Form 3c 2011 NHIS Questionnaire--Sample Child

Attachment 3c Child Core (9 minutes)
Page 1 of 6

2011 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
Question ID:

CID.001_00.000 Instrument Variable Name:

QuestionText:
01-25

21-Oct-10

CURRES

QuestionnaireFileName:

Sample Child

* Enter the line number of the person to whom you are speaking.
Person number of the respondent for Sample Child

UniverseText:

Sample child section not started or not completed

SkipInstructions:

if CSTAT ne empty and CSTAT ne '2' THEN
if ASTAT = empty or ASTAT = '2' THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG ne '1' THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif
goto back.OUTCOMEB1 procedure
endif
<01-25> if this is NOT an allowable line number
goto ERR_CURRES
elseif CURRES = a line number entered in KNOWSC2
store CURRES in CSPAVAIL and CSRESP
goto CSRELTIV
elseif KNOWSC2 = 'Don't know' or 'Refused' or empty (no line numbers in KNOWSC2)
goto KNOAVAIL
else
goto CSPAVAIL
endif

Page 2 of 6

2011 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
Question ID:

CID.010_00.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CSPAVAIL

QuestionnaireFileName:

Sample Child

The next questions are about [fill1: ALIAS of Sample Child].
Is [fill2:KNOWSC2 names] available to answer some questions about [fill3: HISHER] health?
* Enter line number of available respondent from list or enter '96' if no one is available.
* If refused enter CTRL_R.

01-25

Person # of person available to answer questions about Sample Child
No person available

96
UniverseText:

Someone identified as knowledgeable about child's health and knowledgeable person(s) not entered in CURRES

SkipInstructions:

<01-25> if line number not equal one of the line numbers in KNOWSC2
goto child.cid.ERR_CSPAVAIL
else
store child.cid.CSPAVAIL in child.cid.CSRESP
goto child.cid.CSRELTIV
endif
<96> store child.cid.CSPAVAIL in child.cid.CSRESP
goto cbk.CCALLBK1
store '4' in CSTAT(FAMINT)
if ASTAT = empty or ASTAT = '2' THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG ne '1' THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif

Question ID:

CID.030_00.000 Instrument Variable Name:

QuestionText:

CSRELTIV

(book) C1
[fill1: The next questions are about [fill2: ALIAS of Sample Child].]
What is your relationship to [fill2: ALIAS of Sample Child]?

01
02
03
04
05
06
07
08
97
99

Parent (Biological, adoptive, or step)
Grandparent
Aunt/Uncle
Brother/Sister
Other relative
Legal guardian
Foster parent
Other non-relative
Refused
Don't know

UniverseText:

Someone identified as knowledgeable about child's health

SkipInstructions:

<1-8,R,D> If CSRESP = demographics.hhc.RELRESP_A
goto child.chs.BWGT_LB
elseif CSRESP = demographics.hhc.HHRESP
goto child.chs.BWGT_LB
else]
goto CSPVERF_S
endif]

QuestionnaireFileName:

Sample Child

Page 3 of 6

2011 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
Question ID:

CID.040_00.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CSPVERF_S

QuestionnaireFileName:

Sample Child

* Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]'s sex as [fill2: Sex of Sample Child]. Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".

1

Yes
No

2
UniverseText:

Respondent is not the person entered in HHRESP or RELRESP_A.

SkipInstructions:

<1> goto CSPVERF_A
<2> goto NEWSEX

Question ID:

CID.041_00.000 Instrument Variable Name:

QuestionText:

NEWSEX

QuestionnaireFileName:

Sample Child

* Ask if appropriate; otherwise, enter your best guess of the person's sex.
Is [fill: ALIAS of Sample Child] Male or Female?

1

Male
Female

2
UniverseText:

Respondent said child's sex is not correct.

SkipInstructions:

<1,2> store NEWSEX in SEX
goto ERR_NEWSEX
reset CSPVERF_S
goto CSPVERF_S

Question ID:

CID.042_00.000 Instrument Variable Name:

QuestionText:

CSPVERF_A

QuestionnaireFileName:

Sample Child

* Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]'s age as [fill2: Age of Sample Child] old. Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".

1
2

Yes
No

UniverseText:

Respondent verified child's sex

SkipInstructions:

<1> goto CSPVERF_D
<2> goto NEWAGE

Page 4 of 6

2011 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
Question ID:

CID.043_00.000 Instrument Variable Name:

QuestionText:

21-Oct-10

NEWAGE

QuestionnaireFileName:

Sample Child

How old is [fill1: ALIAS of Sample Child]?
* If age given in months, weeks, or days, convert age to appropriate year. If less than one year old, enter "0".

000-120

Age in years

UniverseText:

Respondent said child's age is not correct

SkipInstructions:

<0-120, Refused, Don't know>
if NEWAGE = 'Refused' or NEWAGE = 'Don't know' or NEWAGE = AGE
reset CSPVERF_A
goto ERR_NEWAGE
else
store NEWAGE in AGE
goto NEWDOB_M

Question ID:

CID.044_00.000 Instrument Variable Name:

QuestionText:

CSPVERF_D

QuestionnaireFileName:

Sample Child

* Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]'s birthday as [fill2: Birthday of Sample Child]. Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".

1
2

Yes
No

UniverseText:

Respondent verified child's sex

SkipInstructions:

<1> if AGE of Sample Child ge '18'
goto CNO_MORE
else
goto child.chs.BWGT_LB
endif
<2> goto NEWDOB_M

Page 5 of 6

2011 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
Question ID:

CID.046_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

NEWDOB_M

QuestionnaireFileName:

Sample Child

1 of 3
What is [fill: ALIAS of Sample Child]'s birthday?
*Enter month of birth.

1

January
October
November
December
February
March
April
May
June
July
August
September

10
11
12
2
3
4
5
6
7
8
9
UniverseText:

Respondent said child's date of birth is not correct or child's age is not correct

SkipInstructions:

<01-12, Refused, Don't know> goto NEWDOB_D

Question ID:

CID.046_02.000 Instrument Variable Name:

QuestionText:

NEWDOB_D

QuestionnaireFileName:

2 of 3
* Enter day of birth.

01-31

Day of the month

UniverseText:

Respondent said child's date of birth is not correct or child's age is not correct

SkipInstructions:

<01-31,Refused,Don't know> goto NEWDOB_Y
If days not valid, goto ERR_NEWDOB_D

Sample Child

Page 6 of 6

2011 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
Question ID:

CID.046_03.000 Instrument Variable Name:

QuestionText:

21-Oct-10

NEWDOB_Y

QuestionnaireFileName:

Sample Child

3 of 3
* Enter year of birth.

1880-2020

Year of birth

UniverseText:

Respondent said child's date of birth is not correct or child's age is not correct

SkipInstructions:

<1880-2020, Refused, Don't know> if CSPVERF_A = '2' (No) then reset CSPVERF_A to empty
goto CSPVERF_A
elseif CSPVERF_D = '2' (No) then reset CSPVERF_D to empty
goto CSPVERF_D
endif
(if year GT current year) or (if year = current year and month GT current month) or (if year = current year and
month = current month and day GT current day)
goto ERR1_NEWDOB_Y
endif
(if birth month = '02' and birth day = '29' and this is not a leap year)
goto ERR2_NEWDOB_Y
endif
(if NEWDOB_M = 'Ref' or 'DK') or (if NEWDOB_D = 'Ref' or 'DK') or (if NEWDOB_Y = 'Ref' or 'DK')
goto ERR3_NEWDOB_Y
else
store NEWDOB_M in DOBM
store NEWDOB_D in DOBD
store NEWDOB_Y in DOBY
if CSPVERF_A = '2' (No) then reset CSPVERF_A to empty
goto CSPVERF_A
elseif CSPVERF_D = '2' (No) then reset CSPVERF_D to empty
goto CSPVERF_D
endif
endif
Calculate age from NEWDOB_M, NEWDOB_D, and NEWDOB_Y.
if age from NEWDOB items is ne AGE and age from NEWDOB items is valid
reset CSPVERF_A or CSPVERF_D
goto ERR4_NEWDOB_Y
endif

Page 1 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.010_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

BWGT_LB

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

What was [fill: S.C. name]'s birth weight?
* Enter 'M' to record metric measurements.

01-15

1-15 pounds
Refused
Don't know
Metric

97
99
M
UniverseText:

Sample children <18

SkipInstructions:

<1-12> [goto BWGT_OZ]
<13-15> [goto ERR1_BWGT_LB]
[goto CHGT_FT]
[goto BWGT_GR]
[If NE <1-15, M, R, D> goto ERR2_BWGT_LB]

Question ID:

CHS.010_02.000 Instrument Variable Name:

QuestionText:

BWGT_OZ

* Enter ounces.

00-15

0-15 ounces
Refused
Don't know
Blank

97
99
Blank
UniverseText:

Sample children <18 who have a value entered for weight in pounds.

SkipInstructions:

<0-15,R,D> [goto CHGT_FT]
[if BWGT_LB = <0-15, R, D> and BWGT_OZ = go to CHGT_FT]

Question ID:

CHS.011_00.000 Instrument Variable Name:

QuestionText:
0500-5485
9997
9999

BWGT_GR

QuestionnaireFileName:

* Enter weight in grams.
500-5485 grams
Refused
Don't know

UniverseText:

Sample children <18 whose birth weight will be entered in metric.

SkipInstructions:

<500-5485,R,D> [goto CHGT_FT]
<5486-6900> [goto ERR_BWGT_GR]

Sample Child

Page 2 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.020_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CHGT_FT

QuestionnaireFileName:

Sample Child

How tall is [fill: S.C. name] now (without shoes)?
* If the child's height is given in inches, press 'ENTER' at feet and enter the measure in inches (36 inches maximum).
* Enter 'M' to record metric measurements.

00-07

0-7 feet
Refused
Don't know
Metric

97
99
M
UniverseText:

Sample children 12+

SkipInstructions:

[goto CHGT_IN]
<0-7> [goto CHGT_IN]
[goto CWGT_LB]
[goto CHGT_M]
[If NE <0-7, M, R, D> go to ERR_CHGT_FT]

Question ID:

CHS.020_02.000 Instrument Variable Name:

QuestionText:

CHGT_IN

QuestionnaireFileName:

* Enter inches.

00-36

0-36 inches
Refused
Don't know

97
99
UniverseText:

Sample children 12+ whose height in feet is 0-7 or is left empty.

SkipInstructions:

<0-36> [goto CWGT_LB]
[If both CHGT_FT and CHGT_IN are either or <0>, display ERR1_CHGT_IN]
[If CHGT_FT = <0-7> and CHGT_IN is GE <12> display ERR2_CHGT_IN]

Question ID:

Sample Child

CHS.021_01.000 Instrument Variable Name:

QuestionText:

CHGT_M

QuestionnaireFileName:

Sample Child

* Enter height in metric.
* If the child's height is given in centimeters, press 'ENTER' at meters and enter the measure in centimeters (241
centimeters maximum).

0-2
7
9
Blank

0-2 meters
Refused
Don't know
Blank

UniverseText:

Sample children 12+ whose current height will be entered in metric.

SkipInstructions:

<0-2> [goto CHGT_CM]
[goto CWGT_LB]
[go to CHGT_CM]

Page 3 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.021_02.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CHGT_CM

QuestionnaireFileName:

Sample Child

* Enter centimeters.

000-241

0-241 centimeters
Blank

Blank
UniverseText:

Sample children 12+ whose weight will be entered in metric, and who entered "0-2" for height in meters or left it
empty.

