TELEPHONE NUMBER (_ _ _ - _ _ _ - _ _ _ _ )
NUMBER_GIVEN_A (1) TELEPHONE NUMBER COMPLETE [GO TO TELETYPE]
(2) ENTER TELEPHONE EXTENSION
NUMBER_EXT ENTER EXTENSION TO TELEPHONE NUMBER. (ALLOW FOR UP TO FIVE NUMBERS)
TELETYPE Is this telephone number a cell phone, landline, work number or other type?
CELL / LANDLINE / WORK / OTHER
LOCATE_ADDRESS If we call you back in the future, we may want to mail you a letter explaining more about the survey and the questions we will ask.
IF CASE QUALIFIED FOR NSCH INCENTIVE THEN READ: We'd also like to mail you [$XX] as a token of our appreciation for taking the time to answer our questions.
If AC_NIS_INCENT_EXIT not previously read, READ: In addition, the National Immunization Study will be sending you $[X], which you may have already received.
IF NO ADDRESS, READ: Would you please give me your address?
IF ADDRESS ALREADY OBTAINED, READ: Would you please verify your address?
PROCEED THROUGH ADDRESS COLLECTION OR VERIFICATION.
IF NAME OF SC GIVEN DURING SURVEY, THEN SKIP TO PNAME.
LOCATING_NAME I could refer to your child as [AGEID] if we call you back, or if you prefer, you could give me a first name or initials.
(1) CONTINUE TO USE AGE REFERENCE [GO TO PNAME]
(2) USE NAME
LOCATING_NAME_A ENTER NAME/INITIALS: ____________
PNAME Since following up with your household may be easier if we have your name, could you please give me your name or initials?
ENTER NAME OR INITIALS / NO / RF
K_END 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 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 [PHONE]. If you have questions about your rights as a survey participant, you may call the chairman of the Research Ethics Review Board at 1‑800‑223‑8118. Thank you again.
TERMINATE INTERVIEW WITH RESPONDENT.
LANG1. APPEARS AFTER COMPLETED INTERVIEWS ONLY.
INTERVIEWER: Was this interview completed using English only?
YES / NO
LANG2 INTERVIEWER: Which languages were needed to complete this interview? [Mark all that apply.]
ENGLISH / SPANISH / CANTONESE / KOREAN / MANDARIN / VIETNAMESE / OTHER
LANG3 INTERVIEWER: Was this interview completed “mostly in English” or “mostly in another language”?
MOSTLY IN ENGLISH / MOSTLY IN OTHER LANGUAGE / ABOUT HALF AND HALF
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | kdo7 |
| File Modified | 0000-00-00 |
| File Created | 2021-02-02 |