Download:
pdf |
pdfAttachment 3c Sample Child Core (9 minutes)
Page 1 of 9
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
Question ID:
CID.001_00.000 Instrument Variable Name:
QuestionText:
01-25
08-Aug-12
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
Hard Edit:
ERR_CURRES
* You have selected a non-selectable person.
* Please correct.
Page 2 of 9
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
Question ID:
CID.010_00.000 Instrument Variable Name:
QuestionText:
08-Aug-12
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
96
Person # of person available to answer questions about Sample Child
No person available
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
Hard Edit:
ERR_CSPAVAIL
* You have selected a non-selectable person.
* Please correct.
Page 3 of 9
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
Question ID:
CID.030_00.000 Instrument Variable Name:
08-Aug-12
CSRELTIV
QuestionnaireFileName:
Sample Child
QuestionnaireFileName:
Sample Child
(book) C1
QuestionText:
[fill1: The next questions are about [fill2: ALIAS of Sample Child].]
What is your relationship to [fill2: ALIAS of Sample Child]?
Parent (Biological, adoptive, or step)
Grandparent
Aunt/Uncle
Brother/Sister
Other relative
Legal guardian
Foster parent
Other non-relative
Refused
Don't know
01
02
03
04
05
06
07
08
97
99
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]
Question ID:
CID.040_00.000 Instrument Variable Name:
QuestionText:
CSPVERF_S
* 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
2
Yes
No
UniverseText:
Respondent is not the person entered in HHRESP or RELRESP_A.
SkipInstructions:
<1> goto CSPVERF_A
<2> goto NEWSEX
Page 4 of 9
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
Question ID:
CID.041_00.000 Instrument Variable Name:
08-Aug-12
NEWSEX
QuestionnaireFileName:
Sample Child
QuestionnaireFileName:
Sample Child
Is [fill: ALIAS of Sample Child] Male or Female?
QuestionText:
* If don't know or refused enter your best guess.
Male
Female
1
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
ERR_NEWSEX
Hard Edit:
* The gender will now be changed to [fill: NEWSEX].
goto CSPVERF_S (as the default goto)
Question ID:
CID.042_00.000 Instrument Variable Name:
QuestionText:
CSPVERF_A
* 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 5 of 9
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
Question ID:
CID.043_00.000 Instrument Variable Name:
08-Aug-12
NEWAGE
QuestionnaireFileName:
Sample Child
How old is [fill1: ALIAS of Sample Child]?
QuestionText:
* If age given in months, weeks, or days, convert age to appropriate year. If less than one year old, enter "0".
Age in years
000-120
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
ERR_NEWAGE
Hard Edit:
*Age of [fill1: ALIAS of Sample Child] remains [fill2: Age of Sample Child] years old.
goto CSPVERF_A (whether suppressed or not)
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 6 of 9
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
Question ID:
CID.046_01.000 Instrument Variable Name:
08-Aug-12
NEWDOB_M
QuestionnaireFileName:
Sample Child
1 of 3
QuestionText:
What is [fill: ALIAS of Sample Child]'s birthday?
*Enter month of birth.
January
October
November
December
February
March
April
May
June
July
August
September
1
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
Hard Edit:
ERR_NEWDOB_D
* [fill2: NEWDOB_D] is not a valid day for [fill3: NEWDOB_M].
* Please correct.
Sample Child
Page 7 of 9
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
Question ID:
QuestionText:
CID.046_03.000 Instrument Variable Name:
3 of 3
* Enter year of birth.
1880-2020
Year of birth
08-Aug-12
NEWDOB_Y
QuestionnaireFileName:
Sample Child
Page 8 of 9
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
08-Aug-12
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
Hard Edit:
ERR1_NEWDOB_Y
*Future date invalid: [fill2: , ]
*Please correct.
goto NEWDOB_M (whether suppressed or not)
ERR2_NEWDOB_Y
*Not a valid day: [fill2: , ]
*Please correct.
goto NEWDOB_M (whether suppressed or not)
ERR3_NEWDOB_Y
*DOB of [fill1: ALIAS of Sample Child] remains [fill3: , ]
goto CSPVERF_A
ERR4_NEWDOB_Y
*Data mismatched. Please fix Age or Birthday.
Page 9 of 9
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date:
goto CSPVERF_A (whether suppressed or not)
08-Aug-12
Page 1 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.010_01.000 Instrument Variable Name:
08-Aug-12
BWGT_LB
QuestionnaireFileName:
Sample Child
?[F1]
QuestionText:
What was [fill: S.C.name]'s birth weight?
* Enter 'M' to record metric measurements.
1-15 pounds
Refused
Don't know
Metric
01-15
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, D, R> goto ERR2_BWGT_LB]
ERR2_BWGT_LB
Hard Edit:
* Only "1-15" or "M" or "Don't know/Refused" allowed in this field.
* Please correct.
ERR1_BWGT_LB
Soft Edit:
* [fill: BWGT_LB] is an unusually high number.
* Please verify.
Question ID:
CHS.010_02.000 Instrument Variable Name:
QuestionText:
00-15
97
99
Blank
BWGT_OZ
QuestionnaireFileName:
* Enter ounces.
0-15 ounces
Refused
Don't know
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, D, R> and BWGT_OZ = go to CHGT_FT]
Sample Child
Page 2 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.011_00.000 Instrument Variable Name:
08-Aug-12
BWGT_GR
QuestionnaireFileName:
Sample Child
* Enter weight in grams.
QuestionText:
500 grams or less
501-6899 grams
6900+ grams
Refused
Don't know
0500
0501-6899
6900
9997
9999
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]
Soft Edit:
ERR_BWGT_GR
* [fill1: BWGT_GR] is an unusually high number (equal to [fill2] pounds, [fill3] ounces).
* Please verify.
Question ID:
CHS.020_01.000 Instrument Variable Name:
QuestionText:
CHGT_FT
QuestionnaireFileName:
Sample Child
?[F1]
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
97
99
M
0-7 feet
Refused
Don't know
Metric
UniverseText:
Sample children 12+
SkipInstructions:
[goto CHGT_IN]
<0-7> [goto CHGT_IN]
[goto CWGT_LB]
[goto CHGT_M]
[If NE <0-7, M, D, R> go to ERR_CHGT_FT]
Hard Edit:
ERR_CHGT_FT
* Only "0-7" or "M" or "Don't know/Refused" allowed in this field.
* Please correct.
Page 3 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.020_02.000 Instrument Variable Name:
QuestionText:
00-36
97
99
08-Aug-12
CHGT_IN
QuestionnaireFileName:
* Enter inches.
0-36 inches
Refused
Don't know
UniverseText:
Sample children 12+ whose height in feet is 0-7 or is left empty.
SkipInstructions:
<0-36,R,D> If (CHGT_FT = ‘0’, ’empty’) and (CHGT_IN = ‘0’, ‘empty’)
goto ERR1_CHGT_IN
elseif CHGT_FT = ‘1-7’ and CHGT_IN ge ‘12’
goto ERR2_CHGT_IN
elseif (SEX = ‘1’ and
AGE = ‘12’ and (CHTINCH lt ‘53’ or CHTINCH gt ‘68’)) or
AGE = ‘13’ and (CHTINCH lt ‘55’ or CHTINCH gt ‘72’)) or
AGE = ‘14’ and (CHTINCH lt ‘58’ or CHTINCH gt ‘73’)) or
AGE = ‘15’ and (CHTINCH lt ‘60’ or CHTINCH gt ‘74’)) or
AGE = ‘16’ and (CHTINCH lt ‘61’ or CHTINCH gt ‘74’)) or
AGE = ‘17’ and (CHTINCH lt ‘62’ or CHTINCH gt ‘75’)) or
(SEX = ‘2’ and
AGE = ‘12’ and (CHTINCH lt ‘54’ or CHTINCH gt ‘68’)) or
AGE = ‘13’ and (CHTINCH lt ‘55’ or CHTINCH gt ‘69’)) or
AGE = ‘14’ and (CHTINCH lt ‘57’ or CHTINCH gt ‘69’)) or
AGE = ‘15’ and (CHTINCH lt ‘57’ or CHTINCH gt ‘69’)) or
AGE = ‘16’ and (CHTINCH lt ‘57’ or CHTINCH gt ‘70’)) or
AGE = ‘17’ and (CHTINCH lt ‘57’ or CHTINCH gt ‘69’))
goto ERR3_CHGT_IN
else
goto CWGT_LB
Hard Edit:
ERR1_CHGT_IN
* Must enter an answer in at least the inches item.
* Please correct.
ERR2_CHGT_IN
* Number of inches exceeds maximum allowed.
* Please correct.
Soft Edit:
ERR3_CHGT_IN
* Please verify that the height was entered correctly. Probe only if necessary.
Sample Child
Page 4 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.021_01.000 Instrument Variable Name:
QuestionText:
CHGT_M
08-Aug-12
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,empty> [goto CHGT_CM]
[goto CWGT_LB]
Page 5 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.021_02.000 Instrument Variable Name:
QuestionText:
000-241
Blank
08-Aug-12
CHGT_CM
QuestionnaireFileName:
Sample Child
* Enter centimeters.