SkipInstructions:

<0-241> [goto CWGT_LB]
[if CHGT_M = and CHGT_CM = go to ERR1_CHGT_CM]
[if CHGT_M = 2 and CHGT_CM > 41 goto ERR2_CHGT_CM]
[if CHGT_M = 1 and CHGT_CM >141 goto ERR2_CHGT_CM]

Question ID:

CHS.022_00.000 Instrument Variable Name:

QuestionText:

CWGT_LB

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

How much does [fill: S.C. name] weigh now (without shoes)?
* Enter 'M' to record metric measurements.
* Enter '500' if 500 pounds or more.

001-500

1-500 pounds
Refused
Don't know
Metric

997
999
M
UniverseText:

Sample children 12+

SkipInstructions:

<1-500,R,D> [if age ge <2> goto ADD_1, else, goto ADD1_2]
[goto CWGT_KG]
[if = <501-999> goto ERR1_CWGT_LB]
[if NE <1-999, M, R, D> goto ERR2_CWGT_KG]

Question ID:

CHS.023_00.000 Instrument Variable Name:

QuestionText:
002-226

CWGT_KG

* Enter weight in kilograms.
2-226 kilograms

UniverseText:

Sample children 12+ whose weight will be entered in metric.

SkipInstructions:

<2-226> [if AGE ge <2> goto ADD_1; else goto ADD1_2]
[if CWGT_KG > 226 goto ERR_CWGT_KG]

Page 4 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.031_02.000 Instrument Variable Name:

QuestionText:

ADD1_2

21-Oct-10
QuestionnaireFileName:

Sample Child

Has a doctor or health professional ever told you that [fill: S.C. name] had...
Intellectual disability, also known as mental retardation?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children <2

SkipInstructions:

<1,2,R,D> [goto ADD1_3]

Question ID:

CHS.031_03.000 Instrument Variable Name:

QuestionText:

ADD1_3

QuestionnaireFileName:

Sample Child

* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children <2

SkipInstructions:

<1,2,R,D> [goto CONDL]

Question ID:

CHS.032_01.000 Instrument Variable Name:

QuestionText:

ADD_1

QuestionnaireFileName:

Has a doctor or health professional ever told you that [fill: S.C. name] had...
Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 2-17

SkipInstructions:

<1,2,R,D> [go to ADD_2]

Sample Child

Page 5 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.032_02.000 Instrument Variable Name:

QuestionText:

ADD_2

21-Oct-10
QuestionnaireFileName:

Sample Child

* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Intellectual disability, also known as mental retardation?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 2-17

SkipInstructions:

<1,2,R,D> [go to ADD_3]

Question ID:

CHS.032_03.000 Instrument Variable Name:

QuestionText:

ADD_3

QuestionnaireFileName:

* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 2-17

SkipInstructions:

<1,2,R,D> [go to CONDL]

Sample Child

Page 6 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.060_00.000 Instrument Variable Name:

QuestionText:

CONDL

21-Oct-10
QuestionnaireFileName:

Sample Child

(book) C2 ?[F1]
Looking at this list, has a doctor or health professional ever told you that [fill: SC name] had any of these conditions?
*Read if necessary.
Down syndrome
Cerebral palsy
Muscular dystrophy
Cystic fibrosis
Sickle cell anemia
Autism/Autism spectrum disorder
Diabetes
Arthritis
Congenital heart disease
Other heart condition

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1> [goto CONDL1] <2,R,D> [goto CPOX]

Question ID:

CHS.061_00.000 Instrument Variable Name:

QuestionText:

CONDL1

(book) C2 ?[F1]
Which ones?
* Enter all that apply, separate with commas.

01
02
03
04
05
06
07
08
09
10

Down syndrome
Cerebral palsy
Muscular dystrophy
Cystic fibrosis
Sickle cell anemia
Autism/Autism spectrum disorder
Diabetes
Arthritis
Congenital heart disease
Other heart condition

UniverseText:

Sample children <18 and CONDL=1

SkipInstructions:

<1-10,R,D> [go to CPOX]
[If <0> and <1-10> go to ERR_CONDL]

QuestionnaireFileName:

Sample Child

Page 7 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.070_00.000 Instrument Variable Name:

QuestionText:

CPOX

QuestionnaireFileName:

Sample Child

CPOX12MO

QuestionnaireFileName:

Sample Child

Has [fill: S.C. Name] EVER had chickenpox?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1> [go to CPOX12MO]
<2,R,D> [go to CASHMEV]

Question ID:

CHS.072_00.000 Instrument Variable Name:

QuestionText:

Has [fill: S.C. name] had chickenpox DURING THE PAST 12 MONTHS?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children <18 who have had chickenpox

SkipInstructions:

<1,2,R,D> [goto CASHMEV]

Question ID:

21-Oct-10

CHS.080_00.000 Instrument Variable Name:

QuestionText:

CASHMEV

QuestionnaireFileName:

Has a doctor or other health professional EVER told you that [fill: S.C. name] had asthma?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1> [go to CASSTILL]
<2,R,D> [if AGE LE 2 go to CCONDT1_1; if AGE >2 go to CCONDT_1]

Question ID:

Sample Child

CHS.085_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

CASSTILL

QuestionnaireFileName:

Does [fill: S.C. name] still have asthma?
Yes
No
Refused
Don't know

UniverseText:

Sample children <18 and doctor has informed that child had asthma

SkipInstructions:

<1,2,R,D> [go to CASHYR]

Sample Child

Page 8 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.090_00.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CASHYR

QuestionnaireFileName:

Sample Child

The following questions are about [fill: S.C. name]'s asthma DURING THE PAST 12 MONTHS.
DURING THE PAST 12 MONTHS, has [fill: SC name] had an episode of asthma or an asthma attack?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children <18 and doctor has informed that child had asthma

SkipInstructions:

<1,2,R,D> [goto CASMERYR]

Question ID:

CHS.100_00.000 Instrument Variable Name:

QuestionText:

CASMERYR

QuestionnaireFileName:

DURING THE PAST 12 MONTHS, did [fill1: S.C. name] have to visit an emergency room or urgent care center because
of [fill2: his/her] asthma?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children <18 and doctor has informed that child had asthma

SkipInstructions:

<1,2,R,D> [if AGE LE 2 go to CCONDT1_1,
else go to CCONDT_1]

Question ID:

Sample Child

CHS.111_01.000 Instrument Variable Name:

QuestionText:

2
7
9

QuestionnaireFileName:

DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Hay fever?

1

CCONDT1_1

Yes
No
Refused
Don't know

UniverseText:

Sample children LE 2

SkipInstructions:

<1,2,R,D> [go to CCONDT1_2]

Sample Child

Page 9 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.111_02.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CCONDT1_2

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of respiratory allergy?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children LE 2

SkipInstructions:

<1,2,R,D> [go to CCONDT1_3]

Question ID:

CHS.111_03.000 Instrument Variable Name:

QuestionText:

CCONDT1_3

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of food or digestive allergy?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children LE 2

SkipInstructions:

<1,2,R,D> [go to CCONDT1_4]

Question ID:

CHS.111_04.000 Instrument Variable Name:

QuestionText:

CCONDT1_4

QuestionnaireFileName:

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Eczema or any kind of skin allergy?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children LE 2

SkipInstructions:

<1,2,R,D> [go to CCONDT1_5]

Sample Child

Page 10 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.111_05.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CCONDT1_5

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or repeated diarrhea or colitis?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children LE 2

SkipInstructions:

<1,2,R,D> [go to CCONDT1_6]

Question ID:

CHS.111_06.000 Instrument Variable Name:

QuestionText:

CCONDT1_6

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Anemia?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children LE 2

SkipInstructions:

<1,2,R,D> [go to CCONDT1_8]

Question ID:

CHS.111_08.000 Instrument Variable Name:

QuestionText:

CCONDT1_8

QuestionnaireFileName:

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Three or more ear infections?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children LE 2

SkipInstructions:

<1,2,R,D> [go to CCONDT1_9]

Sample Child

Page 11 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.111_09.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CCONDT1_9

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Seizures?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children LE 2

SkipInstructions:

<1,2,R,D> [go to CHSTATYR]

Question ID:

CHS.115_01.000 Instrument Variable Name:

QuestionText:

CCONDT_1

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Hay fever?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children = 3-17

SkipInstructions:

<1,2,R,D> [go to CCONDT_2]

Question ID:

CHS.115_02.000 Instrument Variable Name:

QuestionText:

CCONDT_2

QuestionnaireFileName:

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of respiratory allergy?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children = 3-17

SkipInstructions:

<1,2,R,D> [go to CCONDT_3]

Sample Child

Page 12 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.115_03.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CCONDT_3

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of food or digestive allergy?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children = 3-17

SkipInstructions:

<1,2,R,D> [go to CCONDT_4]

Question ID:

CHS.115_04.000 Instrument Variable Name:

QuestionText:

CCONDT_4

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Eczema or any kind of skin allergy?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children = 3-17

SkipInstructions:

<1,2,R,D> [go to CCONDT_5]

Question ID:

CHS.115_05.000 Instrument Variable Name:

QuestionText:

CCONDT_5

QuestionnaireFileName:

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or repeated diarrhea or colitis?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children = 3-17

SkipInstructions:

<1,2,R,D> [go to CCONDT_6]

Sample Child

Page 13 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.115_06.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CCONDT_6

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Anemia?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children = 3-17

SkipInstructions:

<1,2,R,D> [go to CCONDT_7]

Question ID:

CHS.115_07.000 Instrument Variable Name:

QuestionText:

CCONDT_7

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or severe headaches, including migraines?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children = 3-17

SkipInstructions:

<1,2,R,D> [go to CCONDT_8]

Question ID:

CHS.115_08.000 Instrument Variable Name:

QuestionText:

CCONDT_8

QuestionnaireFileName:

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Three or more ear infections?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children = 3-17

SkipInstructions:

<1,2,R,D> [go to CCONDT_9]

Sample Child

Page 14 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.115_09.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CCONDT_9

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Seizures?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children = 3-17

SkipInstructions:

<1,2,R,D> [go to CCONDT_10]

Question ID:

CHS.115_10.000 Instrument Variable Name:

QuestionText:

CCONDT_10

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Stuttering or stammering?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children = 3-17

SkipInstructions:

<1,2,R,D> [go to CHSTATYR]

Question ID:

CHS.210_00.000 Instrument Variable Name:

QuestionText:
1
2
3
7
9

CHSTATYR

QuestionnaireFileName:

Sample Child

Compared with 12 months ago, would you say [fill: S.C. name]'s health is now better, worse, or about the same?
Better
Worse
About the same
Refused
Don't know

UniverseText:

Sample children < 18

SkipInstructions:

<1-3,R,D> [if AGE le <4> goto CCOLD2W; else goto SCHDAYR]

Page 15 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.220_00.000 Instrument Variable Name:

QuestionText:

21-Oct-10

SCHDAYR

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, that is, since [fill1: 12-month ref. date], about how many days did [fill2: S.C. name]
miss school because of illness or injury?
* Enter '996' if child did not go to school in the past 12 months.

000

None
1-240 days
Did not go to school
Refused
Don't know

001-240
996
997
999
UniverseText:

Sample children 5-17

SkipInstructions:

<0-99,996,R,D> [goto CCOLD2W]
<100-240> [go to ERR1_SCHDAYR]
<241-995> [goto ERR2_SCHDAYR]

Question ID:

CHS.230_00.000 Instrument Variable Name:

QuestionText:

CCOLD2W

QuestionnaireFileName:

Sample Child

These next questions are about [fill: S.C name]'s recent health during the past 2 weeks.
Did [fill: SC name] have a head cold or chest cold that started during the past two weeks?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1,2,R,D> [goto CINTIL2W]

Question ID:

CHS.240_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

CINTIL2W

QuestionnaireFileName:

Sample Child

Did [fill: S.C. name] have a stomach or intestinal illness with vomiting or diarrhea that started during the past two weeks?
Yes
No
Refused
Don't know

UniverseText:

Sample children <18

SkipInstructions:

<1,2,R,D> [goto CHEARST1]

Page 16 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.250_00.000 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Child

Excellent
Good
A little trouble hearing
Moderate trouble
A lot of trouble
Deaf
Refused
Don't know

2
3
4
5
6
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1-6,R,D> [go to CVISION]

CHS.260_00.000 Instrument Variable Name:

QuestionText:

CVISION

QuestionnaireFileName:

Sample Child

Does [fill1: S.C. name] have any trouble seeing [fill2: , even when wearing glasses or contact lenses]?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1> [goto CBLIND]
<2,R,D> [goto IHSPEQ]

Question ID:

CHEARST1

Which statement best describes [fill: SC name]'s hearing without a hearing aid: Excellent, good, a little trouble hearing,
moderate trouble, a lot of trouble, or is [fill: SC's name] deaf?

