37.5 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

60M Questionnaire - Child, Phase 2g

OMB Specification

60M Questionnaire - Child

Event Category:	Time-Based
Event:	60M
Administration:	N/A
Instrument Target:	Child
Instrument Respondent:	Primary Caregiver
Domain:	Questionnaire
Document Category:	Questionnaire
Method:	Data Collector Administered
Mode (for this instrument*):	In-Person, CAI; Phone, CAI
OMB Approved Modes:	In-Person, CAI; Phone, CAI; Web-Based, CAI
Estimated Administration Time:	15 minutes
Multiple Child/Sibling Consideration:	Per Child
Special Considerations:	N/A
Version:	1.0
MDES Release:	4.0

*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.

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60M Questionnaire - Child

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

PHYSICAL ACTIVITY 3

SUN EXPOSURE 11

NOISE EXPOSURE 17

SCHOOL EXPERIENCES 26

CHILD DEMOGRAPHICS 40

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60M Questionnaire - Child

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

PHYSICAL ACTIVITY

(TIME_STAMP_PA_ST).

DATA COLLECTOR INSTRUCTIONS

• INSERT DATE AND TIME STAMP

• PRELOAD PARTICIPANT ID (P_ID) FOR CHILD AND RESPONDENT ID (R_P_ID) FOR ADULT CAREGIVER.

• PRELOAD C_FNAME AND CHILD_SEX FROM PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE AND DISPLAY APPROPRIATE NAME IN "C_FNAME" THROUGHOUT THE INSTRUMENT.

• IF C_FNAME = -1 OR -2, DISPLAY "the child" IN APPROPRIATE FIELDS THROUGHOUT THE INSTRUMENT.

• IF CHILD_SEX =1 THEN DISPLAY “he”, “him,” “his,” AND “himself” AS APPROPRIATE THROUGHOUT THE INSTRUMENT

• IF CHILD_SEX=2 THEN DISPAY “she,” “her,” “hers,” AND “herself” AS APPROPRIATE THROUGHOUT THE INSTRUMENT.

• PRELOAD MODE.

PA01000. These next questions are about {C_FNAME/the child}’s physical activity.

PA02000/(MED_LIMIT_PA). Does {C_FNAME/the child} have any physical or medical condition that affects {his/her} ability to play and be physically active?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA03000/(COMPARE_AGE). How active would you say {C_FNAME/the child} is compared with other {girls/boys} {C_FNAME/the child}’s age? Would you say:

Label	Code	Go To
A lot less active	1
Less active	2
The same	3
More active	4
A lot more active	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PROGRAMMER INSTRUCTIONS

• IF CHILD_SEX=1, DISPLAY "boys"

• IF CHILD_SEX=2, DISPLAY "girls"

• OTHERWISE, DISPLAY "girls/boys"

PA04000. Thinking about yesterday (or the most recent day you were home with {C_FNAME/the child}), how much time did {he/she} spend outdoors in active play?

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

(OUTDOOR_YEST_HRS) |___|

HOURS

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(OUTDOOR_YEST_MIN) |___|___|

 MINUTES

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

PA05000/(WEATHER_THATDAY). Thinking about that day, what was the weather like? Would you say it was…

Label	Code	Go To
Fine to play outdoors	1	BACKYARD_TYPE
Too wet to play outdoors	2	BACKYARD_TYPE
Too hot or humid to play outdoors	3	BACKYARD_TYPE
Too cold to play outdoors	4	BACKYARD_TYPE
Another reason it was not suitable to play outdoors, for example, bad air quality	-5
REFUSED	-1	BACKYARD_TYPE
DON’T KNOW	-2	BACKYARD_TYPE

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA06000/(WEATHER_THATDAY_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA07000/(BACKYARD_TYPE). What best describes your backyard or the grassy play area in your complex? Would you say you have

Label	Code	Go To
No yard or outside area where your children can play	1	PA09000
A yard or play area that you share with other residents, or	2
A private yard where your children can play?	3
REFUSED	-1
DON’T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA08000/(BACKYARD_SIZE). What best describes the size of your backyard or grassy play area in your complex? Would you say you have a small, medium or large yard or play area?