0-241 centimeters
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,R,D> If (CHGT_M = ‘0’, ’empty’) and (CHGT_CM = ‘0’, ‘empty’)
goto ERR1_CHGT_CM
elseif (CHGT_M eq ‘2’ and CHGT_CM gt ‘41’) or (CHGT_M eq ‘1’ and CHGT_CM gt ‘141’)
goto ERR2_CHGT_CM
elseif (SEX = ‘1’ and
AGE = ‘12’ and (CHTCM lt ‘137’ or CHTCM gt ‘174’)) or
AGE = ‘13’ and (CHTCM lt ‘140’ or CHTCM gt ‘184’)) or
AGE = ‘14’ and (CHTCM lt ‘148’ or CHTCM gt ‘186’)) or
AGE = ‘15’ and (CHTCM lt ‘152’ or CHTCM gt ‘189’)) or
AGE = ‘16’ and (CHTCM lt ‘156’ or CHTCM gt ‘189’)) or
AGE = ‘17’ and (CHTCM lt ‘157’ or CHTCM gt ‘192’)) or
(SEX = ‘2’ and
AGE = ‘12’ and (CHTCM lt ‘138’ or CHTCM gt ‘173’)) or
AGE = ‘13’ and (CHTCM lt ‘141’ or CHTCM gt ‘176’)) or
AGE = ‘14’ and (CHTCM lt ‘145’ or CHTCM gt ‘176’)) or
AGE = ‘15’ and (CHTCM lt ‘145’ or CHTCM gt ‘177’)) or
AGE = ‘16’ and (CHTCM lt ‘145’ or CHTCM gt ‘177’)) or
AGE = ‘17’ and (CHTCM lt ‘145’ or CHTCM gt ‘176’))
goto ERR3_CHGT_CM
else
goto CWGT_LB
Hard Edit:
ERR1_CHGT_CM
* Must enter an answer at least in the centimeters item.
* Please correct.
ERR2_CHGT_CM
* Total height exceeds maximum allowed.
* Please correct.
Soft Edit:
ERR3_CHGT_CM
* Please verify that the height was entered correctly. Probe only if necessary.
Page 6 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.022_00.000 Instrument Variable Name:
QuestionText:
08-Aug-12
CWGT_LB
QuestionnaireFileName:
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
997
999
M
1-500 pounds
Refused
Don't know
Metric
UniverseText:
Sample children 12+
SkipInstructions:
<1-500> if CWGT_LB lt ‘1’ or CWGT_LB gt ‘500’
goto ERR1_CWGT_LB
elseif (SEX = ‘1’ and
AGE = ‘12’ and (CWGT_LB lt ‘62’ or CWGT_LB gt ‘209’)) or
AGE = ‘13’ and (CWGT_LB lt ‘70’ or CWGT_LB gt ‘247’)) or
AGE = ‘14’ and (CWGT_LB lt ‘83’ or CWGT_LB gt ‘266’)) or
AGE = ‘15’ and (CWGT_LB lt ‘94’ or CWGT_LB gt ‘267’)) or
AGE = ‘16’ and (CWGT_LB lt ‘98’ or CWGT_LB gt ‘306’)) or
AGE = ‘17’ and (CWGT_LB lt ‘106’ or CWGT_LB gt ‘317’)) or
(SEX = ‘2’ and
AGE = ‘12’ and (CWGT_LB lt ‘62’ or CWGT_LB gt ‘212’)) or
AGE = ‘13’ and (CWGT_LB lt ‘73’ or CWGT_LB gt ‘238’)) or
AGE = ‘14’ and (CWGT_LB lt ‘84’ or CWGT_LB gt ‘252’)) or
AGE = ‘15’ and (CWGT_LB lt ‘84’ or CWGT_LB gt ‘238’)) or
AGE = ‘16’ and (CWGT_LB lt ‘87’ or CWGT_LB gt ‘257’)) or
AGE = ‘17’ and (CWGT_LB lt ‘90’ or CWGT_LB gt ‘292’))
goto ERR2_CWGT_LB
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE ge ‘2’
goto ADD_1
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE lt ‘2’
goto ADD1_2
else
calculate the BMI (Body Mass Index) – See CBMI spec page
if AGE ge ‘2’
goto ADD_1
else
goto ADD1_2
goto CWGT_KG
Hard Edit:
ERR1_CWGT_LB
* Weight is out of range (1-500).
* Please correct.
Soft Edit:
ERR2_CWGT_LB
* Please verify that the weight was entered correctly. Probe only if necessary.
Sample Child
Page 7 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.023_00.000 Instrument Variable Name:
QuestionText:
002-226
08-Aug-12
CWGT_KG
QuestionnaireFileName:
* Enter weight in kilograms.
2-226 kilograms
UniverseText:
Sample children 12+ whose weight will be entered in metric.
SkipInstructions:
<2-226> if CWGT_KG lt ‘2’ or CWGT_KG gt ‘226’
goto ERR1_CWGT_KG
elseif (SEX = ‘1’ and
AGE = ‘12’ and (CWGT_KG = ‘28’ or CWGT_KG = ‘95’)) or
AGE = ‘13’ and (CWGT_KG = ‘32’ or CWGT_KG = ‘112’)) or
AGE = ‘14’ and (CWGT_KG = ‘38’ or CWGT_KG = ‘121’)) or
AGE = ‘15’ and (CWGT_KG = ‘42’ or CWGT_KG = ‘121’)) or
AGE = ‘16’ and (CWGT_KG = ‘44’ or CWGT_KG = ‘139’)) or
AGE = ‘17’ and (CWGT_KG = ‘48’ or CWGT_KG = ‘144’)) or
(SEX = ‘2’ and
AGE = ‘12’ and (CWGT_KG = ‘28’ or CWGT_KG = ‘96’)) or
AGE = ‘13’ and (CWGT_KG = ‘33’ or CWGT_KG = ‘108’)) or
AGE = ‘14’ and (CWGT_KG = ‘38’ or CWGT_KG = ‘114’)) or
AGE = ‘15’ and (CWGT_KG = ‘38’ or CWGT_KG = ‘108’)) or
AGE = ‘16’ and (CWGT_KG = ‘39’ or CWGT_KG = ‘117’)) or
AGE = ‘17’ and (CWGT_KG = ‘41’ or CWGT_KG = ‘133’))
goto ERR2_CWGT_KG
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE ge ‘2’
goto ADD_1
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE lt ‘2’
goto ADD1_2
else
calculate the BMI (Body Mass Index) – See CBMI spec page
if AGE ge ‘2’
goto ADD_1
else
goto ADD1_2
Hard Edit:
ERR1_CWGT_KG
* Weight is out of range (2-226).
* Please correct.
Soft Edit:
ERR2_CWGT_KG
* Please verify that the weight was entered correctly. Probe only if necessary.
Sample Child
Page 8 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.031_02.000 Instrument Variable Name:
08-Aug-12
ADD1_2
QuestionnaireFileName:
Sample Child
Has a doctor or health professional ever told you that [fill: S.C. name] had…
QuestionText:
an intellectual disability, also known as mental retardation?
Yes
No
Refused
Don't know
1
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:
?[F1]
* 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
SkipInstructions:
<1,2,R,D> [goto CONDL]
Sample Child
Page 9 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.032_01.000 Instrument Variable Name:
08-Aug-12
ADD_1
QuestionnaireFileName:
Sample Child
?[F1]
QuestionText:
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)?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children 2-17
SkipInstructions:
<1,2,R,D> [go to ADD_2]
Question ID:
CHS.032_02.000 Instrument Variable Name:
QuestionText:
ADD_2
QuestionnaireFileName:
* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had….
an intellectual disability, also known as mental retardation?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children 2-17
SkipInstructions:
<1,2,R,D> [go to ADD_3]
Sample Child
Page 10 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.032_03.000 Instrument Variable Name:
ADD_3
08-Aug-12
QuestionnaireFileName:
Sample Child
?[F1]
QuestionText:
* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children 2-17
SkipInstructions:
<1,2,R,D> [go to CONDL]
Question ID:
CHS.060_00.000 Instrument Variable Name:
QuestionText:
CONDL
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
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children <18
SkipInstructions:
<1> [goto CONDL1] <2,R,D> [goto CPOX]
Page 11 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.061_00.000 Instrument Variable Name:
08-Aug-12
CONDL1
QuestionnaireFileName:
Sample Child
CPOX
QuestionnaireFileName:
Sample Child
(book) C2 ?[F1]
QuestionText:
Which ones?
* Enter all that apply, separate with commas.
Down syndrome
Cerebral palsy
Muscular dystrophy
Cystic fibrosis
Sickle cell anemia
Autism/Autism spectrum disorder
Diabetes
Arthritis
Congenital heart disease
Other heart condition
01
02
03
04
05
06
07
08
09
10
UniverseText:
Sample children <18 and CONDL=1
SkipInstructions:
<1-10, R,D> [go to CPOX]
Question ID:
CHS.070_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
Has [fill: SC Name] EVER had chickenpox?