1

Question ID:

21-Oct-10

CHS.270_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

CBLIND

Is [fill: S.C. name] blind or unable to see at all?
Yes
No
Refused
Don't know

UniverseText:

Sample children <18 having trouble seeing

SkipInstructions:

<1,2,R,D> [goto IHSPEQ]

QuestionnaireFileName:

Sample Child

Page 17 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.290_00.000 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Child

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1,2,R,D> [goto IHMOB]

CHS.300_00.000 Instrument Variable Name:

QuestionText:

IHMOB

QuestionnaireFileName:

Sample Child

Does [fill1: S.C. name] have an impairment or health problem that limits [fill2: his/her] ability to (crawl), walk, run, or
play?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1> [goto IHMOBYR]
<2,R,D> [goto PROBRX]

Question ID:

IHSPEQ

Does [fill1: S.C. name] have any impairment or health problem that requires [fill2: him/her] to use special equipment,
such as a brace, a wheelchair, or a hearing aid (excluding ordinary eyeglasses or corrective shoes)?

1

Question ID:

21-Oct-10

CHS.310_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

IHMOBYR

QuestionnaireFileName:

Is this an impairment or health problem that has lasted, or is expected to last, 12 months or longer?
Yes
No
Refused
Don't know

UniverseText:

Sample children <18 that have limited ability to crawl, walk, run, or play

SkipInstructions:

<1,2,R,D> [goto PROBRX]

Sample Child

Page 18 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.311_00.000 Instrument Variable Name:

QuestionText:

21-Oct-10

PROBRX

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1,2,R,D> [if AGE LE <1> go to CUSUALPL;
if AGE GE <3> go to LEARND;
if AGE = <2> and SEX = <1> go to CMHAGM11_1;
if AGE = <2> and SEX = <2> go to CMHAGF11_1]

CHS.312_00.000 Instrument Variable Name:

QuestionText:

LEARND

QuestionnaireFileName:

Sample Child

Has a representative from a school or a health professional ever told you that [fill: S.C. name] had a learning disability?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 3-17

SkipInstructions:

<1,2,R,D> [if AGE > 3 go to CUSUALPL;
if AGE = 3 and SEX = 1 go to CMHAGM11_1;
if AGE = 3 and SEX = 2 go to CMHAGF11_1]

Question ID:

Sample Child

Does [fill1: S.C. name] NOW have a problem for which [fill2: he/she] has regularly taken prescription medication for at
least three months?

1

Question ID:

QuestionnaireFileName:

CHS.321_01.000 Instrument Variable Name:

QuestionText:

CMHAGM11_1

QuestionnaireFileName:

Sample Child

(book) C3
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has been uncooperative?

0
1
2
7
9

Not true
Sometimes true
Often true
Refused
Don't know

UniverseText:

Male sample children 2-3

SkipInstructions:

<0-2,R,D> [go to CMHAGM11_2]

Page 19 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.321_02.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CMHAGM11_2

QuestionnaireFileName:

Sample Child

(book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has trouble getting to sleep?

0

Not true
Sometimes true
Often true
Refused
Don't know

1
2
7
9
UniverseText:

Male sample children 2-3

SkipInstructions:

<0-2,R,D> [go to CMHAGM11_3]

Question ID:

CHS.321_03.000 Instrument Variable Name:

QuestionText:

CMHAGM11_3

QuestionnaireFileName:

Sample Child

(book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has speech problems?

0
1
2
7
9

Not true
Sometimes true
Often true
Refused
Don't know

UniverseText:

Male sample children 2-3

SkipInstructions:

<0-2,R,D> [go to CMHAGM11_4]

Page 20 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.321_04.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CMHAGM11_4

QuestionnaireFileName:

Sample Child

(book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has been unhappy, sad, or depressed?

0

Not true
Sometimes true
Often true
Refused
Don't know

1
2
7
9
UniverseText:

Male sample children 2-3

SkipInstructions:

<0-2,R,D> [go to CUSUALPL]

Question ID:

CHS.361_01.000 Instrument Variable Name:

QuestionText:

CMHAGF11_1

QuestionnaireFileName:

Sample Child

(book) C3
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has temper tantrums or a hot temper?

0
1
2
7
9

Not true
Sometimes true
Often true
Refused
Don't know

UniverseText:

Female sample children 2-3

SkipInstructions:

<0-2,R,D> [go to CMHAGF11_2]

Page 21 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.361_02.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CMHAGF11_2

QuestionnaireFileName:

Sample Child

(book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has speech problems?

0

Not true
Sometimes true
Often true
Refused
Don't know

1
2
7
9
UniverseText:

Female sample children 2-3

SkipInstructions:

<0-2,R,D> [go to CMHAGF11_3]

Question ID:

CHS.361_03.000 Instrument Variable Name:

QuestionText:

CMHAGF11_3

QuestionnaireFileName:

Sample Child

(book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has been nervous or high-strung?

0
1
2
7
9

Not true
Sometimes true
Often true
Refused
Don't know

UniverseText:

Female sample children 2-3

SkipInstructions:

<0-2,R,D> [go to CMHAGF11_4]

Page 22 of 22

2011 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:

CHS.361_04.000 Instrument Variable Name:

QuestionText:

21-Oct-10

CMHAGF11_4

QuestionnaireFileName:

Sample Child

(book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has been unhappy, sad, or depressed?

0
1
2
7
9

Not true
Sometimes true
Often true
Refused
Don't know

UniverseText:

Female sample children 2-3

SkipInstructions:

<0-2,R,D> [go to CUSUALPL]

Page 1 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.020_00.000 Instrument Variable Name:

CUSUALPL

QuestionnaireFileName:

Sample Child

The next questions are about health care.

QuestionText:

Is there a place that [fill1: alias] USUALLY goes when [fill2: he/she] is sick or you need advice
about [fill3: his/her] health?
Yes
There is NO place
There is MORE THAN ONE place
Refused
Don't know

1
2
3
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1,3> [go to CPLKIND]
<2,R,D> [go to CHCPLKND]

Question ID:

CAU.030_00.000 Instrument Variable Name:

CPLKIND

QuestionnaireFileName:

[fill1: What kind of place is it / What kind of place does [fill2: alias] go to most often] - a clinic, doctor's office, emergency
room, or some other place?

QuestionText:

Clinic or health center
Doctor's office or HMO
Hospital emergency room
Hospital outpatient department
Some other place
Doesn't go to one place most often
Refused
Don't know

1
2
3
4
5
6
7
9
UniverseText:

Sample children <18 with one or more usual places to go when sick or need health advice

SkipInstructions:

<1-5> [go to CHCPLROU]
<6,R,D> [go to CHCPLKND]

Question ID:

Sample Child

CAU.035_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

CHCPLROU

QuestionnaireFileName:

Sample Child

Is that [fill1: CPLKIND/CAU.030] the same place [fill2: alias] USUALLY goes when [fill3: he/she] needs routine or
preventive care, such as a physical examination or (well baby/child) check-up?
Yes
No
Refused
Don't know

UniverseText:

Sample children <18 with one or more usual places to go when sick or need health advice who reported that place as
a clinic or health center, doctor's office or HMO, hospital emergency room, hospital outpatient department, or some
other place

SkipInstructions:

<1> [go to CHCCHGYR]
<2,R,D> [go to CHCPLKND]

Page 2 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.037_00.000 Instrument Variable Name:

CHCPLKND

QuestionnaireFileName:

Sample Child

What kind of place does [fill1: alias] USUALLY go to when [fill2: he/she] needs routine or preventive care, such as a
physical examination or (well baby/child) check-up?

QuestionText:

Doesn't get preventive care anywhere
Clinic or health center
Doctor's office or HMO
Hospital emergency room
Hospital outpatient department
Some other place
Doesn't go to one place most often
Refused
Don't know

0
1
2
3
4
5
6
7
9
UniverseText:

Sample children <18 who do not have a usual source of sick care; who Ref/NA/DK if have a usual source of sick
care; who have a usual source of sick care but does not go to one place most often; who have a usual source of sick
care but Ref/NA/DK what kind of place; who have a usual source of sick care, but it is not same place as usual source
of routine/preventive care; who have a usual source of sick care but Ref/NA/DK if it is same place as usual source of
routine/preventive care.

SkipInstructions:

<0-6,R,D> if CUSUALPL=2 [goto CNOUSLPL]; else if CUSUALPL=,R,D [goto CPRVTRYR]; else [goto CHCCHGYR]

Question ID:

CAU.040_00.000 Instrument Variable Name:

CHCCHGYR

QuestionnaireFileName:

Sample Child

At any time IN THE PAST 12 MONTHS did you CHANGE the place(s) to which [fill: alias] USUALLY goes for health
care?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <18 with one or more place to go when sick/need advice [or who reported same place as usual
source of routine/preventive care]

SkipInstructions:

<1> [go to CHCCHGHI]
<2,R,D> [goto to CPRVTRYR]

Question ID:

CAU.050_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

CHCCHGHI

QuestionnaireFileName:

Was this change for a reason related to health insurance?
Yes
No
Refused
Don't know

UniverseText:

Sample children <18 that have changed their usual place of health care in the past 12 months

SkipInstructions:

<1,2,R,D> [goto CPRVTRYR]

Sample Child

Page 3 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.050_00.010

Instrument Variable Name:

CNOUSLPL

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

Why doesn’t [fill: alias] have a usual source of medical care?

QuestionText:

*Enter all that apply, separate with commas.
Doesn’t need a doctor/Haven't had any problems
Doesn’t like/trust/believe in doctors
Doesn’t know where to go
Previous doctor is not available/moved
Too expensive/no insurance/cost
Speak a different language
No care available/Care too far away, not convenient
Put it off/Didn't get around to it
Other
Refused
Don't know

01
02
03
04
05
06
07
08
09
97
99

Sample children 18+ without a place of usual care

UniverseText:
SkipInstructions:

Question ID:

<1-9,R,D>[goto CPRVTRYR]

CAU.052_00.010 Instrument Variable Name:

CPRVTRYR

DURING THE PAST 12 MONTHS, did you have any trouble finding a general doctor or provider who would see [fill: alias]?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1> [goto CPRVTRFD ] <2,R,D> [goto CDRNANP]

Question ID:

CAU.053_00.010 Instrument Variable Name:

QuestionText:
1
2
7
9

CPRVTRFD

QuestionnaireFileName:

Were you able to find a general doctor or provider who could see [fill: alias]?
Yes
No
Refused
Don’t know

UniverseText:

Sample children <18 who had trouble finding a provider in the last year

SkipInstructions:

<1,2,R,D> [goto CDRNANP]

Sample Child

Page 4 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.055_00.010

QuestionText:

DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they would not accept [fill: alias] as a new patient?