Label	Code	Go To
A SMALL YARD OR PLAY AREA (UP TO 1/8 ACRE)	1
A MEDIUM-SIZED YARD OR PLAY AREA (1/8 TO ¼ ACRE)	2
A LARGE YARD OR PLAY AREA (GREATER THAN ¼ ACRE)	3
REFUSED	-1
DON’T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA09000. Do you have access to any of the following facilities within your backyard or home environment?

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) 

PA10000/(PLAY_EQUIP_BACKYARD). Play equipment like a swing set, slide, or climbing gym?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA11000/(POOL_BACKYARD). Pool or spa? 

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) 

PA12000/(BIKE_AREA_BACKYARD). Area suitable to ride a tricycle, bike or scooter?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA14000. I am going to read several statements.  Please tell me how often the statement applies to you or the child.

PA15000/(OUTDOOR_PLAY_OFTEN). My child plays outside when the weather is suitable.   

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO THE APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON’T KNOW	-2

SOURCE

Family Health Behavior Scale (modified)

PA16000/(PART_OFTEN_CAREGIVERS). My child participates in physical activity with parents and caregivers. 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RSPONSE OPTIONS

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON’T KNOW	-2

SOURCE

Family Health Behavior Scale (modified)

PA17000/(ACTIVE_DAILY_30MIN). My child is physically active for at least 30 minutes a day. 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON’T KNOW	-2

SOURCE

Family Health Behavior Scale (modified)

PA18000/(PART_ORG_SPORTS). My child participates in organized sports. 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARDS.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON’T KNOW	-2

SOURCE

Family Health Behavior Scale (modified)

PA19000/(PREFER_INDOOR). My child prefers indoor activities over outdoor activities. 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON’T KNOW	-2

SOURCE

Family Health Behavior Scale (modified)

PA20000/(PART_WITH_CHILD). I participate in physical activity with my child. 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCRDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON’T KNOW	-2

SOURCE

Family Health Behavior Scale (modified)

PA21000/(OBSERVE_PHYS_ACT). My child observes me being physically active. 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARDS.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS. 

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON’T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA22000/(WORRY_CHILD_INJURE). When my child plays I worry that {he/she} may injure {himself/herself}. 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON’T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA23000/(BASIC_LEARNING_FOC). I focus upon my child developing {his/her} basic learning skills such as numbers and letters. 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON’T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA24000/(WORK_LIMIT_PLAY). My work schedule or other commitments limit the time I have to play with my child. 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON’T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

(TIME_STAMP_PA_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

SUN EXPOSURE

(TIME_STAMP_SE_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

SE01000. These next questions ask about you, {C_FNAME/the child}, and your views and habits when out in the sun.

SOURCE

​Sun Habits Survey

SE02000/(HOURS_SUN_WEEKDAY). On average, how long was {C_FNAME/the child} outdoors in the sun on weekdays between 10 a.m. and 4 p.m. last summer? 

Label	Code	Go To
1 HOUR OR LESS	1
2 HOURS	2
3 HOURS	3
4 HOURS	4
5 HOURS	5
6 HOURS	6
REFUSED	-1
DON’T KNOW	-2

SOURCE

Sun Habits Survey

SE03000/(HOURS_SUN_WEEKEND). On average, how long was {C_FNAME/the child} outdoors in the sun on weekends between 10 a.m. and 4 p.m. last summer? 

Label	Code	Go To
1 HOUR OR LESS	1
2 HOURS	2
3 HOURS	3
4 HOURS	4
5 HOURS	5
6 HOURS	6
REFUSED	-1
DON’T KNOW	-2

SOURCE

Sun Habits Survey

SE04000. When {C_FNAME/the child} is outdoors in the sun, how often do you have {C_FNAME/the child} do each of the following?

SOURCE

Sun Habits Survey

SE05000/(SUN_SHIRT_SLEEVES). …Wear a shirt with sleeves?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (When {C_FNAME/the child} is outdoors in the sun, how often do you have {C_FNAME/the child}...) AS NEEDED. 

Label	Code	Go To
RARELY OR NEVER	1
SOMETIMES	2
USUALLY	3
ALWAYS	4
REFUSED	-1
DON’T KNOW	-2

SOURCE

Sun Habits Survey

SE06000/(SUN_SHADE). …Stay in the shade or under an umbrella?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT: (When {C_FNAME/the child} is  outdoors in the sun, how oftern do you have {C_FNAME/the child}...) AS NEEDED.