Yes
No
Refused
Don't know
UniverseText:
Sample children <18
SkipInstructions:
<1> [go to CPOX12MO]
<2, D, R> [go to CASHMEV]
Page 12 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.072_00.000 Instrument Variable Name:
CPOX12MO
QuestionnaireFileName:
Sample Child
Has [fill: SC name] had chickenpox DURING THE PAST 12 MONTHS?
QuestionText:
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children <18 who have had chickenpox
SkipInstructions:
<1,2,R,D> [goto CASHMEV]
Question ID:
08-Aug-12
CHS.080_00.000 Instrument Variable Name:
CASHMEV
QuestionnaireFileName:
Sample Child
? [F1]
QuestionText:
Has a doctor or other health professional EVER told you that [fill: SC name] had asthma?
Yes
No
Refused
Don't know
1
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:
CHS.085_00.000 Instrument Variable Name:
QuestionText:
Does [fill: SC name] still have asthma?
1
2
7
9
CASSTILL
QuestionnaireFileName:
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 13 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.090_00.000 Instrument Variable Name:
08-Aug-12
CASHYR
QuestionnaireFileName:
Sample Child
The following questions are about [fill: SC name]'s asthma DURING THE PAST 12 MONTHS.
QuestionText:
DURING THE PAST 12 MONTHS, has [fill: SC name] had an episode of asthma or an asthma attack?
Yes
No
Refused
Don't know
1
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:
CASMERYR
QuestionnaireFileName:
DURING THE PAST 12 MONTHS, did [fill1: SC name] have to visit an emergency room or urgent care center because
of [fill2: his/her] asthma?
QuestionText:
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children <18 and doctor has informed that child had asthma
SkipInstructions:
<1,2,R,D> if CASSTILL=1 or CASHYR=1 [go to CASMHSP];
else if CASSTILL=2,R,D and CASHYR=2,R,D and AGE LE 2 [go to CCONDT1_1];
else [go to CCONDT_1]
Question ID:
Sample Child
CHS.100_00.010 Instrument Variable Name:
QuestionText:
1
2
7
9
CASMHSP
QuestionnaireFileName:
Sample Child
DURING THE PAST 12 MONTHS, has [fill: S.C. name] stayed overnight in a hospital because of asthma?
Yes
No
Refused
Don't know
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to CWZMSWK]
Page 14 of 38
DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.030 Instrument Variable Name:
08-Aug-12
CWZMSWK
QuestionnaireFileName:
Sample Child
DURING THE PAST 12 MONTHS, HOW MANY DAYS of [fill1: daycare or preschool/fill2: school/fill3: school or
work] did [fill: S.C. name] miss because of [fill: his/her] asthma?
QuestionText:
*Enter '0' for none.
*Enter 995 if child home schooled.
*Enter 996 if child did not go to [fill1: daycare or preschool/fill2: school/fill3: school or work].
000-365 days
Child was home schooled
child did not go to day care, preschool, school, or work
Refused
Don't know
000-365
995
996
997
999
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<0-100,995,996,R,D> [go to CASMPMED]
<101-365> [go to ERR1_CWZMSWK]
<366-994> [go to ERR2_CWZMSWK]
Question ID:
CHS.100_00.060 Instrument Variable Name:
QuestionText:
CASMPMED
QuestionnaireFileName:
Sample Child
Now I'm going to ask you about two different kinds of ASTHMA medicine. One prevents symptoms over the long term.
The other is for quick relief of symptoms during an attack or episode. This quick relief medicine is breathed in through
your mouth using a canister inhaler or a disk inhaler.
DURING THE PAST 3 MONTHS, has [fill: S.C. name] used the kind of PRESCRIPTION asthma inhaler that gives
QUICK relief from asthma symptoms during an attack? Include only medications prescribed by a health care professional.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1> [goto CASMTYP] <2,R,D> [go to CASMDTP2]
Page 15 of 38
DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.065 Instrument Variable Name:
08-Aug-12
CASMTYP
QuestionnaireFileName:
Sample Child
When [fill: S.C. name] takes [his/her]rescue prescription asthma medication, would you say that [he/she] most often uses
an inhaler and/or disk, or does [he/she] most often use a nebulizer?
QuestionText:
*Read if necessary: Both an inhaler or a disk inhaler are very portable canisters or devices used to inhale medication in
one or two breaths. A nebulizer is a machine that turns liquid medication into a mist that you inhale into the lungs over a
few minutes
Inhaler or disk
Nebulizer
Refused
Don't know
1
2
7
9
UniverseText:
Sample child <18 who have used a quick relief prescription asthma inhaler in the past three months
SkipInstructions:
<1> [go to CASMCAN] <2,R,D> [go to CASMDTP2]
Question ID:
CHS.100_00.070 Instrument Variable Name:
QuestionText:
1
2
7
9
CASMCAN
QuestionnaireFileName:
Sample Child
DURING THE PAST 3 MONTHS did [fill: S.C. name] use more than three canisters or disks of this type of quick relief
inhaler?
Yes
No
Refused
Don't Know
UniverseText:
Sample child <18 who have used a prescription asthma inhaler/disk most often in the past three months
SkipInstructions:
<1,2,R,D> [go to CASMDTP2]
Page 16 of 38
DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.090 Instrument Variable Name:
08-Aug-12
CASMDTP2
QuestionnaireFileName:
Sample Child
The second kind of asthma medication is different from inhalers used for quick relief. It is the preventive kind that is used
to protect your lungs and keep you from having attacks. It can be either a pill or an inhaler.
QuestionText:
Is [fill: S.C. name] NOW taking a preventive asthma medication every day or almost every day, less often, or never?
Every day or almost every day
Less often
Never
Refused
Don't know
1
2
3
7
9
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1-3,R,D> [go to CASWMP]
Question ID:
CHS.100_00.100 Instrument Variable Name:
QuestionText:
CASWMP
QuestionnaireFileName:
An asthma action plan is a printed form with specific instructions based on [fill: S.C. name]'s asthma that tells when to
change the amount or type of medicine, when to call the doctor for advice, and when to go to the emergency room.
Has a doctor or other health professional EVER given [fill: S.C. name] an asthma action plan?
*Read if necessary: Include nurses and asthma educators.
1
2
7
9
Sample Child
Yes
No
Refused
Don't know
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to CASCLASS]
Page 17 of 38
DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.110 Instrument Variable Name:
08-Aug-12
CASCLASS
QuestionnaireFileName:
Sample Child
Has [fill: S.C. name] ever taken a course or class on how to manage [fill: his/her] asthma?
QuestionText:
*Include adult(s) who took a course for the child's asthma.
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to CAS_REC]
Question ID:
CHS.100_00.116 Instrument Variable Name:
CAS_REC
QuestionnaireFileName:
Sample Child
Has a doctor or other health professional EVER taught [fill: S.C. name] or [fill: his/her] parent or guardian
QuestionText:
...how to recognize early signs or symptoms of an asthma episode?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to CAS_RES]
Question ID:
CHS.100_00.117 Instrument Variable Name:
QuestionText:
CAS_RES
QuestionnaireFileName:
*Read if necessary: Has a doctor or other health professional EVER taught [fill: S.C. name] or [fill: his/her] parent or
guardian
...how to respond to episodes of asthma?
1
2
7
9
Sample Child
Yes
No
Refused
Don't know
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to CAS_MON]
Page 18 of 38
DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.118 Instrument Variable Name:
08-Aug-12
CAS_MON
QuestionnaireFileName:
Sample Child
*Read if necessary: Has a doctor or other health professional EVER taught [fill: S.C. name] or [fill: his/her] parent or
guardian
QuestionText:
...how to monitor peak flow for daily therapy?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1,2,R,D> [go to CAPENVLN]
Question ID:
CHS.100_00.130 Instrument Variable Name:
QuestionText:
1
2
3
7
9
CAPENVLN
QuestionnaireFileName:
Sample Child
Has a doctor or other health professional EVER advised you to change things in [fill: S.C. name]'s home, school, or work
to improve [fill: his/her] asthma?
Yes
No
Was told no changes needed
Refused
Don't know
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<1-3,R,D> [go to CAROUTIN]
Page 19 of 38
DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.135 Instrument Variable Name:
08-Aug-12
CAROUTIN
QuestionnaireFileName:
Sample Child
During the past 12 months how many times did [fill: S.C. name] see a doctor or other health professional for a routine
checkup for [fill: his/her] asthma? Please do not include emergency room visits, visits to urgent care centers, or other visits
for acute care for an asthma episode or attack.
QuestionText:
*Enter '0' for none.