Instrument Variable Name:

UniverseText:

Sample children <18

SkipInstructions:

<1,2,R,D>[goto CDRNAI]

CAU.056_00.010 Instrument Variable Name:

CDRNAI

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they did not accept [fill: alias]'s health care
coverage?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:
SkipInstructions:

Question ID:

Sample Child

Yes
No
Refused
Don't know

1
2
7
9

Question ID:

CDRNANP QuestionnaireFileName:

Sample children <18
<1,2,R,D>[goto CHCDLYR_1]

CAU.080_01.000 Instrument Variable Name:

CHCDLYR1_1

QuestionnaireFileName:

Sample Child

QuestionText:

There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the
following reasons IN THE PAST 12 MONTHS...
You couldn't get through on the telephone.
1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children <18

SkipInstructions:

<1,2,R,D> [goto CHCDLYR1_2]

Page 5 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.080_02.000 Instrument Variable Name:

CHCDLYR1_2

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the
following reasons IN THE PAST 12 MONTHS...
You couldn't get an appointment for [fill: alias] soon enough.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1,2,R,D> [goto CHCDLYR1_3]

Question ID:

CAU.080_03.000 Instrument Variable Name:

CHCDLYR1_3

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the
following reasons IN THE PAST 12 MONTHS...
Once you get there, [fill: alias] has to wait too long to see the doctor.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1,2,R,D> [goto CHCDLYR1_4]

Question ID:

CAU.080_04.000 Instrument Variable Name:

QuestionText:

CHCDLYR1_4

QuestionnaireFileName:

Sample Child

* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the
following reasons IN THE PAST 12 MONTHS...
The (clinic/doctor's office) wasn't open when you could get there.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children <18

SkipInstructions:

<1,2,R,D> [goto CHCDLYR1_5]

Page 6 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.080_05.000 Instrument Variable Name:

CHCDLYR1_5

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the
following reasons IN THE PAST 12 MONTHS...
You didn’t have transportation.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1,2,R,D> if age LT 2 [goto CHCAFYR]; else [goto CHCAFYR1_1]

Question ID:

CAU.130_00.000 Instrument Variable Name:

CHCAFYR

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it
because you couldn't afford it...

QuestionText:

Prescription medicines?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <2

SkipInstructions:

<1,2,R,D> [goto CHCAFYRN]

Question ID:

CAU.133_00.010 Instrument Variable Name:

QuestionText:

SkipInstructions:

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it
because you couldn't afford it...
To see a specialist?

1
2
7
9
UniverseText:

CHCAFYRN

Yes
No
Refused
Don't know
Sample children <2
<1,2,R,D> [goto CHCAFYRF]

Page 7 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.133_00.020

Instrument Variable Name: CHCAFYRF

QuestionnaireFileName: Sample Child

QuestionText:

DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it
because you couldn't afford it...
Follow-up care?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <2

SkipInstructions:

<1,2,R,D> [if AGE <1 goto CHCSYR1_2; else goto CDENLONG]

Question ID:

CAU.135_01.000 Instrument Variable Name:

CHCAFYR1_1

QuestionnaireFileName:

Sample Child

QuestionText:

DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it
because you couldn't afford it...
Prescription medicines?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children GE 2

SkipInstructions:

<1,2,R,D> [goto CHCAFYR1_2]

Question ID:

CAU.135_02.000 Instrument Variable Name:

QuestionText:

CHCAFYR1_2

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it
because you couldn't afford it...
Mental health care or counseling?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children GE 2

SkipInstructions:

<1,2,R,D> [goto CHCAFYR1_3]

Page 8 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.135_03.000 Instrument Variable Name:

CHCAFYR1_3

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it
because you couldn't afford it...
Dental care (including check-ups)?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children GE 2

SkipInstructions:

<1,2,R,D> [goto CHCAFYR1_4]

Question ID:

CAU.135_04.000 Instrument Variable Name:

CHCAFYR1_4

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it
because you couldn't afford it...
Eyeglasses?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children GE 2

SkipInstructions:

<1,2,R,D> [goto CHCAFYR1_6]

Question ID:

CAU.135_05.010 Instrument Variable Name:

QuestionText:

CHCAFYR1_6

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it
because you couldn't afford it...
To see a specialist?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children GE 2

SkipInstructions:

<1,2,R,D> [goto CHCAFYR1_7]

Page 9 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.135_06.010 Instrument Variable Name:

CHCAFYR1_7

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it
because you couldn't afford it...
Follow-up care?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children GE 2

SkipInstructions:

<1,2,R,D> [goto CDENLONG]

Question ID:

CAU.160_00.000 Instrument Variable Name:

CDENLONG

QuestionnaireFileName:

Sample Child

(book) C4

QuestionText:

About how long has it been since [fill: alias] last saw a dentist? Include all types of dentists, such as orthodontists, oral
surgeons, and all other dental specialists, as well as dental hygienists.
Never
6 months or less
More than 6 months, but not more than 1 year ago
More than 1 year, but not more than 2 years ago
More than 2 years, but not more than 5 years ago
More than 5 years ago
Refused
Don't know

0
1
2
3
4
5
7
9
UniverseText:

Sample children GE 1

SkipInstructions:

<0-5,R,D> [if AGE GE <2> goto CHCSYR_1; else go to CHCSYR1_2]

Question ID:

CAU.170_01.000 Instrument Variable Name:

CHCSYR1_2

QuestionnaireFileName:

Sample Child

QuestionText:

DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], has anyone in the family seen or talked to
any of the following health care providers about [fill2: alias]'s health?
An optometrist, ophthalmologist, or eye doctor (someone who prescribes eyeglasses)?
1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children <2

SkipInstructions:

<1,2,R,D> [goto CHCSYR1_3]

Page 10 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.170_02.000 Instrument Variable Name:

CHCSYR1_3

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], has anyone in the family seen or talked to
any of the following health care providers about [fill2: alias]'s health?
A foot doctor?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <2

SkipInstructions:

<1,2,R,D> [goto CHCSYR1_5]

Question ID:

CAU.170_03.000 Instrument Variable Name:

CHCSYR1_5

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], has anyone in the family seen or talked to
any of the following health care providers about [fill2: alias]'s health?
A physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <2

SkipInstructions:

<1,2,R,D> [goto CHCSYR1_6]

Question ID:

CAU.170_04.000 Instrument Variable Name:

QuestionText:

CHCSYR1_6

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], has anyone in the family seen or talked to
any of the following health care providers about [fill2: alias]'s health?
A nurse practitioner, physician assistant or midwife?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children <2

SkipInstructions:

<1,2,R,D> [goto CHCSYR8]

Page 11 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.175_01.000 Instrument Variable Name:

CHCSYR_1

QuestionnaireFileName:

Sample Child

QuestionText:

DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the
following health care providers about [fill2: alias]'s health?
A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children GE 2

SkipInstructions:

<1,2,R,D> [goto CHCSYR_2]

Question ID:

CAU.175_02.000 Instrument Variable Name:

CHCSYR_2

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the
following health care providers about [fill2: alias]'s health?
An optometrist, ophthalmologist, or eye doctor (someone who prescribes eyeglasses)?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children GE 2

SkipInstructions:

<1,2,R,D> [goto CHCSYR_3]

Question ID:

CAU.175_03.000 Instrument Variable Name:

QuestionText:

CHCSYR_3

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the
following health care providers about [fill2: alias]'s health?
A foot doctor?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children GE 2

SkipInstructions:

<1,2,R,D> [goto CHCSYR_4]

Page 12 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.175_04.000 Instrument Variable Name:

CHCSYR_4

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the
following health care providers about [fill2: alias]'s health?
A chiropractor?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children GE 2

SkipInstructions:

<1,2,R,D> [goto CHCSYR_5]

Question ID:

CAU.175_05.000 Instrument Variable Name:

CHCSYR_5

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the
following health care providers about [fill2: alias]'s health?
A physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children GE 2

SkipInstructions:

<1,2,R,D> [goto CHCSYR_6]

Question ID:

CAU.175_06.000 Instrument Variable Name:

QuestionText:

CHCSYR_6

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the
following health care providers about [fill2: alias]'s health?
A nurse practitioner, physician assistant or midwife?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children GE 2

SkipInstructions:

<1,2,R,D> [if SEX eq <2> and AGE GE 15 goto CHCSYR7; else goto CHCSYR8]

Page 13 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.230_00.000 Instrument Variable Name:

Sample Child

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children GE 15 who are female

SkipInstructions:

<1,2,R,D> [goto CHCSYR8_1]

CAU.240_01.000 Instrument Variable Name:

CHCSYR8_1

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to the following
about [fill2: alias]'s health?
A medical doctor who specializes in a particular medical disease or problem (fill3:other than obstetrician/ gynecologist,
psychiatrist or ophthalmologist? /fill4: other than psychiatrist or ophthalmologist)?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1,2,R,D> [goto CHCSYR8_2]

Question ID:

QuestionnaireFileName:

DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to a doctor who
specializes in women's health (an obstetrician/gynecologist) about [fill2: alias]'s health?

QuestionText:

Question ID:

CHCSYR7

CAU.240_02.000 Instrument Variable Name:

QuestionText:

CHCSYR8_2

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to the following
about [fill2: alias]'s health?
A general doctor who treats a variety of illnesses (a doctor in general practice, pediatrics, family medicine, or internal
medicine)?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children <18

SkipInstructions:

<1> [goto CHCSYR10]
<2,R,D> [goto CHPEXYR]

Page 14 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.260_00.000 Instrument Variable Name:

CHCSYR10

QuestionnaireFileName:

Does that doctor treat children and adults (a doctor in general practice or family medicine)?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <18 who have seen or talked to a general doctor during the past 12 months

SkipInstructions:

<1,2,R,D> [goto CHCSYREM]

Question ID:

CAU.265_00.000 Instrument Variable Name:

CHCSYREM

QuestionnaireFileName:

Sample Child

Did you see or talk to this general doctor because of an emotional or behavioral problem that [fill1: alias] may have?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <18 who have seen a general doctor in the past 12 months

SkipInstructions:

<1,2,R,D> [goto CHPEXYR]

Question ID:

Sample Child

CAU.270_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

CHPEXYR

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, did [fill1: alias] receive a well-child check-up, that is a general check-up, when [fill2:
he/she] was not sick or injured?
Yes
No
Refused
Don't know

UniverseText:

Sample children <18

SkipInstructions:

<1,2,R,D> [goto CHERNOYR]

Page 15 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.280_00.000 Instrument Variable Name:

CHERNOYR

QuestionnaireFileName:

Sample Child

(book) C5

QuestionText:

DURING THE PAST 12 MONTHS, HOW MANY TIMES has [fill1: alias] gone to a HOSPITAL EMERGENCY ROOM
about [fill2: his/her] health? (This includes emergency room visits that resulted in a hospital admission.)
None
1
2-3
4-5
6-7
8-9
10-12
13-15
16 or more
Refused
Don't know

00
01
02
03
04
05
06
07
08
97
99

Sample children <18

UniverseText:

SkipInstructions:

<0,R,D> [goto CHCHYR] <1-8> [goto CERVISND]

Question ID: CAU.281_00.010 Instrument Variable Name: CERVISND

QuestionnaireFileName:

Thinking about [fill: S.C. name]'s most recent emergency room visit, did [fill: he/she] go to the emergency room at night
or on the weekend?

QuestionText:

Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children <18 who had at least one ER visit in the past year

SkipInstructions:

<1,2,R,D> [go to CERHOS]

Question ID:

Sample Child

CAU.282_00.010 Instrument Variable Name:

QuestionText:
1
2
7
9

CERHOS

QuestionnaireFileName:

Did this emergency room visit result in a hospital admission?
Yes
No
Refused
Don't know

UniverseText:

Sample children <18 who had at least one ER visit in the past year

SkipInstructions:

<1,R,D> [goto CHCHYR] < 2> [go to CERREAS1]

Sample Child

Page 16 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.283_01.010 Instrument Variable Name:

CERREAS1

QuestionnaireFileName:

Sample Child

Tell me which of these apply to [fill: alias] last emergency room visit?