Label	Code	Go To
RARELY OR NEVER	1
SOMETIMES	2
USUALLY	3
ALWAYS	4
REFUSED	-1
DON’T KNOW	-2

SOURCE

Sun Habits Survey

SE07000/(SUN_SUNSCREEN). …Wear sunscreen?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (When {C_FNAME/the child} is outdoors in the sun, how often do you have {C_FNAME/the child}...) AS NEEDED.

Label	Code	Go To
RARELY OR NEVER	1
SOMETIMES	2
USUALLY	3
ALWAYS	4
REFUSED	-1
DON’T KNOW	-2

SOURCE

Sun Habits Survey

SE08000/(APPLY_SUNSCREEN_FREQ). How often do you or {C_FNAME/the child} apply sunscreen on him/her before s/he goes to outdoor activities?

Label	Code	Go To
RARELY OR NEVER	1
SOMETIMES	2
USUALLY	3
ALWAYS	4
REFUSED	-1
DON’T KNOW	-2

SOURCE

Sun Habits Survey

SE09000/(APPLY_SUNSCREEN_TIME). When do you (or {C_FNAME/the child}) usually first put sunscreen on?

Label	Code	Go To
First thing in the morning	1
Before going outside	2
After being outside	3
DO NOT APPLY SUNSCREEN	-7
REFUSED	-1
DON’T KNOW	-2

SOURCE

Sun Habits Survey

SE10000/(CHILD_NAT_HAIR_COLOR). What is {C_FNAME/the child}’s natural hair color?

Label	Code	Go To
RED	1	CHILD_EYE_COLOR
BLONDE	2	CHILD_EYE_COLOR
BROWN	3	CHILD_EYE_COLOR
BLACK	4	CHILD_EYE_COLOR
REFUSED	-1	CHILD_EYE_COLOR
DON’T KNOW	-2	CHILD_EYE_COLOR
OTHER	-5

SOURCE

Sun Habits Survey (modified)

SE10100/(CHILD_NAT_HAIR_COLOR_OTH). ​SPECIFY: __________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

​Sun Habits Survey (modified)

SE11000/(CHILD_EYE_COLOR). What is the color of {C_FNAME/the child}’s eyes?

Label	Code	Go To
GREEN	1	CHILD_SKIN_COLOR
BLUE	2	CHILD_SKIN_COLOR
HAZEL	3	CHILD_SKIN_COLOR
BROWN	4	CHILD_SKIN_COLOR
BLACK	5	CHILD_SKIN_COLOR
OTHER	-5
REFUSED	-1	CHILD_SKIN_COLOR
DON’T KNOW	-2	CHILD_SKIN_COLOR

SOURCE

Sun Habits Survey (modified)

SE12000/(CHILD_EYE_COLOR_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey (modified)

SE13000/(CHILD_SKIN_COLOR). What is the color of {C_FNAME/the child}’s untanned skin?

Label	Code	Go To
Very fair	1	TAN_30MIN_SUN
Fair	2	TAN_30MIN_SUN
Olive	3	TAN_30MIN_SUN
Dark	4	TAN_30MIN_SUN
Very dark	5	TAN_30MIN_SUN
OTHER	-5
REFUSED	-1	TAN_30MIN_SUN
DON’T KNOW	-2	TAN_30MIN_SUN

SOURCE

Sun Habits Survey

SE14000/(CHILD_SKIN_COLOR_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey (modified)

SE15000/(TAN_30MIN_SUN). After being in direct sunlight for more than 30 minutes, does {C_FNAME/the child} get: 

Label	Code	Go To
A severe burn with blistering	1
A severe burn without blistering	2
A mild burn, but then tan or darken	3
Tanned easily	4
Tanned slowly	5
IS NEVER IN DIRECT SUNLIGHT FOR MORE THAN 30 MINUTES	-7
REFUSED	-1
DON’T KNOW	-2

SOURCE

Sun Habits Survey (modified)

SE16000/(EVER_SUNBURN). Has {C_FNAME/the child} ever had a sunburn?