None
001-365 times
Refused
Don't know
000
001-365
997
999
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months
SkipInstructions:
<0> [if AGE LE 2 go to CCONDT1_1; else go to CCONDT_1]; <1-50,R,D> [go to CASYMPT] <51-365> [goto
ERR_CAROUTIN]
Question ID:
CHS.100_00.140 Instrument Variable Name:
QuestionText:
CASYMPT
QuestionnaireFileName:
Sample Child
At his/her last visit, did [fill: S.C. name]'s doctor or other health professional ask HOW OFTEN
….[fill: he/she] had asthma symptoms?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months and saw a
doctor/health professional about S.C.'s asthma in the past year
SkipInstructions:
<1,2,R,D> if CASMPMED=1 [go to CARESCUE]; else [goto CAACTLIM]
Page 20 of 38
DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.100_00.145 Instrument Variable Name:
08-Aug-12
CARESCUE
QuestionnaireFileName:
Sample Child
At his/her last visit, did [fill: S.C. name]’s doctor or other health professional ask HOW OFTEN
QuestionText:
….[fill: he/she] used [fill: his/her] quick relief inhaler?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months and use a quick relief
inhaler and saw a doctor/health professional about S.C.'s asthma in the past year
SkipInstructions:
<1,2,R,D> [go to CAACTLIM]
Question ID:
CHS.100_00.150 Instrument Variable Name:
CAACTLIM
QuestionnaireFileName:
Sample Child
At his/her last visit, did [fill: S.C. name]’s doctor or other health professional ask HOW OFTEN
QuestionText:
…asthma symptoms limited [fill: his/her] daily activities?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample child <18 who still have asthma or who had asthma episode/attack in past 12 months and saw a
doctor/health professional about S.C.'s asthma in the past year
SkipInstructions:
<1,2,R,D> [if AGE LE 2 go to CCONDT1_1; else go to CCONDT_1]
Question ID:
CHS.111_01.000 Instrument Variable Name:
QuestionText:
2
7
9
QuestionnaireFileName:
DURING THE PAST 12 MONTHS, has [fill: SC 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 21 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.111_02.000 Instrument Variable Name:
08-Aug-12
CCONDT1_2
QuestionnaireFileName:
Sample Child
* Read if necessary.
QuestionText:
DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions...
Any kind of respiratory allergy?
Yes
No
Refused
Don't know
1
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:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions...
Any kind of food or digestive allergy?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children LE 2
SkipInstructions:
<1,2,R,D> [go to CCONDT1_4]
Sample Child
Page 22 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.111_04.000 Instrument Variable Name:
08-Aug-12
CCONDT1_4
QuestionnaireFileName:
Sample Child
* Read if necessary.
QuestionText:
DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions...
Eczema or any kind of skin allergy?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children LE 2
SkipInstructions:
<1,2,R,D> [go to CCONDT1_5]
Question ID:
CHS.111_05.000 Instrument Variable Name:
QuestionText:
CCONDT1_5
QuestionnaireFileName:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC 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 LE 2
SkipInstructions:
<1,2,R,D> [go to CCONDT1_6]
Sample Child
Page 23 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.111_06.000 Instrument Variable Name:
08-Aug-12
CCONDT1_6
QuestionnaireFileName:
Sample Child
* Read if necessary.
QuestionText:
DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions...
Anemia?
Yes
No
Refused
Don't know
1
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: SC 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 24 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.111_09.000 Instrument Variable Name:
08-Aug-12
CCONDT1_9
QuestionnaireFileName:
Sample Child
* Read if necessary.
QuestionText:
DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions...
Seizures?
Yes
No
Refused
Don't know
1
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:
2
7
9
QuestionnaireFileName:
DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions...
Hay fever?
1
CCONDT_1
Yes
No
Refused
Don't know
UniverseText:
Sample children = 3-17
SkipInstructions:
<1,2,R,D> [go to CCONDT_2]
Sample Child
Page 25 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.115_02.000 Instrument Variable Name:
08-Aug-12
CCONDT_2
QuestionnaireFileName:
Sample Child
* Read if necessary.
QuestionText:
DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions...
Any kind of respiratory allergy?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children = 3-17
SkipInstructions:
<1,2,R,D> [go to CCONDT_3]
Question ID:
CHS.115_03.000 Instrument Variable Name:
QuestionText:
CCONDT_3
QuestionnaireFileName:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions...
Any kind of food or digestive allergy?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children = 3-17
SkipInstructions:
<1,2,R,D> [go to CCONDT_4]
Sample Child
Page 26 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.115_04.000 Instrument Variable Name:
08-Aug-12
CCONDT_4
QuestionnaireFileName:
Sample Child
* Read if necessary.
QuestionText:
DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions...
Eczema or any kind of skin allergy?
Yes
No
Refused
Don't know
1
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: SC 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 27 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.115_06.000 Instrument Variable Name:
08-Aug-12
CCONDT_6
QuestionnaireFileName:
Sample Child
* Read if necessary.
QuestionText:
DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions...
Anemia?
Yes
No
Refused
Don't know
1
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:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions...
Frequent or severe headaches, including migraines?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children = 3-17
SkipInstructions:
<1,2,R,D> [go to CCONDT_8]
Sample Child
Page 28 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.115_08.000 Instrument Variable Name:
08-Aug-12
CCONDT_8
QuestionnaireFileName:
Sample Child
* Read if necessary.
QuestionText:
DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions...
Three or more ear infections?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children = 3-17
SkipInstructions:
<1,2,R,D> [go to CCONDT_9]
Question ID:
CHS.115_09.000 Instrument Variable Name:
QuestionText:
CCONDT_9
QuestionnaireFileName:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions...
Seizures?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children = 3-17
SkipInstructions:
<1,2,R,D> [go to CCONDT_10]
Sample Child
Page 29 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.115_10.000 Instrument Variable Name:
08-Aug-12
CCONDT_10
QuestionnaireFileName:
Sample Child
* Read if necessary.
QuestionText:
DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions...
Stuttering or stammering?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children = 3-17
SkipInstructions:
<1,2,R,D> [goto 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: SC 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 30 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.220_00.000 Instrument Variable Name:
08-Aug-12
SCHDAYR
QuestionnaireFileName:
Sample Child
DURING THE PAST 12 MONTHS about how many days did [fill2: SC name] miss school because of illness or injury?
QuestionText:
* Enter '996' if child did not go to school in the past 12 months.
None
1-240 days
Did not go to school
Refused
Don't know
000
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]
ERR2_SCHDAYR
Hard Edit:
* "241-995" days not allowed in this field.
* Please correct.
ERR1_SCHDAYR
Soft Edit:
[fill4: SCHDAYR] is an unusually large number. Did [fill2: SC name] miss [fill: SCHDAYR] days of school
because of illness or injury?
* Please verify.
Question ID:
CHS.230_00.000 Instrument Variable Name:
QuestionText:
CCOLD2W
QuestionnaireFileName:
These next questions are about [fill: SC name]'s recent health DURING THE LAST 2 WEEKS.
Did [fill: SC name] have a head cold or chest cold that started DURING THE LAST 2 WEEKS?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children <18
SkipInstructions:
<1,2,R,D> [goto CINTIL2W]
Sample Child
Page 31 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.240_00.000 Instrument Variable Name:
CINTIL2W
QuestionnaireFileName:
Sample Child
Did [fill: SC name] have a stomach or intestinal illness with vomiting or diarrhea that started DURING THE LAST 2
WEEKS?
QuestionText:
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children <18
SkipInstructions:
<1,2,R,D> [goto CHEARST1]
Question ID:
08-Aug-12
CHS.250_00.000 Instrument Variable Name:
QuestionText:
1
2
3
4
5
6
7
9
CHEARST1
QuestionnaireFileName:
Sample Child
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?
Excellent
Good
A little trouble hearing
Moderate trouble
A lot of trouble
Deaf
Refused
Don't know
UniverseText:
Sample children <18
SkipInstructions:
<1-6,R,D> [go to CVISION]
Page 32 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.260_00.000 Instrument Variable Name:
Sample Child
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children <18
SkipInstructions:
<1> [goto CBLIND]
<2,R,D> [goto IHSPEQ]
CHS.270_00.000 Instrument Variable Name:
CBLIND
QuestionnaireFileName:
Sample Child
QuestionnaireFileName:
Sample Child
Is [fill: SC name] blind or unable to see at all?
QuestionText:
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children <18 having trouble seeing
SkipInstructions:
<1,2,R,D> [goto IHSPEQ]
Question ID:
QuestionnaireFileName:
Does [fill1: SC name] have any trouble seeing [fill2: , even when wearing glasses or contact lenses]?
QuestionText:
Question ID:
CVISION
08-Aug-12
CHS.290_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
IHSPEQ
Does [fill1: SC 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)?
Yes
No
Refused
Don't know
UniverseText:
Sample children <18
SkipInstructions:
<1,2,R,D> [goto IHMOB]
Page 33 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.300_00.000 Instrument Variable Name:
IHMOB
QuestionnaireFileName:
Sample Child
Does [fill1: SC name] have an impairment or health problem that limits [fill2: his/her] ability to (crawl), walk, run, or play?