QuestionText:

… [fill: alias] didn’t have another place to go
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CERREAS2]

Question ID:

CAU.283_02.020

Instrument Variable Name: CERREAS2

QuestionText:

*Read lead-in if necessary.

QuestionnaireFileName:

Sample Child

Tell me which of these apply to [fill: alias] last emergency room visit?
… [fill: alias] doctor’s office or clinic was not open
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CERREAS3]

Question ID:

CAU.283_03.030 Instrument Variable Name:

QuestionText:

CERREAS3

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary.
Tell me which of these apply to [fill: alias] last emergency room visit?
… [fill: alias] health provider advised that [fill: he/she] go

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CERREAS4]

Page 17 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.283_04.040 Instrument Variable Name:

CERREAS4

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary.

QuestionText:

Tell me which of these apply to [fill: alias] last emergency room visit?
… The problem was too serious for the doctor’s office or clinic
Yes
No
Refused
Don’t' know

1
2
7
9
UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CERREAS5]

Question ID:

CAU.283_05.050

Instrument Variable Name:

CERREAS5

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary.

QuestionText:

Tell me which of these apply to [fill: alias] last emergency room visit?
… Only a hospital could help [fill: alias]
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CERREAS6]

Question ID:

CAU.283_06.060 Instrument Variable Name:

QuestionText:

CERREAS6

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary.
Tell me which of these apply to [fill: alias] last emergency room visit?
… the emergency room is [fill: alias]'s closest provider

1
2
7
9

Yes
No
Refused
Don’t know

UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CERREAS7]

Page 18 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.283_07.070 Instrument Variable Name:

CERREAS7

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary.

QuestionText:

Tell me which of these apply to [fill: alias] last emergency room visit?
…[fill: alias] gets most of [fill: his/her] care at the emergency room
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CERREAS8]

Question ID:

CAU.283_08.080 Instrument Variable Name:

CERREAS8

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary.

QuestionText:

Tell me which of these apply to [fill: alias] last emergency room visit?
…[fill: alias] arrived by ambulance or other emergency vehicle
1
2
7
9
UniverseText:
SkipInstructions:

Question ID:

Yes
No
Refused
Don’t know
Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission
<1,2,R,D> [goto CHCHYR]

CAU.290_00.000 Instrument Variable Name:

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, did [fill1: alias] receive care AT HOME from a nurse or other health care professional?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1> [goto CHCHMOYR]

Question ID:

CHCHYR

<2,R,D> [goto CHCNOYR]

CAU.300_00.000 Instrument Variable Name:

QuestionText:

01-12
97
99

CHCHMOYR

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, how many months did [fill: alias] receive care AT HOME from a health care
professional?
1-12 months
Refused
Don't know

UniverseText:

Sample children <18 that have received home care from health professional during the past 12 months

SkipInstructions:

<01-12,R,D> [goto CHCHNOYR]

Page 19 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.310_00.000 Instrument Variable Name:

CHCHNOYR

QuestionnaireFileName:

Sample Child

(book) C6

QuestionText:

What was the total number of home visits received for [fill1: alias] during [fill2: that month/those months]?
01
02
03
04
05
06
07
08
97
99
UniverseText:
SkipInstructions:

Question ID:

1
2-3
4-5
6-7
8-9
10-12
13-15
16 or more
Refused
Don't know
Sample children <18 that have received home care from health professional during the past 12 months
<1-8,R,D> [goto CHCNOYR]

CAU.320_00.000 Instrument Variable Name:

CHCNOYR

QuestionnaireFileName:

Sample Child

(book) C5

QuestionText:

DURING THE PAST 12 MONTHS, HOW MANY TIMES has [fill1: alias] seen a doctor or other health care professional
about [fill2: his/her] health at A DOCTOR’S OFFICE, A CLINIC, OR SOME OTHER PLACE? Do not include times
[fill1: alias] was hospitalized overnight, visits to hospital emergency rooms, home visits, dental visits or telephone calls.
None
1
2-3
4-5
6-7
8-9
10-12
13-15
16 or more
Refused
Don't know
Sample children <18

00
01
02
03
04
05
06
07
08
97
99
UniverseText:

Question ID:

SkipInstructions:

CAU.330_00.000 Instrument Variable Name:

QuestionText:

<1-8,R,D> [goto CSRGYR]

CSRGYR

QuestionnaireFileName:

DURING THE PAST 12 MONTHS has [fill1: alias] had SURGERY or other surgical procedures either as an inpatient or
outpatient?
* Read if necessary.
This includes both major surgery and minor procedures such as setting bones or removing growths.

1
2
7
9

Sample Child

Yes
No
Refused
Don't know

UniverseText:

Sample children <18

SkipInstructions:

<1> [goto CSRGNOYR]
<2,R,D> [goto CMDLONG]

Page 20 of 20

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 13-Aug-10

Question ID:

CAU.340_00.000 Instrument Variable Name:

CSRGNOYR

QuestionnaireFileName:

Sample Child

Including any times you may have already told me about, HOW MANY DIFFERENT TIMES has [fill1: alias] had surgery
DURING THE PAST 12 MONTHS?

QuestionText:

* Enter '95' for 95 or more times.
1-94 times
95+ times
Refused
Don't know

01-94
95
97
99
UniverseText:

Sample children <18 that have undergone surgery during the past 12 months

SkipInstructions:

<1-10,R,D> [goto CMDLONG]
<11-95> [goto ERR_CMDLONG]

Question ID:

CAU.345_00.000 Instrument Variable Name:

QuestionText:

CMDLONG

QuestionnaireFileName:

Sample Child

(book) C4
About how long has it been since anyone in the family last saw or talked to a doctor or other health care professional about
[fill1: alias]'s health? Include doctors seen while [fill2: he/she] was a patient in a hospital.

0
1
2
3
4
5
7
9

Never
6 months or less
More than 6 months, but not more than 1 year ago
More than 1 year, but not more than 2 years ago
More than 2 years, but not more than 5 years ago
More than 5 years ago
Refused
Don't know

UniverseText:

Sample children <18

SkipInstructions:

<0-5, D, R> [goto next section]

Page 1 of 4

2011 NHIS Questionnaire - Sample Child
Child Mental Health Brief Questionnaire
Document Version Date:
Question ID:

CMB.010_00.000 Instrument Variable Name:

QuestionText:

22-Oct-10

CMHCOPY

QuestionnaireFileName:

Sample Child

* The following statements are not to be read to the respondent. They are displayed and included here for legal reasons.
* The next 6 items contained in CMHMF_1 through CMHDIFF are included in this survey with permission as indicated
below.
* The SDQ questions are copyrighted by Robert Goodman, Ph.D., FRCPSYCH, MRCP. State and local agencies may
use these questions without charge and without seeking separate permission provided the wording is not modified, all the
questions are retained, and Dr. Goodman's copyright is acknowledged.
* Enter 1 to Continue.

1

Enter 1 to continue

UniverseText:

Sample children GE 4

SkipInstructions:

<1> [goto CMHMF_1]

Question ID:

CMB.020_01.000 Instrument Variable Name:

QuestionText:

CMHMF_1

QuestionnaireFileName:

Sample Child

(book) C7
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,
SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...is generally well behaved, usually does what adults request.

1
2
3
7
9

Not true
Somewhat true
Certainly true
Refused
Don't know

UniverseText:

Sample children GE 4

SkipInstructions:

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

Page 2 of 4

2011 NHIS Questionnaire - Sample Child
Child Mental Health Brief Questionnaire
Document Version Date:
Question ID:

CMB.020_02.000 Instrument Variable Name:

QuestionText:

22-Oct-10

CMHMF_2

QuestionnaireFileName:

Sample Child

(book) C7
* Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,
SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...has many worries, or often seems worried.

1

Not true
Somewhat true
Certainly true
Refused
Don't know

2
3
7
9
UniverseText:

Sample children GE 4

SkipInstructions:

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

Question ID:

CMB.020_03.000 Instrument Variable Name:

QuestionText:

CMHMF_3

QuestionnaireFileName:

Sample Child

(book) C7
* Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,
SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...is often unhappy, depressed or tearful.

1
2
3
7
9

Not true
Somewhat true
Certainly true
Refused
Don't know

UniverseText:

Sample children GE 4

SkipInstructions:

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

Page 3 of 4

2011 NHIS Questionnaire - Sample Child
Child Mental Health Brief Questionnaire
Document Version Date:
Question ID:

CMB.020_04.000 Instrument Variable Name:

QuestionText:

22-Oct-10

CMHMF_4

QuestionnaireFileName:

Sample Child

(book) C7
* Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,
SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...gets along better with adults than with other [fill3: children/youth].

1

Not true
Somewhat true
Certainly true
Refused
Don't know

2
3
7
9
UniverseText:

Sample children GE 4

SkipInstructions:

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

Question ID:

CMB.020_05.000 Instrument Variable Name:

QuestionText:

CMHMF_5

QuestionnaireFileName:

Sample Child

(book) C7
* Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,
SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...has good attention span, sees chores or homework through to the end.

1
2
3
7
9

Not true
Somewhat true
Certainly true
Refused
Don't know

UniverseText:

Sample children GE 4

SkipInstructions:

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

Page 4 of 4

2011 NHIS Questionnaire - Sample Child
Child Mental Health Brief Questionnaire
Document Version Date:
Question ID:

CMB.030_00.000 Instrument Variable Name:

QuestionText:

CMHDIFF

22-Oct-10
QuestionnaireFileName:

Sample Child

(book) C8
Overall, do you think that [fill1: SC name] has difficulties in any of the following areas: emotions, concentration,
behavior, or being able to get along with other people?

1
2
3
4
7
9

No
Yes, minor difficulties
Yes, definite difficulties
Yes, severe difficulties
Refused
Don't know

UniverseText:

Sample children GE 4

SkipInstructions:

<1-4,R,D> [goto next section]

Page 1 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.001_00.000 Instrument Variable Name:

DIFF6M

25-Oct-10
QuestionnaireFileName:

Sample Child

Has [fill: SC name] had any difficulties with emotions, concentration, behavior, or getting along with others DURING
THE PAST 6 MONTHS?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children 4-17

SkipInstructions:

<1> [goto DIFFINTF] <2,R,D> [if CMHDIFF IN ('2',3','4') [goto DIFFINTF]; else [goto PRESCP6M]

Question ID:

CMS.005_00.000 Instrument Variable Name:

DIFFINTF

QuestionnaireFileName:

Sample Child

DURING THE PAST 6 MONTHS, did the difficulties interfere with or limit [fill1: SC name] being able to get along in
your family, in school, or in daily activities?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children 4-17 who have at least minor difficulties with emotions, concentration, behavior, or being able to
get along with others

SkipInstructions:

<1> [goto DIFFDEG] <2,R,D> [goto DIFFLNG]

Question ID:

CMS.007_00.000 Instrument Variable Name:

QuestionText:

DIFFDEG

QuestionnaireFileName:

Sample Child

How much did these difficulties interfere with [fill: S.C. name] being able to get along in your family, in school, or in
daily activities? Would you say...
*Read categories below.

1
2
3
7
9

A lot
Some
A little
Refused
Don't know

UniverseText:

Sample children 4-17 whose difficulties interfere with child being able to get along in the family, school, or daily
activities

SkipInstructions:

<1-3,R,D> [goto DIFFLNG]

Page 2 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.008_00.000 Instrument Variable Name:

25-Oct-10

DIFFLNG

QuestionnaireFileName:

How long have these difficulties been present?