Label	Code	Go To
YES	1
NO	2	TIME_STAMP_SE_ET
REFUSED	-1	TIME_STAMP_SE_ET
DON'T KNOW	-2	TIME_STAMP_SE_ET

SOURCE

Sun Habits Survey

SE17000/(NUM_SUNBURNS_PREV_SUMMER). How many times last summer did this child get a sunburn?

Label	Code	Go To
NONE	0
ONE	1
TWO	2
THREE	3
FOUR	4
FIVE OR MORE	5
REFUSED	-1
DON’T KNOW	-2

SOURCE

Sun Habits Survey

(TIME_STAMP_SE_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

NOISE EXPOSURE

(TIME_STAMP_NE_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

NE01000. We would now like to ask you some questions about noise during activities in places where {C_FNAME/the child} spends time - other than in the home {or the child care arrangements we have just talked about}. We understand that you may not spend much time at these places, so please consider the noise the child may experience during his/her time in these places. 

NE02000/(NOISY_ACTIVITIES). Is your child around loud noise associated with any of the following activities? 

INTERVIEWER INSTRUCTIONS

• SELECT ALL THAT APPLY.

Label	Code	Go To
Sports	1
Music classes	2
Other loud activities	-5
REFUSED	-1
DON’T KNOW	-2

SOURCE

New

INTERVIEWER INSTRUCTIONS

• IF NOISY_ACTIVITIES= ANY COMBINATION OF 1 AND/OR 2, GO TO NOISE_CHILD_ACTIVITIES.

• IF NOISY_ACTIVITIES= -5 OR ANY COMBINATION OF 1 AND/OR 2 WITH -5, GO TO NOISY_ACTIVITIES_OTH.

• IF NOISY_ACTIVITIES= -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO NE06000

NE03000/(NOISY_ACTIVITIES_OTH). What type of other loud activities?

 

SPECIFY: ___________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

New

NE04000/(NOISE_CHILD_ACTIVITIES). Thinking about the noise {C_FNAME/the child} experiences during these noisy activities, how much would you say the noise bothers, disturbs, or annoys {him/her}? 

Label	Code	Go To
Extremely	1
Very much	2
Moderately	3
Slightly	4
Not at all	5	NE06000
REFUSED	-1	NE06000
DON’T KNOW	-2	NE06000

SOURCE

The International Commission on Biological Effects of Noise’s (ICBEN’s) Community Response to Noise Team, Cohen/Bronzaft airport studies (modified)

NE05000/(NOISE_ACTIVITY_SCALE). What number from zero to ten best shows how much you would say {C_FNAME/the child} is bothered, disturbed, or annoyed by noise in these noisy activities? Zero means {he/she} is not bothered at all and ten means {he/she} is extremely bothered. 

Label	Code	Go To
0	0
1	1
2	2
3	3
4	4
5	5
6	6
7	7
8	8
9	9
10	10
REFUSED	-1
DON'T KNOW	-2

SOURCE

The International Commission on Biological Effects of Noise’s (ICBEN’s) Community Response to Noise Team (modified)

NE06000. We would now like to ask you some questions about your child’s use of headphones, ear phones, or ear buds for any reason, e.g., to listen to music, watch television or movies, or play games, etc.

NE07000/(NOISE_PEDUSE_EARPHONES). Does your child ever wear headphones, ear phones, or ear buds?

Label	Code	Go To
YES	1
NO	2	NE10000
REFUSED	-1	NE10000
DON'T KNOW	-2	NE10000

SOURCE

New

NE08000/(NOISE_PEDUSE_FREQ). On average, how much time each day would you estimate your child wears headphones, ear phones or ear buds?

Label	Code	Go To
Less than 1 hour per day	1
About 1 hour per day	2
About 2-3 hours per day	3
More than 4 hours per day	4
REFUSED	-1
DON’T KNOW	-2

SOURCE

New

NE09000/(NOISE_PEDUSE_INTENSITY). When {C_FNAME/the child} is wearing headphones, ear phones or earbuds, is {he/she} able to hear you speak? 

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

New

NE10000. We would now like to ask you some questions about noise in and around the child’s home.

NE11000/(NOISE_OUTSIDE). When inside {C_FNAME/the child}’s home, how much would you say noise from outdoor sources bothers, disturbs, or annoys {him/her}? 