QuestionText:
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children <18
SkipInstructions:
<1> [goto IHMOBYR]
<2,R,D> [goto PROBRX]
Question ID:
08-Aug-12
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 34 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.311_00.000 Instrument Variable Name:
08-Aug-12
PROBRX
QuestionnaireFileName:
Sample Child
?[F1]
QuestionText:
Does [fill1: SC name] NOW have a problem for which [fill2: he/she] has regularly taken prescription medication for at
least three months?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children <18
SkipInstructions:
<1,2,R,D> [if AGE LE <1> go to CAU.CUSUALPL;
else if AGE GE 3 go to LEARND;
else if AGE = 2 and SEX = 1 go to CMHAGM11_1;
if AGE = 2 and SEX = 2 go to CMHAGF11_1]
Question ID:
CHS.312_00.000 Instrument Variable Name:
QuestionText:
LEARND
QuestionnaireFileName:
Sample Child
?[F1]
Has a representative from a school or a health professional ever told you that [fill: SC name] had a learning disability?
1
2
7
9
Yes
No
Refused
Don't know
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]
Page 35 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.321_01.000 Instrument Variable Name:
08-Aug-12
CMHAGM11_1
QuestionnaireFileName:
Sample Child
(book) C3 ?[F1]
QuestionText:
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: SC name] DURING THE PAST TWO MONTHS.
He:
Has been uncooperative?
Not true
Sometimes true
Often true
Refused
Don't know
0
1
2
7
9
UniverseText:
Male sample children 2-3
SkipInstructions:
<0-2,R,D> [go to CMHAGM11_2]
Question ID:
CHS.321_02.000 Instrument Variable Name:
QuestionText:
CMHAGM11_2
QuestionnaireFileName:
Sample Child
(book) C3 ?[F1]
* 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: SC name] DURING THE PAST TWO MONTHS.
He:
Has trouble getting to sleep?
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_3]
Page 36 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.321_03.000 Instrument Variable Name:
08-Aug-12
CMHAGM11_3
QuestionnaireFileName:
Sample Child
(book) C3 ?[F1]
QuestionText:
* 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: SC name] DURING THE PAST TWO MONTHS.
He:
Has speech problems?
Not true
Sometimes true
Often true
Refused
Don't know
0
1
2
7
9
UniverseText:
Male sample children 2-3
SkipInstructions:
<0-2,R,D> [go to CMHAGM11_4]
Question ID:
CHS.321_04.000 Instrument Variable Name:
QuestionText:
CMHAGM11_4
QuestionnaireFileName:
Sample Child
(book) C3 ?[F1]
* 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: SC name] DURING THE PAST TWO MONTHS.
He:
Has been unhappy, sad, or depressed?
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 CAU.CUSUALPL]
Page 37 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.361_01.000 Instrument Variable Name:
08-Aug-12
CMHAGF11_1
QuestionnaireFileName:
Sample Child
(book) C3 ?[F1]
QuestionText:
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?
Not true
Sometimes true
Often true
Refused
Don't know
0
1
2
7
9
UniverseText:
Female sample children 2-3
SkipInstructions:
<0-2,R,D> [go to CMHAGF11_2]
Question ID:
CHS.361_02.000 Instrument Variable Name:
QuestionText:
CMHAGF11_2
QuestionnaireFileName:
Sample Child
(book) C3 ?[F1]
* 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
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_3]
Page 38 of 38
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date:
Question ID:
CHS.361_03.000 Instrument Variable Name:
08-Aug-12
CMHAGF11_3
QuestionnaireFileName:
Sample Child
(book) C3 ?[F1]
QuestionText:
* 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?
Not true
Sometimes true
Often true
Refused
Don't know
0
1
2
7
9
UniverseText:
Female sample children 2-3
SkipInstructions:
<0-2,R,D> [go to CMHAGF11_4]
Question ID:
CHS.361_04.000 Instrument Variable Name:
QuestionText:
CMHAGF11_4
QuestionnaireFileName:
Sample Child
(book) C3 ?[F1]
* 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 CAU.CUSUALPL]
Page 1 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.020_00.000 Instrument Variable Name:
08-Aug-12
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:
QuestionText:
1
2
3
4
5
6
7
9
CPLKIND
QuestionnaireFileName:
Sample Child
[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?
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
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]
Page 2 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.035_00.000 Instrument Variable Name:
08-Aug-12
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?
QuestionText:
Yes
No
Refused
Don't know
1
2
7
9
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]
Question ID:
CAU.037_00.000 Instrument Variable Name:
QuestionText:
0
1
2
3
4
5
6
7
9
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?
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
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]
Page 3 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.040_00.000 Instrument Variable Name:
08-Aug-12
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 4 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.050_00.010 Instrument Variable Name:
08-Aug-12
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
UniverseText:
Sample children <18 who don't have a usual place of care
SkipInstructions:
<1-9,R,D>[goto CPRVTRYR]
Question ID:
CAU.052_00.010 Instrument Variable Name:
QuestionText:
1
2
7
9
CPRVTRYR
DURING THE PAST 12 MONTHS, did you have any trouble finding a general doctor or provider who would see [fill:
alias]?
Yes
No
Refused
Don't know
UniverseText:
Sample children <18
SkipInstructions:
<1> [goto CPRVTRFD ] <2,R,D> [goto CDRNANP]
Page 5 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.053_00.010 Instrument Variable Name:
08-Aug-12
CPRVTRFD
QuestionnaireFileName:
Were you able to find a general doctor or provider who could see [fill: alias]?
QuestionText:
Yes
No
Refused
Don’t know
1
2
7
9
UniverseText:
Sample children <18 who had trouble finding a provider in the last year
SkipInstructions:
<1,2,R,D> [goto CDRNANP]
Question ID:
CAU.055_00.010 Instrument Variable Name:
CDRNANP
QuestionnaireFileName:
Sample Child
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?
QuestionText:
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children <18
SkipInstructions:
<1,2,R,D>[goto CDRNAI]
Question ID:
Sample Child
CAU.056_00.010 Instrument Variable Name:
QuestionText:
1
2
7
9
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?
Yes
No
Refused
Don't know
UniverseText:
Sample children <18
SkipInstructions:
<1,2,R,D>[goto CHCDLYR_1]
Page 6 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.080_01.000 Instrument Variable Name:
08-Aug-12
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.
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children <18
SkipInstructions:
<1,2,R,D> [goto CHCDLYR1_2]
Question ID:
CAU.080_02.000 Instrument Variable Name:
QuestionText:
CHCDLYR1_2
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...
You couldn't get an appointment for [fill: alias] soon enough.
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children <18
SkipInstructions:
<1,2,R,D> [goto CHCDLYR1_3]
Page 7 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.080_03.000 Instrument Variable Name:
08-Aug-12
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 8 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.080_05.000 Instrument Variable Name:
08-Aug-12
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 GE <2> goto CHCAFYR1_1; else goto CHCAFYR]
Question ID:
CAU.130_00.000 Instrument Variable Name:
QuestionText:
2
7
9
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...
Prescription medicines?
1
CHCAFYR
Yes
No
Refused
Don't know
UniverseText:
Sample children <2
SkipInstructions:
<1,2,R,D> [goto CHCAFYRN]
Page 9 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.133_00.010 Instrument Variable Name:
08-Aug-12
CHCAFYRN
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...
To see a specialist?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children <2
SkipInstructions:
<1,2,R,D> [goto CHCAFYRF]
Question ID:
CAU.133_00.020 Instrument Variable Name:
QuestionText:
CHCAFYRF
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...
Follow-up care?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children <2
SkipInstructions:
<1,2,R,D> [if AGE <1 goto CHCSYR1_2; else goto CDENLONG]
Page 10 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.135_01.000 Instrument Variable Name:
08-Aug-12
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 11 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.135_03.000 Instrument Variable Name:
08-Aug-12
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:
QuestionText:
CHCAFYR1_4
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...
Eyeglasses?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children GE 2
SkipInstructions:
<1,2,R,D> [goto CHCAFYR1_5]
Page 12 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.135_05.010 Instrument Variable Name:
08-Aug-12
CHCAFYR1_5
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...
To see a specialist?
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_06.010 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...
Follow-up care?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children GE 2
SkipInstructions:
<1,2,R,D> [goto CDENLONG]
Page 13 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.160_00.000 Instrument Variable Name:
08-Aug-12
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:
QuestionText:
CHCSYR1_2
QuestionnaireFileName:
DURING THE PAST 12 MONTHS, 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
Sample Child
Yes
No
Refused
Don't know
UniverseText:
Sample children <2
SkipInstructions:
<1,2,R,D> [goto CHCSYR1_3]
Page 14 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.170_02.000 Instrument Variable Name:
08-Aug-12
CHCSYR1_3
QuestionnaireFileName:
Sample Child
?[F1]
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, 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:
QuestionText:
CHCSYR1_5
QuestionnaireFileName:
Sample Child
?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS, 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?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children <2
SkipInstructions:
<1,2,R,D> [goto CHCSYR1_6]
Page 15 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.170_04.000 Instrument Variable Name:
08-Aug-12
CHCSYR1_6
QuestionnaireFileName:
Sample Child
* Read if necessary.