QuestionText:

Less than a month
1-5 months
6 to 12 months
Over a year
Refused
Don’t know

1
2
3
4
7
9
UniverseText:

Sample children 4-17 who have at least minor difficulties with emotions, concentration,
behavior, or being able to get along with others

SkipInstructions:

<1-4,R,D> [goto PRESCP6M]

Question ID:

Sample Child

CMS.010_00.000 Instrument Variable Name:

PRESCP6M

QuestionnaireFileName:

Sample Child

DURING THE PAST 6 MONTHS, was [fill1: S.C. name] prescribed medication or taking prescription medication for
difficulties with emotions, concentration, behavior, or being able to get along with others?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children 4-17

SkipInstructions:

<1> [goto PRESHELP] <2,R,D> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [end]; else [goto NSDUH21]

Question ID:

CMS.011_04.000 Instrument Variable Name:

QuestionText:

1
2
3
4
7
9

PRESHELP

QuestionnaireFileName:

Sample Child

During the past 6 months, how much has this prescription medication helped [fill: S.C. name]? Would you say…*Read
categories below.
Not at all
A little
Some
A lot
Refused
Don't know

UniverseText:

Sample children 4-17 have taken prescription medicine in the past 6 mos

SkipInstructions:

<1-4,R,D> [goto PMEDPED]

Page 3 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.012_01.000 Instrument Variable Name:

25-Oct-10

PMEDPED

QuestionnaireFileName:

Sample Child

Who FIRST prescribed the medication? Was it

QuestionText:

...A pediatrician or other family doctor?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children 4-17 who have been prescribed or have taken prescription medication in the past 6 months

SkipInstructions:

<1> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto NSDUH21]; <2,R,D> [goto
PMEDPSY]

Question ID:

CMS.012_02.000 Instrument Variable Name:

PMEDPSY

QuestionnaireFileName:

Sample Child

*Read if necessary.

QuestionText:

Who FIRST prescribed the medication? Was it
...A psychiatrist, psychologist or other mental health professional?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children 4-17 who were prescribed medication in the past 6 months by someone other than a pediatrician
or other family doctor

SkipInstructions:

<1> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto NSDUH21];
<2,R,D> [goto PMEDNEU]

Question ID:

CMS.012_03.000 Instrument Variable Name:

QuestionText:

PMEDNEU

QuestionnaireFileName:

Sample Child

*Read if necessary.
Who FIRST prescribed the medication? Was it
...A neurologist?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who were prescribed medication in the past 6 months by someone other than a pediatrician,
psychiatrist/ or other family doctor

SkipInstructions:

<1> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto NSDUH21];
<1> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto NSDUH21];
<2,R,D> [goto PMEDOTH]

Page 4 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.012_04.000 Instrument Variable Name:

25-Oct-10

PMEDOTH

QuestionnaireFileName:

Sample Child

*Read if necessary.

QuestionText:

Who FIRST prescribed the medication? Was it
...Someone else?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children 4-17 who were prescribed medication in the past 6 months by someone other than a pediatrician,
family doctor, psychiatrist or neurologist

SkipInstructions:

<1> [goto PMEDSP]; <2,R,D> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto
NSDUH21]

Question ID:

CMS.012_05.000 Instrument Variable Name:

PMEDSP

QuestionnaireFileName:

Sample Child

*Enter the person who prescribed the medication.

QuestionText:

Refused
Don't know
verbatim

7
9
verbatim
UniverseText:

Sample children 4-17 who were prescribed medication in the past 6 months by someone other than a pediatrician,
family doctor, or mental health professional

SkipInstructions:

if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto NSDUH21]

Question ID:

CMS.014_00.000 Instrument Variable Name:

QuestionText:

NSDUH21

QuestionnaireFileName:

Sample Child

Sometimes students get treatment or counseling through the school system for DIFFICULTIES WITH emotions,
concentration, behavior, or being able to get along with others.
DURING THE PAST 6 MONTHS, did [fill: S.C. name] receive any treatment or
counseling FROM A SCHOOL SOCIAL WORKER, SCHOOL PSYCHOLOGIST, SCHOOL NURSE, SCHOOL
COUNSELOR, SPECIAL ED TEACHER, OR SCHOOL SPEECH, OCCUPATIONAL OR PHYSICAL THERAPIST?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NSDUH3]

Page 5 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.015_00.000 Instrument Variable Name:

NSDUH3

25-Oct-10
QuestionnaireFileName:

Sample Child

At any time DURING THE PAST 6 MONTHS did [fill1: S.C. name] attend a school for students with difficulties with
emotions, concentration, behavior, or being able to get along with others?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,> [go to NSDUH31 <2,R,D> [go to NSDUH4]

Question ID:

CMS.015_00.010 Instrument Variable Name:

NSDUH31

QuestionnaireFileName:

Sample Child

Was it a day school or school where {S.C. name} stayed overnight or longer?

QuestionText:

Day School
Overnight School
Refused
Don't know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with
emotions, concentration, behavior, or being able to get along in the past 6 months, and attend a special school

SkipInstructions:

<1> [goto NSDUH32] <2,R,D [got to NSDUH4]

Question ID:

CMS.015_00.020 Instrument Variable Name:

QuestionText:

NSDUH32

QuestionnaireFileName:

Sample Child

Who provided the treatment or counseling?
*Enter all that apply, separate with commas.

1
2
3
4
5
7
9

Special Ed teacher
Other school teacher
School counselor, pychologist, nurse or social worker
School speech, occupational or physical therapist
Other school official
Refused
Don't know

UniverseText:

Sample children 4-17 who participated in a special day school with program for these difficulties

SkipInstructions:

<1-5,R,D> [goto NSDUH4];

Page 6 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.016_00.000 Instrument Variable Name:

25-Oct-10

NSDUH4

QuestionnaireFileName:

Sample Child

Regular schools sometimes provide programs for students with difficulties with emotions, concentration, behavior, or
being able to get along with others.

QuestionText:

DURING THE PAST 6 MONTHS, did [fill1: S.C. name] participate in a school program that was just for students with
these kinds of difficulties?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1> [goto NSDUH5] <2,R,D> if age 4-6 [goto TRETWHR1]; else [goto TRETWHR2]

Question ID:

CMS.017_00.000 Instrument Variable Name:

NSDUH5

QuestionnaireFileName:

Sample Child

Who provided the treatment or counseling?

QuestionText:

*Enter all that apply, separate with commas.
Special Ed teacher
Other school teacher
School counselor, psychologist, nurse or social worker
School speech, occupational or physical therapist
Other school official
Refused
Don’t know

1
2
3
4
5
7
9
UniverseText:

Sample children 4-17 who participated in a special school program for these difficulties

SkipInstructions:

<1-5,R,D> age 4-6 [goto TRETWHR1]; else [goto TRETWHR2]

Question ID:

CMS.020_01.000 Instrument Variable Name:

QuestionText:

TRETWHR1

QuestionnaireFileName:

Sample Child

Now I’d like to ask about places other than {S.C.name}’s school where children and adolescents receive treatment or
counseling for difficulties with emotions, concentration, behavior, or being able to get along with others.
DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
At daycare, child care, or play group?

1
2
7
9

Yes
No
Refused
Don’t know

UniverseText:

Sample children 4-6 who had at least minor difficulties

SkipInstructions:

<1> [goto TRETWHO1] <2,R,D> [goto TRETWHR2]

Page 7 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.020_02.000 Instrument Variable Name:

25-Oct-10

TRETWHO1

QuestionnaireFileName:

Sample Child

(book) C9

QuestionText:

Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
Pediatrician or family doctor
Psychiatrist, psychologist, clinical social worker or psychiatric nurse
Speech, occupational or physical therapist
Religious or spiritual counselor or advisor
Probation of juvenile corrections officer or court counselor
Other
Refused
Don’t know

1
2
3
4
5
6
7
9
UniverseText:

Sample children 4-6 who received counseling at daycare, child care, or play group

SkipInstructions:

<1,3-6,R,D> [goto TRETWHR2] <2> [goto TRTMHP1]

Question ID:

CMS.020_03.000 Instrument Variable Name:

TRTMHP1

QuestionnaireFileName:

Sample Child

You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or psychiatric
nurse. Who was this?

QuestionText:

*Enter all that apply, separate with commas
Psychiatrist
Psychologist
Clinical social worker
Psychiatric nurse
Refused
Don't know

1
2
3
4
7
9
UniverseText:

Sample children 4-6 who received counseling or treatment from mental health provider

SkipInstructions:

<1-4,R,D> [goto TRETWHR2]

Question ID:

CMS.021_01.000 Instrument Variable Name:

QuestionText:

TRETWHR2

QuestionnaireFileName:

Sample Child

[fill2: Now I’d like to ask about places other than {S.C. name}’s school where children and adolescents receive treatment
or counseling for difficulties with emotions, concentration, behavior, or being able to get along with others.]
DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
In an office, clinic or center in your community?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who had at least minor difficulties

SkipInstructions:

<1> [goto TRETWHO2] <2,R,D> [goto TRETWHR3]

Page 8 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.021_02.000 Instrument Variable Name:

25-Oct-10

TRETWHO2

QuestionnaireFileName:

Sample Child

(book) C9

QuestionText:

Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
Pediatrician or family doctor
Psychiatrist, psychologist, clinical social worker or psychiatric nurse
Speech, occupational or physcial therapist
Religious or spiritual counselor or advisor
Probation or juvenile corrections officer or court counselor
Other
Refused
Don't know

1
2
3
4
5
6
7
9
UniverseText:

Sample children 4-17 who received counseling at an office, clinic or community center

SkipInstructions:

<1,3-6,R,D> [goto TRETWHR3] <2> [goto TRTMHP2]

Question ID:

CMS.021_03.000 Instrument Variable Name:

TRTMHP2

QuestionnaireFileName:

Sample Child

You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or psychiatric
nurse. Who was this?

QuestionText:

*Enter all that apply, separate with commas
Psychiatrist
Psychologist
Clinical social worker
Psychiatric nurse
Refused
Don't know

1
2
3
4
7
9
UniverseText:

Sample children 4-17 who received counseling or treatment from mental health provider

SkipInstructions:

<1-4,R,D> [goto TRETWHR3]

Question ID:

CMS.022_01.000 Instrument Variable Name:

QuestionText:

TRETWHR3

2
7
9

Sample Child

DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
In your home, for example, from a visiting teacher or counselor?

1

QuestionnaireFileName:

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who had at least minor difficulties

SkipInstructions:

<1> [goto TRETWHO3] <2,R,D> [goto TRETWHR4]

Page 9 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.022_02.000 Instrument Variable Name:

25-Oct-10

TRETWHO3

QuestionnaireFileName:

Sample Child

(book) C9

QuestionText:

Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
Pediatrician or family doctor
Psychiatrist, psychologist, clinical social worker or psychiatric nurse
Speech, occupational or physical therapist
Religious or spiritual counselor or advisor
Probation or juvenile corrections officer or court counselor
Other
Refused
Don’t know

1
2
3
4
5
6
7
9
UniverseText:

Sample children 4-17 who received counseling at home from visiting teacher or counselor

SkipInstructions:

<1,3-6,R,D> [goto TRETWHR4] <2> [goto TRTMHP3]

Question ID:

CMS.022_03.000 Instrument Variable Name:

TRTMHP3

QuestionnaireFileName:

Sample Child

You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or psychiatric
nurse. Who was this?

QuestionText:

*Enter all that apply, separate with commas
Psychiatrist
Psychologist
Clinical social worker
Psychiatric nurse
Refused
Don’t know

1
2
3
4
7
9
UniverseText:

Sample children 4-17 who received counseling or treatment from mental health provider

SkipInstructions:

<1-4,R,D> [goto TRETWHR4]

Question ID:

CMS.023_01.000 Instrument Variable Name:

QuestionText:

TRETWRE4

2
7
9

Sample Child

DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
In a hospital emergency room, crisis center, or emergency shelter?