Label	Code	Go To
Extremely	1
Very much	2
Moderately	3
Slightly	4
Not at all	5	NOISE_INSIDE
REFUSED	-1	NOISE_INSIDE
DON’T KNOW	-2	NOISE_INSIDE

SOURCE

The International Commission on Biological Effects of Noise’s (ICBEN’s) Community Response to Noise Team, Cohen/Bronzaft airport studies (modified)

NE12000/(NOISE_OUTSIDE_SCALE). When inside the home, what number from zero to ten best shows how much you would say {C_FNAME/the child} is bothered, disturbed, or annoyed by noise from outdoor sources? Zero means {he/she} is not bothered at all and ten means {he/she} is extremely bothered. 

Label	Code	Go To
0	0
1	1
2	2
3	3
4	4
5	5
6	6
7	7
8	8
9	9
10	10
REFUSED	-1
DON'T KNOW	-2

SOURCE

The International Commission on Biological Effects of Noise’s (ICBEN’s) Community Response to Noise Team (modified)

NE13000/(NOISE_OUTSIDE_TYPE). What types of outdoor noises bother, disturb, or annoy {C_FNAME/the child}?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• SELECT ALL THAT APPLY.

Label	Code	Go To
AIRPLANE	1
CAR/TRUCK	2
GARDEN EQUIPMENT	3
DOGS BARKING	4
LOUD MUSIC	5
NEIGHBOR VOICES	6
ROWDY PASSERBY VOICES	7
NO PARTICULAR SOURCE	8
SOME OTHER SOURCE	-5
REFUSED	-1
DON’T KNOW	-2

SOURCE

The International Commission on Biological Effects of Noise's (ICBEN’s) Cohen/Bronzaft airport studies (modified)

PROGRAMMER INSTRUCTIONS

• IF NOISE_OUTSIDE_TYPE=ANY COMBINATION OF 1 THROUGH 7, GO TO NOISE_INSIDE.

• IF NOISE _OUTSIDE_TYPE=-5 OR ANY COMBINATION OF 1 THROUGH 7 AND-5,GO TO NOISE_OUTSIDE_OTH.

• IF NOISE_OUTSIDE_TYPE= 8, -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO NOISE_INSIDE.

NE14000/(NOISE_OUTSIDE_OTH). What other type of outdoor noise?

 

SPECIFY: ___________________________________

INTERVIEWER INSTRUCTIONS

• PROBE “Anything else?”

• LIST ALL OTHER OUTDOOR NOISE SOURCES SEPARATED BY COMMAS. 

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

The International Commission on Biological Effects of Noise's (ICBEN’s) Cohen/Bronzaft airport studies (modified)

NE15000/(NOISE_INSIDE). At {C_FNAME/the child}’s home, how much would you say noise from indoor sources bothers, disturbs, or annoys {C_FNAME/the child}?

Label	Code	Go To
Extremely	1
Very much	2
Moderately	3
Slightly	4
Not at all	5	NOISE_INTERFERE
REFUSED	-1	NOISE_INTERFERE
DON’T KNOW	-2	NOISE_INTERFERE

SOURCE

The International Commission on Biological Effects of Noise’s (ICBEN’s) Community Response to Noise Team (modified)

NE16000/(NOISE_INSIDE_SCALE). What number from zero to ten best shows how much {C_FNAME/the child} is bothered, disturbed, or annoyed by noise from indoor sources? Zero means {he/she} is not bothered at all and ten means {he/she} is extremely bothered. 

Label	Code	Go To
0	0
1	1
2	2
3	3
4	4
5	5
6	6
7	7
8	8
9	9
10	10
REFUSED	-1
DON'T KNOW	-2

SOURCE

The International Commission on Biological Effects of Noise’s (ICBEN’s) Community Response to Noise Team (modified)

NE17000/(NOISE_INSIDE_TYPE). What types of indoor noise would you say bother, disturb or annoy {C_FNAME/the child}?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• SELECT ALL THAT APPLY.