QuestionText:
DURING THE PAST 12 MONTHS, 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?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children <2
SkipInstructions:
<1,2,R,D> [goto CHCSYR8_1]
Question ID:
CAU.175_01.000 Instrument Variable Name:
QuestionText:
CHCSYR_1
QuestionnaireFileName:
Sample Child
DURING THE PAST 12 MONTHS, 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?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children GE 2
SkipInstructions:
<1,2,R,D> [goto CHCSYR_2]
Page 16 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.175_02.000 Instrument Variable Name:
08-Aug-12
CHCSYR_2
QuestionnaireFileName:
Sample Child
* Read if necessary.
QuestionText:
DURING THE PAST 12 MONTHS, 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
?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS, 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 17 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.175_04.000 Instrument Variable Name:
08-Aug-12
CHCSYR_4
QuestionnaireFileName:
Sample Child
?[F1]
QuestionText:
Read if necessary.
DURING THE PAST 12 MONTHS, 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:
QuestionText:
CHCSYR_5
QuestionnaireFileName:
Sample Child
?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS, 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?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children GE 2
SkipInstructions:
<1,2,R,D> [goto CHCSYR_6]
Page 18 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.175_06.000 Instrument Variable Name:
08-Aug-12
CHCSYR_6
QuestionnaireFileName:
Sample Child
?[F1]
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, 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?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children GE 2
SkipInstructions:
<1,2,R,D> [if SEX eq <2> and AGE GE 15 goto CHCSYR7; else goto CHCSYR8_1]
Question ID:
CAU.230_00.000 Instrument Variable Name:
QuestionText:
CHCSYR7
QuestionnaireFileName:
Sample Child
?[F1]
DURING THE PAST 12 MONTHS, have you seen or talked to a doctor who specializes in women's health (an
obstetrician/gynecologist) about [fill2: alias]'s health?
1
2
7
9
Yes
No
Refused
Don't know
UniverseText:
Sample children GE 15 who are female
SkipInstructions:
<1,2,R,D> [goto CHCSYR8_1]
Page 19 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.240_01.000 Instrument Variable Name:
CHCSYR8_1
QuestionnaireFileName:
Sample Child
DURING THE PAST 12 MONTHS, 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:
08-Aug-12
CAU.240_02.000 Instrument Variable Name:
QuestionText:
CHCSYR8_2
QuestionnaireFileName:
Sample Child
* Read if necessary.
DURING THE PAST 12 MONTHS, 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 20 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.260_00.000 Instrument Variable Name:
08-Aug-12
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 21 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.280_00.000 Instrument Variable Name:
08-Aug-12
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
UniverseText:
Sample children <18
SkipInstructions:
<0,R,D> [goto CHCHYR] <1-8> [goto CERVISND]
Question ID:
CAU.281_00.010 Instrument Variable Name:
QuestionText:
1
2
7
9
CERVISND
QuestionnaireFileName:
Sample Child
Thinking about [fill: S.C. name]'s most recent emergency room visit, did [fill: he/she ] go to the emergency room either at
night or on the weekend?
Yes
No
Refused
Don't know
UniverseText:
Sample children <18 who had at least one ER visit in the past year
SkipInstructions:
<1,2,R,D> [go to CERHOS]
Page 22 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.282_00.010 Instrument Variable Name:
08-Aug-12
CERHOS
QuestionnaireFileName:
Did this emergency room visit result in a hospital admission?
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> [goto CERREAS1]
Question ID:
Sample Child
CAU.283_01.010 Instrument Variable Name:
CERREAS1
QuestionnaireFileName:
Sample Child
Tell me which of these apply to [fill: alias]'s last emergency room visit?
QuestionText:
… [fill: He/She] 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
SkipInstructions:
<1,2,R,D> [goto CERREAS2]
Question ID:
CAU.283_02.020 Instrument Variable Name:
QuestionText:
CERREAS2
QuestionnaireFileName:
*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
… [fill: alias]'s doctor’s office or clinic was not open
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
SkipInstructions:
<1,2,R,D> [goto CERREAS3]
Sample Child
Page 23 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.283_03.030 Instrument Variable Name:
08-Aug-12
CERREAS3
QuestionnaireFileName:
Sample Child
*Read if necessary.
QuestionText:
Tell me which of these apply to [fill: alias]'s last emergency room visit?
… [fill: alias]'s health provider advised that [fill: he/she] 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
SkipInstructions:
<1,2,R,D> [goto CERREAS4]
Question ID:
CAU.283_04.040 Instrument Variable Name:
QuestionText:
CERREAS4
QuestionnaireFileName:
*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
… The problem was too serious for the doctor’s office or clinic
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
SkipInstructions:
<1,2,R,D> [goto CERREAS5]
Sample Child
Page 24 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.283_05.050 Instrument Variable Name:
08-Aug-12
CERREAS5
QuestionnaireFileName:
Sample Child
*Read if necessary.
QuestionText:
Tell me which of these apply to [fill: alias]'s 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
SkipInstructions:
<1,2,R,D> [goto CERREAS6]
Question ID:
CAU.283_06.060 Instrument Variable Name:
QuestionText:
CERREAS6
QuestionnaireFileName:
*Read if necessary.
Tell me which of these apply to [fill: alias]'s 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
SkipInstructions:
<1,2,R,D> [goto CERREAS7]
Sample Child
Page 25 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.283_07.070 Instrument Variable Name:
08-Aug-12
CERREAS7
QuestionnaireFileName:
Sample Child
*Read if necessary.
QuestionText:
Tell me which of these apply to [fill: alias]'s 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
SkipInstructions:
<1,2,R,D> [goto CERREAS8]
Question ID:
CAU.283_08.080 Instrument Variable Name:
QuestionText:
CERREAS8
QuestionnaireFileName:
*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
…[fill: alias] arrived by ambulance or other emergency vehicle
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
SkipInstructions:
<1,2,R,D> [goto CHCHYR]
Sample Child
Page 26 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.290_00.000 Instrument Variable Name:
CHCHYR
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]
<2,R,D> [goto CHCNOYR]
Question ID:
08-Aug-12
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 27 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.310_00.000 Instrument Variable Name:
08-Aug-12
CHCHNOYR
QuestionnaireFileName:
Sample Child
(book) C6 ?[F1]
QuestionText:
What was the total number of home visits received for [fill1: alias] during [fill2: that month/those months]?
1
2-3
4-5
6-7
8-9
10-12
13-15
16 or more
Refused
Don't know
01
02
03
04
05
06
07
08
97
99
UniverseText:
Sample children <18 that have received home care from health professional during the past 12 months
SkipInstructions:
<1-8,R,D> [goto CHCNOYR]
Question ID:
CAU.320_00.000 Instrument Variable Name:
QuestionText:
CHCNOYR
QuestionnaireFileName:
Sample Child
(book) C5 ?[F1]
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.
00
01
02
03
04
05
06
07
08
97
99
None
1
2-3
4-5
6-7
8-9
10-12
13-15
16 or more
Refused
Don't know
UniverseText:
Sample children <18
SkipInstructions:
<0-8,R,D> [goto CSRGYR]
Page 28 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.330_00.000 Instrument Variable Name:
08-Aug-12
CSRGYR
QuestionnaireFileName:
Sample Child
DURING THE PAST 12 MONTHS has [fill1: alias] had SURGERY or other surgical procedures either as an inpatient or
outpatient?
QuestionText:
* Read if necessary.
This includes both major surgery and minor procedures such as setting bones or removing growths.
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children <18
SkipInstructions:
<1> [goto CSRGNOYR]
<2,R,D> [goto CMDLONG]
Question ID:
CAU.340_00.000 Instrument Variable Name:
QuestionText:
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?
* Enter '95' for 95 or more times.
01-94
95
97
99
1-94 times
95+ times
Refused
Don't know
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]
Soft Edit:
ERR_CMDLONG
[fill2: CSRGNOYR] is an unusually large number. Did [fill1: alias] have [fill2: CSRGNOYR] surgical procedures?
*Please verify.
Page 29 of 29
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization
Document Version Date:
Question ID:
CAU.345_00.000 Instrument Variable Name:
QuestionText:
08-Aug-12
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> [if AGE=4-17 goto CMHCOPY; else goto CH1N1_1]
Page 1 of 4
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Brief Questionnaire
Document Version Date:
Question ID:
CMB.010_00.000 Instrument Variable Name:
08-Aug-12
CMHCOPY
QuestionnaireFileName:
Sample Child
* The following statements are not to be read to the respondent. They are displayed and included here for legal reasons.
QuestionText:
* 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.
Enter 1 to continue
1
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.