1

QuestionnaireFileName:

Yes
No
Refused
Don’t know

UniverseText:

Sample children 4-17 who had at least minor difficulties

SkipInstructions:

<1> [goto TRETWHO4] <2,R,D> [goto TRETWHR5]

Page 10 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.023_02.000 Instrument Variable Name:

25-Oct-10

TRETWHO4

QuestionnaireFileName:

Sample Child

(book) C9

QuestionText:

Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
Pediatrician or family doctor
Psychiatrist, psychologist, clinical social worker or psychiatric nurse
Speech, occupational or physical therapist
Religious or spiritual counselor or advisor
Probation or juvenile corrections officer or court counselor
Other
Refused
Don’t know

1
2
3
4
5
6
7
9
UniverseText:

Sample children 4-17 who received counseling at hospital/ER/crisis center/shelter

SkipInstructions:

<1,3-6,R,D> [goto TRETWHR5] <2> [goto TRTMHP4]

Question ID:

CMS.023_03.000 Instrument Variable Name:

TRTMHP4

QuestionnaireFileName:

Sample Child

You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or psychiatric
nurse. Who was this?

QuestionText:

*Enter all that apply, separate with commas
Psychiatrist
Psychologist
Clinical social worker
Psychiatric nurse
Refused
Don't know

1
2
3
4
7
9
UniverseText:

Sample children 4-17 who received counseling or treatment from mental health provider

SkipInstructions:

<1-4,R,D> [goto TRETWHR5]

Question ID:

CMS.024_01.000 Instrument Variable Name:

QuestionText:

TRETWRE5

2
7
9

Sample Child

DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
At a day treatment program in a hospital or in your community?

1

QuestionnaireFileName:

Yes
No
Refused
Don’t know

UniverseText:

Sample children 4-17 who had at least minor difficulties

SkipInstructions:

<1> [goto TRETWHO5] <2,R,D> [goto TRETWHR6]

Page 11 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.024_02.000 Instrument Variable Name:

25-Oct-10

TRETWHO5

QuestionnaireFileName:

Sample Child

(book) C9

QuestionText:

Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
Pediatrician or family doctor
Psychiatrist, psychologist, clinial social worker or psychiatric nurse
Speech, occupational or physical therapist
Religious or spiritual counselor or advisor
Probation or juvenile corrections officer or court counselor
Other
Refused
Don’t know

1
2
3
4
5
6
7
9
UniverseText:

Sample children 4-17 who received counseling at day treatment program in a hospital or community

SkipInstructions:

<1,3-6,R,D> [goto TRETWHR6] <2> [goto TRTMHP5]

Question ID:

CMS.024_03.000 Instrument Variable Name:

TRTMHP5

QuestionnaireFileName:

Sample Child

You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or psychiatric
nurse. Who was this?

QuestionText:

*Enter all that apply, separate with commas
Psychiatrist
Psychologist
Clinical social worker
Psychiatric nurse
Refused
Don't know

1
2
3
4
7
9
UniverseText:

Sample children 4-17 who received counseling or treatment from mental health provider

SkipInstructions:

<1-4,R,D> [goto TRETWHR6]

Question ID:

CMS.025_01.000 Instrument Variable Name:

QuestionText:

TRETWRE6

2
7
9

Sample Child

DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
Any other place?

1

QuestionnaireFileName:

Yes
No
Refused
Don’t know

UniverseText:

Sample children 4-17 who had at least minor difficulties

SkipInstructions:

<1> [goto TRETWHO6] <2,R,D> [goto OVERNT6M]

Page 12 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.025_02.000 Instrument Variable Name:

25-Oct-10

TRETWHO6

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

(book) C9

QuestionText:

Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
Pediatrician or family doctor
Psychiatrist, psychologist, clinical social worker or psychiatric nurse
Speech, occupational or physical therapist
Religious or spiritual counselor or advisor
Probation or juvenile corrections or court counselor
Other
Refused
Don’t know

1
2
3
4
5
6
7
9
UniverseText:

Sample children 4-17 who received counseling at another place

SkipInstructions:

<1,3-6,R,D> [goto OVERNT6M] <2> [goto TRTMHP6]

Question ID:

CMS.025_03.000 Instrument Variable Name:

TRTMHP6

You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or psychiatric
nurse. Who was this?

QuestionText:

*Enter all that apply, separate with commas
Psychiatrist
Psychologist
Clinical social worker
Psychiatric nurse
Refused
Don’t know

1
2
3
4
7
9
UniverseText:

Sample children 4-17 who received counseling or treatment from mental health provider

SkipInstructions:

<1-4,R,D> [goto OVERNT6M]

Question ID:

CMS.050_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

OVERNT6M

QuestionnaireFileName:

Sample Child

DURING THE PAST 6 MONTHS, in addition to a school you may have told me about, did [fill: S.C. name] stay
overnight or longer in a hospital, any type of group home, any type of juvenile detention center, sometimes called juvie, or
juvenile hall, youth prison, training school or jail, foster care home, or another special type of center or shelter to receive
counseling or treatment for these difficulties?
Yes
No
Refused
Don’t know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1> [goto OVERWHCH] <2,R,D> [goto SH1]

Page 13 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.060_00.000 Instrument Variable Name:

25-Oct-10

OVERWHCH

QuestionnaireFileName:

Sample Child

Which ones?

QuestionText:

*Read list if necessary.
*Enter all that apply, separate with commas.
Hospital
Residential treatment center
Foster care or therapeutic foster care home
In any type of juvenile detention center, sometimes called "juvie", prison, or jail
Group home
Homeless shelter
In another place
Refused
Don’t know

01
02
03
04
05
06
07
97
99
UniverseText:

Sample children 4-17 who stayed overnight in a hospital or other overnight location for difficulties

SkipInstructions:

<1-7,R,D> [goto SH1]

Question ID:

CMS.070_00.000 Instrument Variable Name:

SH1

QuestionnaireFileName:

Sample Child

DURING THE PAST 6 MONTHS, did [fill1: S.C. name] take part in a self-help group for children and youth with these
difficulties?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto SH2]

Question ID:

CMS.080_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

SH2

QuestionnaireFileName:

Sample Child

DURING THE PAST 6 MONTHS, did [fill1: S.C. name] use the Internet to seek treatment or counseling for these
difficulties?
Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto CASEM6M]

Page 14 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.100_00.000 Instrument Variable Name:

25-Oct-10

CASEM6M

QuestionnaireFileName:

Sample Child

Parents and caregivers sometimes get help from people sometimes called case managers or care coordinators who help to
find or organize treatment for children's difficulties with emotions, concentration, behavior, or being able to get along with
others.

QuestionText:

*Read if necessary: This type of help is sometimes called care coordination or case management. People or agencies that
do this work might also help you develop a service plan, contact providers for you, and provide support to you in getting
the help your child or adolescent needs.
DURING THE PAST 6 MONTHS, did you or [fill1: S.C. name] receive this type of help from any individual or agency?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1> [goto CASEMWHO];
<2,R,D> IF PRESCP6M=1 or NSDUH21=1 or NSDUH3=1 or NSDUH4=1 or TRETWHR1=1 or
TRETWHR2=1 or TRETWHR3=1 or TRETWHR4=1 or TRETWHR5=1 or TRETWHR6=1 or OVERNT6M=1
or SH1=1 or SH2=1 or CASEM6M=1 [goto TRETHELP]; else [goto TRTNEED1]

Question ID:

CMS.110_00.000 Instrument Variable Name:

QuestionText:

CASEMWHO

QuestionnaireFileName:

Sample Child

Who provides help arranging or coordinating [fill1: S.C. name]'s care?
*Enter the MAIN answer.

01
02
03
04
05
06
07
08
09
10
97
99

Child welfare/social services/family and child services agency
School or educational system
Mental health agency
Private mental health professional
Juvenile justice agency or court system
Private insurance service
Family or friend
Pediatrician or other family doctor
Family or youth advocacy groups
Other
Refused
Don't know

UniverseText:

Sample children 4-17 who received help from case managers/care coordinators in the past 6 months

SkipInstructions:

<1-10,R,D> if PRESCP6M=1 or NSDUH21=1 or NSDUH3=1 or NSDUH4=1 or TRETWHR1=1 or
TRETWHR2=1 or TRETWHR3=1 or TRETWHR4=1 or TRETWHR5=1 or TRETWHR6=1 or
OVERNT6M=1 or SH1=1 or SH2=1 or CASEM6M=1 [goto TRETHELP]; else [goto TRTNEED1]

Page 15 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.115_00.000 Instrument Variable Name:

25-Oct-10

TRETHELP

QuestionnaireFileName:

Sample Child

You told us that [S.C. child] has received treatment or counseling for difficulties with emotions, behaviors, concentrations
or getting along with others. During the past 6 months, how much has this treatment or counseling helped [S.C. child]?
Would you say…

QuestionText:

* Read answer categories below.
Not at all
A little
Some
A lot
Refused
Don’t know

1
2
3
4
7
9
UniverseText:

Sample children 4-17 who received treatment in the past 6 months

SkipInstructions:

<1-4,R,D> [goto TRPAYPHI]

Question ID:

CMS.120_01.000 Instrument Variable Name:

TRPAYPHI

QuestionnaireFileName:

Sample Child

Next I'm going to read a list of ways that treatment and counseling get paid for. Please tell me who pays or paid for [fill1:
S.C. name]'s treatment or counseling during the past 6 months.

QuestionText:

Private health insurance, such as insurance that comes with a job?
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto TRPAYSCH]

Question ID:

CMS.120_02.000 Instrument Variable Name:

QuestionText:

TRPAYSCH

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.
School system?

1
2
7
9

Yes
No
Refused
Don’t know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto TRPAYSLF]

Page 16 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.120_03.000 Instrument Variable Name:

25-Oct-10

TRPAYSLF

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.

QuestionText:

You or your family (sometimes called out of pocket or co-payment)?
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto TRPAYMED]

Question ID:

CMS.120_04.000 Instrument Variable Name:

TRPAYMED

QuestionnaireFileName:

Sample Child

(Book) F14

QuestionText:

*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.
Medicaid?
*Read if necessary: In this State it is also called *(Refer to flashcard F14 for state Medicaid names).
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto TRPAYCHP]

Question ID:

CMS.120_05.000 Instrument Variable Name:

QuestionText:

TRPAYCHP

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.
[fill2: A state SCHIP/CHIP program?/ [STNAME1]]?

1
2
7
9

Yes
No
Refused
Don’t know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto TRPAYMIL]

Page 17 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.120_06.000 Instrument Variable Name:

25-Oct-10

TRPAYMIL

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.

QuestionText:

Military health care?
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto TRPAYSHP]

Question ID:

CMS.120_07.000 Instrument Variable Name:

TRPAYSHP

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.

QuestionText:

Some other state or county sponsored health plan, Medicare or other government program?
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1> [goto TRPAYSP] <2,R,D> [goto TRPAYIHS]

Question ID:

CMS.120_08.000 Instrument Variable Name:

QuestionText:
7
9
Verbatim

TRPAYSP

QuestionnaireFileName:

*Enter the name of the state sponsored health plan, Medicare, or other government program.
Refused
Don’t know
Verbatim

UniverseText:

Sample children 4-17 who paid for treatment with a state sponsored health plan, etc.

SkipInstructions:

[goto TRPAYIHS]

Sample Child

Page 18 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.120_09.000 Instrument Variable Name:

25-Oct-10

TRPAYIHS

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.

QuestionText:

Indian Health Service?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1,2,R,D> [goto TRPAYOTH]

Question ID:

CMS.120_10.000 Instrument Variable Name:

TRPAYOTH

QuestionnaireFileName:

Sample Child

*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.