0
1
2
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
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Brief Questionnaire
Document Version Date:
Question ID:
CMB.020_02.000 Instrument Variable Name:
08-Aug-12
CMHMF_2
QuestionnaireFileName:
Sample Child
(book) C7
QuestionText:
* 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.
Not true
Somewhat true
Certainly true
Refused
Don't know
0
1
2
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.
0
1
2
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
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Brief Questionnaire
Document Version Date:
Question ID:
CMB.020_04.000 Instrument Variable Name:
08-Aug-12
CMHMF_4
QuestionnaireFileName:
Sample Child
(book) C7
QuestionText:
* 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].
Not true
Somewhat true
Certainly true
Refused
Don't know
0
1
2
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.
0
1
2
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
DRAFT 2013 NHIS Questionnaire - Sample Child
Document Version Date:
Question ID:
CMB.030_00.000 Instrument Variable Name:
QuestionText:
CMHDIFF
08-Aug-12
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 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.001_00.000 Instrument Variable Name:
DIFF6M
08-Aug-12
QuestionnaireFileName:
Sample Child
Has [fill: SC name] had any difficulties with emotions, concentration, behavior, or getting along with others DURING
THE PAST 6 MONTHS, that is since [fill month and year of 6 month reference period]?
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 (variable name in layouts is RSCL6) IN ('2',3','4') [goto
DIFFINTF]; else [goto PRESCP6M]
Question ID:
CMS.005_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
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?
Yes
No
Refused
Don't know
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]
Page 2 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.007_00.000 Instrument Variable Name:
DIFFDEG
08-Aug-12
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...
QuestionText:
*Read categories below.
A lot
Some
A little
Refused
Don't know
1
2
3
7
9
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]
Question ID:
CMS.008_00.000 Instrument Variable Name:
QuestionText:
1
2
3
4
7
9
DIFFLNG
QuestionnaireFileName:
How long have these difficulties been present?
Less than a month
1-5 months
6 to 12 months
Over a year
Refused
Don’t know
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]
Sample Child
Page 3 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.010_00.000 Instrument Variable Name:
08-Aug-12
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_00.000 Instrument Variable Name:
QuestionText:
PRESHELP
QuestionnaireFileName:
During the past 6 months, how much has this prescription medication helped [fill: S.C. name]? Would you say…
*Read categories below.
1
2
3
4
7
9
Sample Child
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 4 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.012_01.000 Instrument Variable Name:
08-Aug-12
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 TRETHELP]; else [goto NSDUH21]; <2,R,D> [goto
PMEDPSY]
Question ID:
CMS.012_02.000 Instrument Variable Name:
QuestionText:
PMEDPSY
QuestionnaireFileName:
Sample Child
*Read if necessary.
Who FIRST prescribed the medication? Was it
...A psychiatrist, psychologist or other mental health professional?
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
or other family doctor
SkipInstructions:
<1> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto TRETHELP]; else [goto NSDUH21]; <2,R,D> [goto
PMEDNEU]
Page 5 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.012_03.000 Instrument Variable Name:
08-Aug-12
PMEDNEU
QuestionnaireFileName:
Sample Child
*Read if necessary.
QuestionText:
Who FIRST prescribed the medication? Was it
...A neurologist?
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,
psychiatrist/ or other family doctor
SkipInstructions:
<1> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto TRETHELP]; else [goto NSDUH21]; <2,R,D> [goto
PMEDOTH]
Question ID:
CMS.012_04.000 Instrument Variable Name:
QuestionText:
PMEDOTH
QuestionnaireFileName:
Sample Child
*Read if necessary.
Who FIRST prescribed the medication? Was it
...Someone else?
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,
family doctor, psychiatrist or neurologist
SkipInstructions:
<1,2,R,D> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto TRETHELP]; else [goto NSDUH21]
Page 6 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.014_00.000 Instrument Variable Name:
NSDUH21
08-Aug-12
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.
QuestionText:
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?
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 NSDUH3]
Question ID:
CMS.015_00.000 Instrument Variable Name:
QuestionText:
1
2
7
9
NSDUH3
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?
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> [go to NSDUH31 <2,R,D> [go to NSDUH4]
Page 7 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.015_00.010 Instrument Variable Name:
NSDUH31
08-Aug-12
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 needs
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, psychologist, 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 needs day school with program for these difficulties
SkipInstructions:
<1-5,R,D> [goto NSDUH4];
Page 8 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.016_00.000 Instrument Variable Name:
08-Aug-12
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:
QuestionText:
NSDUH5
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, psychologist, 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 school program for difficulties with emotions, concentration, behavior
SkipInstructions:
<1-5,R,D> age 4-6 [goto TRETWHR1]; else [goto TRETWHR2]
Page 9 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.020_01.000 Instrument Variable Name:
08-Aug-12
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.
QuestionText:
DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
At daycare, child care, or play group?
Yes
No
Refused
Don’t know
1
2
7
9
UniverseText:
Sample children 4-6 who had at least minor difficulties
SkipInstructions:
<1> [goto TRETWHO1] <2,R,D> [goto TRETWHR2]
Question ID:
CMS.020_02.000 Instrument Variable Name:
QuestionText:
TRETWHO1
QuestionnaireFileName:
(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1
2
3
4
5
6
7
9
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
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]
Sample Child
Page 10 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.020_03.000 Instrument Variable Name:
08-Aug-12
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 at daycare, child care, or play group 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 11 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.021_02.000 Instrument Variable Name:
08-Aug-12
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 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 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:
QuestionText:
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?
*Enter all that apply, separate with commas
1
2
3
4
7
9
Psychiatrist
Psychologist
Clinical social worker
Psychiatric nurse
Refused
Don't know
UniverseText:
Sample children 4-17 who received counseling or treatment at an office, clinic or community center from mental
health provider
SkipInstructions:
<1-4,R,D> [goto TRETWHR3]
Page 12 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.022_01.000 Instrument Variable Name:
08-Aug-12
TRETWHR3
QuestionnaireFileName:
Sample Child
DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
QuestionText:
In your home, for example, from a visiting teacher or counselor?
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample children 4-17 who had at least minor difficulties
SkipInstructions:
<1> [goto TRETWHO3] <2,R,D> [goto TRETWHR4]
Question ID:
CMS.022_02.000 Instrument Variable Name:
QuestionText:
TRETWHO3
QuestionnaireFileName:
(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1
2
3
4
5
6
7
9
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
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]
Sample Child
Page 13 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.022_03.000 Instrument Variable Name:
08-Aug-12
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 at home from mental health provider
SkipInstructions:
<1-4,R,D> [goto TRETWHR4]
Question ID:
CMS.023_01.000 Instrument Variable Name:
QuestionText:
TRETWHR4
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 14 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.023_02.000 Instrument Variable Name:
08-Aug-12
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:
QuestionText:
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?
*Enter all that apply, separate with commas
1
2
3
4
7
9
Psychiatrist
Psychologist
Clinical social worker
Psychiatric nurse
Refused
Don't know
UniverseText:
Sample children 4-17 who received counseling or treatment at hospital/ER/crisis center/shelter from mental health
provider
SkipInstructions:
<1-4,R,D> [goto TRETWHR5]
Page 15 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.024_01.000 Instrument Variable Name:
08-Aug-12
TRETWHR5
QuestionnaireFileName:
Sample Child
DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
QuestionText:
At a day treatment program in a hospital or in your community?
Yes
No
Refused
Don’t know
1
2
7
9
UniverseText:
Sample children 4-17 who had at least minor difficulties
SkipInstructions:
<1> [goto TRETWHO5] <2,R,D> [goto TRETWHR6]
Question ID:
CMS.024_02.000 Instrument Variable Name:
QuestionText:
TRETWHO5
QuestionnaireFileName:
Sample Child
(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1
2
3
4
5
6
7
9
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
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]
Page 16 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.024_03.000 Instrument Variable Name:
08-Aug-12
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 at day treatment program in a hospital or community
from mental health provider
SkipInstructions:
<1-4,R,D> [goto TRETWHR6]
Question ID:
CMS.025_01.000 Instrument Variable Name:
QuestionText:
TRETWHR6
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 17 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.025_02.000 Instrument Variable Name:
08-Aug-12
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:
QuestionText:
TRTMHP6
You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or psychiatric
nurse. Who was this?
*Enter all that apply, separate with commas
1
2
3
4
7
9
Psychiatrist
Psychologist
Clinical social worker
Psychiatric nurse
Refused
Don’t know
UniverseText:
Sample children 4-17 who received counseling or treatment at another place from mental health provider
SkipInstructions:
<1-4,R,D> [goto OVERNT6M]
Page 18 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.050_00.000 Instrument Variable Name:
08-Aug-12
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?
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 OVERWHCH] <2,R,D> [goto SH1]
Question ID:
CMS.060_00.000 Instrument Variable Name:
QuestionText:
OVERWHCH
QuestionnaireFileName:
Sample Child
Which ones?
*Read list if necessary.
*Enter all that apply, separate with commas.