QuestionText:

Some other source?
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1> [goto TRPAYOTS];
<2,R,D> if TRPAYPHI=2,R,D and TRPAYSCH=2,R,D and TRPAYSLF=2,R,D and TRPAYMED=2,R,D and
TRPAYCHP=2,R,D and TRPAYMIL=2,R,D and TRPAYSHP=2,R,D and TRPAYIHS=2,R,D and
TRPAYOTH=2,R,D [goto TRETFREE]; else [goto TRTNEED1]

Question ID:

CMS.120_11.000 Instrument Variable Name:

QuestionText:
7
9
Verbatim

TRPAYOTS

QuestionnaireFileName:

*Enter the name of the other source.
Refused
Don’t know
Verbatim

UniverseText:

Sample children 4-17 who paid for treatment with some other source

SkipInstructions:

[goto TRTNEED1]

Sample Child

Page 19 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.120_12.000 Instrument Variable Name:

TRETFREE

QuestionnaireFileName:

Sample Child

Was ALL OF THE treatment or counseling [fill1: S.C. name] RECEIVED during the past 6 months free?

QuestionText:

Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children 4-17 who did not pay for treatment

SkipInstructions:

<1,2,R,D>[goto TRTNEED1]

Question ID:

25-Oct-10

CMS.150_00.000 Instrument Variable Name:

TRTNEED1

QuestionnaireFileName:

Sample Child

DURING THE PAST 6 MONTHS, did [fill1: S.C. name] need treatment or counseling for these difficulties but didn't get
it ?

QuestionText:

Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months

SkipInstructions:

<1> [goto NTRTCOST] <2,R,D> [goto next section]

Question ID:

CMS.150_01.000 Instrument Variable Name:

QuestionText:

NTRTCOST

QuestionnaireFileName:

Sample Child

Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Help was too expensive?

1
2
7
9

Yes
No
Refused
Don’t know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTLOC]

Page 20 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.150_02.000 Instrument Variable Name:

25-Oct-10

NTRTLOC

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:

QuestionText:

Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You didn't know where to go?
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTNEXP]

Question ID:

CMS.150_03.000 Instrument Variable Name:

NTRTNEXP

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:

QuestionText:

Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You had a negative experience with professionals?
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTFEAR]

Question ID:

CMS.150_04.000 Instrument Variable Name:

QuestionText:

NTRTFEAR

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You are afraid or you don't like professionals?

1
2
7
9

Yes
No
Refused
Don’t know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTLOSE]

Page 21 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.150_05.000 Instrument Variable Name:

25-Oct-10

NTRTLOSE

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:

QuestionText:

Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You were afraid [fill1: S.C. name] would be taken from your home or that you would lose your parental rights or custody?
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTSAY]

Question ID:

CMS.150_06.000 Instrument Variable Name:

NTRTSAY

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:

QuestionText:

Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You were afraid of what your family or friends would say?
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTWAIT]

Question ID:

CMS.150_07.000 Instrument Variable Name:

QuestionText:

NTRTWAIT

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You had to wait a long time for an appointment?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTTRAN]

Page 22 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.150_08.000 Instrument Variable Name:

25-Oct-10

NTRTTRAN

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:

QuestionText:

Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You had no way to get there?
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTINCV]

Question ID:

CMS.150_09.000 Instrument Variable Name:

NTRTINCV

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:

QuestionText:

Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Services were too inconvenient to use?
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTFAR]

Question ID:

CMS.150_10.000 Instrument Variable Name:

QuestionText:

NTRTFAR

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Services were too far away?

1
2
7
9

Yes
No
Refused
Don’t know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTCHNO]

Page 23 of 23

2011 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:

CMS.150_11.000 Instrument Variable Name:

25-Oct-10

NTRTCHNO

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:

QuestionText:

Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
[fill1: S.C. name] did not want to go?
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1,2,R,D> [goto NTRTOTH]

Question ID:

CMS.150_12.000 Instrument Variable Name:

QuestionText:

NTRTOTH

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Some other reason?

1
2
7
9

Yes
No
Refused
Don’t know

UniverseText:

Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months

SkipInstructions:

<1> [goto NTRTSPEC] <2,R,D> [goto next section]

Page 1 of 3

2011 NHIS Questionnaire - Sample Child
Child Influenza Immunization
Document Version Date:
Question ID:

CFI.005_00.010

QuestionText:

Instrument Variable Name:

21-Oct-10

CH1N_1R

QuestionnaireFileName:

Sample Child

During the past 12 months, several kinds of flu vaccines have been available. I will ask you about {S.C. name’s} most
recent flu vaccinations.
DURING THE PAST 12 MONTHS, has {SC name} had a flu vaccination? A flu vaccination is usually given in the fall
and protects against influenza for the flu season.
*Read if necessary: {fill: SC name}’s most recent flu vaccination could have been the new 2010-2011 flu vaccine
available starting this fall, or either of the two types available last season, one called “seasonal” and the other called
“H1N1” or “swine” flu vaccine.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample Child LE 17 years

SkipInstructions:

<1> [goto CH1N_2R] <2,R,D> [goto next section]

Question ID:

CFI.005_00.020

QuestionText:
1
2
7
9

Instrument Variable Name:

CH1N_2R

QuestionnaireFileName:

How many vaccinations has {S.C. name} received?
1 vaccination or dose
2 or more vaccination doses
Refused
Don't know

UniverseText:

Sample Child LE 17 years who have had a vaccine dose in the past 12 months

SkipInstructions:

<1,2> [goto CH1N_3MR] [goto next section]

Sample Child

Page 2 of 3

2011 NHIS Questionnaire - Sample Child
Child Influenza Immunization
Document Version Date:
Question ID:

CFI.005_00.030

QuestionText:

Instrument Variable Name:

21-Oct-10

CH1N_3MR

QuestionnaireFileName:

Sample Child

1 of 2
During what month and year did {S.C. name} receive {fill: his/her} most recent flu vaccine?

01

January
February
March
April
May
June
July
August
September
October
November
December
Refused
Don't know

02
03
04
05
06
07
08
09
10
11
12
97
99
UniverseText:

Sample Child LE 17 who have had one or more vaccine doses in the past 12 months

SkipInstructions:

<1-12,D> [ goto CH1N_4YR] [goto CH1N_5R]

Question ID:

CFI.005_00.040

QuestionText:

Instrument Variable Name:

CH1N_4YR

QuestionnaireFileName:

Sample Child

2 of 2
*Enter year of most recent flu vaccine.

Year

Year
Refused
Don't know

9997
9999
UniverseText:

Sample Child LE 17 years who have had one or more vaccine doses in the past 12 months and gave month/don't
know month of vaccine dose

SkipInstructions:

[goto CH1N_5R]
[If CH1N_3MR and CH1N_4YR = a future date] goto ERR1_ CH1N_4YR]
[If CH1N_3MR and CH1N_4YR = a date prior to birth] goto ERR2_ CH1N_4YR]
[If CH1N_3MR and CH1N_4YR = a date prior to 12 months ago] goto ERR3_ CH1N_4YR]

Question ID:

CFI.005_00.050

QuestionText:

Instrument Variable Name:

CH1N_5R

QuestionnaireFileName:

Was this a shot, or was it a vaccine sprayed in the nose?
*Read if necessary: The flu nasal spray is called FluMistTM.

1
2
7
9

Flu shot
Flu nasal spray (spray, mist or drop in nose)
Refused
Don't know

UniverseText:

Sample Child LE 17 years who have had one or more vaccine doses in the past 12 months

SkipInstructions:

<1-2,R,D> if CH1N_2R=1 [goto next section]; else if CH1N_2R=2 [goto CH1N_6MR]

Sample Child

Page 3 of 3

2011 NHIS Questionnaire - Sample Child
Child Influenza Immunization
Document Version Date:
Question ID:

CFI.005_00.060

QuestionText:

Instrument Variable Name:

21-Oct-10

CH1N_6MR

QuestionnaireFileName:

Sample Child

1 of 2
During what month and year did {S.C. name} receive {fill: his/her} next most recent flu vaccine?

01

January
February
March
April
May
June
July
August
September
October
November
December
Refused
Don't know

02
03
04
05
06
07
08
09
10
11
12
97
99
UniverseText:

Sample Child LE 17 years who have had more than one vaccine dose in the past 12 months

SkipInstructions:

<1-12,D> [ goto CH1N_7YR] [goto CH1N_8R]

Question ID:

CFI.005_00.070

QuestionText:

Instrument Variable Name:

CH1N_7YR

QuestionnaireFileName:

Sample Child

2 of 2
*Enter year of next most recent flu vaccine.

Year

Year
Refused
Don't know

9997
9999
UniverseText:

Sample Child LE 17 years who have had more than one vaccine dose in the past 12 months and gave month/don't
know month of vaccine dose

SkipInstructions:

[goto CH1N_8R]
[If CH1N_6MR and CH1N_7YR = a future date] goto ERR1_ CH1N_7YR]
[If CH1N_6MR and CH1N_7YR = a date prior to birth] goto ERR2_ CH1N_7YR]
[If CH1N_6MR and CH1N_7YR = a date prior to 12 months ago] goto ERR3_ CH1N_7YR]

Question ID:

CFI.005_00.080

QuestionText:

Instrument Variable Name:

CH1N_8R

QuestionnaireFileName:

Was this a shot, or was it a vaccine sprayed in the nose?
*Read if necessary: The flu nasal spray is called FluMistTM.

1
2
7
9

Flu shot
Flu nasal spray (spray, mist or drop in nose)
Refused
Don't know

UniverseText:

Sample Child LE 17 years who have had more than one vaccine dose in the past 12 months

SkipInstructions:

<1-2,R,D> [goto next section]

Sample Child

Page 1 of 2

2011 NHIS Questionnaire - Sample Child
Child Disability
Document Version Date:
Question ID:

CDB.020_00.000 Instrument Variable Name:

QuestionText:

25-Oct-10

P2DCHEAR

QuestionnaireFileName:

Sample Child

With this next set of questions, we want to learn about people who have physical, mental, or emotional conditions that
cause serious difficulties with their daily activities. Though different, these questions may sound similar to ones I asked
earlier.
Is {S.C. name} deaf or does {S.C. name} have serious difficulty hearing?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 1-17 years and random number generator=1

SkipInstructions:

<1,2,D,R> goto P2DCSEE

Question ID:

CDB.040_00.000 Instrument Variable Name:

QuestionText:

P2DCSEE

Sample Child

Is {S.C. name} blind or does {S.C. name} have serious difficulty seeing even when wearing glasses?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 1-17 years and random number generator=1

SkipInstructions:

<1,2,D,R> goto P2DCCON

Question ID:

QuestionnaireFileName:

CDB.060_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

P2DCCON

QuestionnaireFileName:

Sample Child

Because of a physical, mental, or emotional condition, does {S.C. name} have serious difficulty concentrating,
remembering, or making decisions?
Yes
No
Refused
Don't know

UniverseText:

Sample children 5-17 years and random number generator=1

SkipInstructions:

<1,2,D,R> goto P2DCWALK

Page 2 of 2

2011 NHIS Questionnaire - Sample Child
Child Disability
Document Version Date:
Question ID:

CDB.080_00.000 Instrument Variable Name:

QuestionText:

25-Oct-10

P2DCWALK

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 5-17 years and random number generator=1

SkipInstructions:

<1,2,D,R> goto P2DCDRES

CDB.100_00.000 Instrument Variable Name:

QuestionText:

P2DCDRES

Does {S.C. name} have difficulty dressing or bathing?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample children 5-17 years and random number generator=1

SkipInstructions:

<1,2,D,R> goto P2DCERR

Question ID:

Sample Child

Does {S.C. name} have serious difficulty walking or climbing stairs?

1

Question ID:

QuestionnaireFileName:

CDB.120_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

P2DCERR

Because of a physical, mental, or emotional condition, does {S.C. name} have difficulty doing errands alone such as
visiting a doctor's office or shopping?
Yes
No
Refused
Don't know

UniverseText:

Sample children 15-17 years and random number generator=1

SkipInstructions:

<1,2,D,R> goto end of section