01
02
03
04
05
06
07
97
99
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
UniverseText:
Sample children 4-17 who stayed overnight in a hospital or other overnight location for difficulties
SkipInstructions:
<1-7,R,D> [goto SH1]
Page 19 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.070_00.000 Instrument Variable Name:
SH1
08-Aug-12
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 20 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.100_00.000 Instrument Variable Name:
08-Aug-12
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> [goto TRETHELP]
Page 21 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.115_00.000 Instrument Variable Name:
08-Aug-12
TRETHELP
QuestionnaireFileName:
Sample Child
You told us that [S.C. child] has received treatment or counseling for difficulties with emotions, concentration, behavior,
or being able to get 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> if CMHDIFF=2-4 and DIFF6M=1 [goto TRPAYPHI];
else [goto next section]
Question ID:
CMS.120_01.000 Instrument Variable Name:
QuestionText:
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.
Private health insurance, such as insurance that comes with a job?
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 and received some type of treatment or counseling in the
past 6 months
SkipInstructions:
<1,2,R,D> [goto TRPAYSCH]
Page 22 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.120_02.000 Instrument Variable Name:
08-Aug-12
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.
QuestionText:
School system?
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 and received some type of treatment or counseling in the
past 6 months
SkipInstructions:
<1,2,R,D> [goto TRPAYSLF]
Question ID:
CMS.120_03.000 Instrument Variable Name:
QuestionText:
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.
You or your family (sometimes called out of pocket or co-payment)?
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 and received some type of treatment or counseling in the
past 6 months
SkipInstructions:
<1,2,R,D> [goto TRPAYMED]
Page 23 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.120_04.000 Instrument Variable Name:
08-Aug-12
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 and received some type of treatment or counseling 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 CHIP/SCHIP 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 and received some type of treatment or counseling in the
past 6 months
SkipInstructions:
<1,2,R,D> [goto TRPAYMIL]
Page 24 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.120_06.000 Instrument Variable Name:
08-Aug-12
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 and received some type of treatment or counseling in the
past 6 months
SkipInstructions:
<1,2,R,D> [goto TRPAYSHP]
Question ID:
CMS.120_07.000 Instrument Variable Name:
QuestionText:
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.
Some other state or county sponsored health plan, Medicare or other government program?
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 and received some type of treatment or counseling in the
past 6 months
SkipInstructions:
<1,2,R,D> [goto TRPAYIHS]
Page 25 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.120_09.000 Instrument Variable Name:
08-Aug-12
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 and received some type of treatment or counseling in the
past 6 months
SkipInstructions:
<1,2,R,D> [goto TRPAYOTH]
Question ID:
CMS.120_10.000 Instrument Variable Name:
QuestionText:
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.
Some other source?
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 and received some type of treatment or counseling in the
past 6 months
SkipInstructions:
<1,2,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]
Page 26 of 32
DRAFT 2013 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:
08-Aug-12
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 27 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.150_02.000 Instrument Variable Name:
08-Aug-12
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:
QuestionText:
NTRTNEXP
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 a negative experience with 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 NTRTFEAR]
Page 28 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.150_04.000 Instrument Variable Name:
08-Aug-12
NTRTFEAR
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 are afraid or you don't like 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 NTRTLOSE]
Question ID:
CMS.150_05.000 Instrument Variable Name:
QuestionText:
NTRTLOSE
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 were afraid [fill1: S.C. name] would be taken from your home or that you would lose your parental rights or custody?
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 NTRTSAY]
Page 29 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.150_06.000 Instrument Variable Name:
08-Aug-12
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 30 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.150_08.000 Instrument Variable Name:
08-Aug-12
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:
QuestionText:
NTRTINCV
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 inconvenient to use?
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 NTRTFAR]
Page 31 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.150_10.000 Instrument Variable Name:
08-Aug-12
NTRTFAR
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 far away?
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 NTRTCHNO]
Question ID:
CMS.150_11.000 Instrument Variable Name:
QuestionText:
NTRTCHNO
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.
[fill1: S.C. name] did not want to go?
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 NTRTOTH]
Page 32 of 32
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Mental Health Services
Document Version Date:
Question ID:
CMS.150_12.000 Instrument Variable Name:
QuestionText:
NTRTOTH
08-Aug-12
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:
<1,2,R,D> [goto next section]
Page 1 of 4
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Influenza Immunization
Document Version Date:
Question ID:
CFI.005_00.010
Instrument Variable Name:
08-Aug-12
CH1N1_1
QuestionnaireFileName:
Sample Child
?[F1]
QuestionText:
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.
Yes
No
Refused
Don't know
1
2
7
9
UniverseText:
Sample Child LE 17 years
SkipInstructions:
<1> [goto CH1N1_2]
<2,R,D> [goto next section]
Question ID:
CFI.005_00.020
QuestionText:
1
2
7
9
Instrument Variable Name:
CH1N1_2
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 an vaccine dose
SkipInstructions:
<1,2> [goto CH1N1_3M]
[goto next section]
QuestionnaireFileName:
Sample Child
Page 2 of 4
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Influenza Immunization
Document Version Date:
Question ID:
CFI.005_00.030
Instrument Variable Name:
08-Aug-12
CH1N1_3M
QuestionnaireFileName:
Sample Child
1 of 2
QuestionText:
During what month and year did {S.C. name} receive {fill: his/her} most recent flu vaccine?
January
February
March
April
May
June
July
August
September
October
November
December
Refused
Don't know
01
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
SkipInstructions:
<1-12,D> [ goto CH1N1_4Y] [goto CH1N1_5]
Question ID:
CFI.005_00.040
QuestionText:
Instrument Variable Name:
CH1N1_4Y
QuestionnaireFileName:
Sample Child
2 of 2
*Enter year of most recent flu vaccine.
Year
9997
9999
Year
Refused
Don't know
UniverseText:
Sample Child LE 17 years who have had one or more vaccine doses and gave month/don't know month of vaccine
dose
SkipInstructions:
[goto CH1N1_5]
[If CH1N1_3M and CH1N1_4Y = a future date] goto ERR1_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to birth] goto ERR2_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to 12 months ago] goto ERR3_ CH1N1_4Y]
Hard Edit:
ERR1_ CH1N1_4Y
*Future date invalid.
ERR2_ CH1N1_4Y
*Date before birth.
ERR3_ CH1N1_4Y
*Date before 12 months ago.
Page 3 of 4
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Influenza Immunization
Document Version Date:
Question ID:
CFI.005_00.050
Instrument Variable Name:
08-Aug-12
CH1N1_5
QuestionnaireFileName:
Sample Child
Was this a shot, or was it a vaccine sprayed in the nose?
QuestionText:
*Read if necessary: The flu nasal spray is called FluMist(trademark).
Flu shot
Flu nasal spray (spray, mist or drop in nose)
Refused
Don't know
1
2
7
9
UniverseText:
Sample Child LE 17 years who have had one or more vaccine doses
SkipInstructions:
<1-2,R,D> IF CH1N1_2=1 [goto next section]; else if CH1N1_2=2 [goto CH1N1_6M]
Question ID:
CFI.005_00.060
QuestionText:
Instrument Variable Name:
CH1N1_6M
QuestionnaireFileName:
1 of 2
During what month and year did {S.C. name} receive {fill: his/her} next most recent flu vaccine?
01
02
03
04
05
06
07
08
09
10
11
12
97
99
January
February
March
April
May
June
July
August
September
October
November
December
Refused
Don't know
UniverseText:
Sample Child LE 17 years who have had more than one vaccine doses
SkipInstructions:
<1-12,D> [ goto CH1N1_7Y] [goto CH1N1_8]
Sample Child
Page 4 of 4
DRAFT 2013 NHIS Questionnaire - Sample Child
Child Influenza Immunization
Document Version Date:
Question ID:
CFI.005_00.070
Instrument Variable Name:
08-Aug-12
CH1N1_7Y
QuestionnaireFileName:
Sample Child
2 of 2
QuestionText:
*Enter year of next most recent flu vaccine.
Year
Refused
Don't know
Year
9997
9999
UniverseText:
Sample Child LE 17 years who have had more than one vaccine doses and gave month/don't know month of
vaccine dose
SkipInstructions:
[goto CH1N1_8]
[If CH1N1_6M and CH1N1_7Y = a future date] goto ERR1_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to birth] goto ERR2_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to 12 months ago] goto ERR3_ CH1N1_7Y]
ERR1_ CH1N1_7Y
*Future date invalid.
Hard Edit:
ERR2_ CH1N1_7Y
*Date before birth.
ERR3_ CH1N1_7Y
*Date before 12 months ago.
Question ID:
CFI.005_00.080
QuestionText:
Instrument Variable Name:
CH1N1_8
Was this a shot, or was it a vaccine sprayed in the nose?
*Read if necessary: The flu nasal spray is called FluMist(trademark).
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 more than one vaccine dose
SkipInstructions:
<1-2,R,D> [goto next section]
QuestionnaireFileName:
Sample Child
| File Type | application/pdf |
| File Modified | 2012-11-27 |
| File Created | 2012-08-10 |