Label	Code	Go To
BUILDING/MECHANICAL NOISE SUCH AS – FAN, AIR CONDITIONING, ETC.	1
LOUD MUSIC	2
LOUD TALKING, CRYING, ETC. BY HOUSEHOLD MEMBERS, INCLUDING CHILDREN	3
DOGS BARKING	4
SOME OTHER SOURCE	-5
REFUSED	-1
DON’T KNOW	-2

SOURCE

The International Commission on Biological Effects of Noise’s (ICBEN’s) Community Response to Noise Team (modified)

PROGRAMMER INSTRUCTIONS

• IF NOISE_INSIDE_TYPE=ANY COMBINATION OF 1 THROUGH 4, GO TO NOISE_INTERFERE.

• IF NOISE _INSIDE_TYPE=-5 OR ANY COMBINATION OF 1 THROUGH 4 AND -5, GO TO NOISE_INSIDE_OTH.

• IF NOISE_INSIDE_TYPE=-1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO NOISE_INTERFERE​.

NE18000/(NOISE_INSIDE_OTH). What other type of indoor noise ?

 

SPECIFY: ___________________________________

INTERVIEWER INSTRUCTIONS

• PROBE “Anything else?”

• LIST ALL OTHER INDOOR NOISE SOURCES SEPARATED BY COMMAS. 

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

The International Commission on Biological Effects of Noise's (ICBEN’s) Cohen/Bronzaft airport studies (modified)

NE19000/(NOISE_INTERFERE). How does noise interfere with life activities at {C_FNAME/the child}’s home?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARDS. 

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• SELECT ALL THAT APPLY.

Label	Code	Go To
PREVENTS YOU FROM OPENING WINDOWS	1
DISTURBS YOUR SLEEP	2
INTERFERES WITH YOUR RADIO/TV LISTENING	3
INTERFERES WITH YOUR TALKING ON THE PHONE	4
INTERFERES WITH YOUR TALKING TO OTHERS	5
DOES NOT INTERERE WITH YOUR LIFE ACTIVITIES	-7
INTERFERES WITH YOUR LIFE ACTIVITIES IN SOME OTHER WAY	-5
REFUSED	-1
DON’T KNOW	-2

SOURCE

The International Commission on Biological Effects of Noise's (ICBEN’s) Cohen/Bronzaft airport studies (modified)

PROGRAMMER INSTRUCTIONS

• IF NOISE_INTERFERE=ANY COMBINATION OF 1 THROUGH 5, GO TO NOISE_COMPLAIN.

• IF NOISE_INTERFERE=-5 OR ANY COMBINATION OF 1 THROUGH 5 AND -5, GO TO NOISE_INTERFERE_OTH.

• IF NOISE_INTERFERE=-7, -1, OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO NOISE_COMPLAIN.

NE20000/(NOISE_INTERFERE_OTH). What other type of interference?

 

SPECIFY: ___________________________________

INTERVIEWER INSTRUCTIONS

• PROBE “Anything else?”

• LIST ALL OTHER NOISE INTERFERENCE TYPES SEPARATED BY COMMAS. 

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

The International Commission on Biological Effects of Noise's (ICBEN’s) Cohen/Bronzaft airport studies (modified)

NE21000/(NOISE_COMPLAIN). Since our last interview on {DATE OF LAST INTERVIEW}, have you or others complained to police or government officials about noise in the area around {C_FNAME/the child}’s home?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

The International Commission on Biological Effects of Noise's (ICBEN’s) Cohen/Bronzaft airport studies (modified)

(TIME_STAMP_NE_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

SCHOOL EXPERIENCES

(TIME_STAMP_SEZ_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

SEZ01000/(ATTEND_SCHOOL). Is {C_FNAME/the child} attending or enrolled in school?

Label	Code	Go To
YES	1	SCHOOL_GRADE
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview (modified)

SEZ02000/(REAS_NO_SCHOOL). Why is {C_FNAME/the child} not attending school this year?

Label	Code	Go To
NOT OLD ENOUGH	1	TIME_STAMP_SEZ_ET
NOT READY SOCIALLY	2	TIME_STAMP_SEZ_ET
NOT READY ACADEMICALLY	3	TIME_STAMP_SEZ_ET
OTHER	-5
REFUSED	-1	TIME_STAMP_SEZ_ET
DON’T KNOW	-2	TIME_STAMP_SEZ_ET

SOURCE

New

SEZ02100/(REAS_NO_SCHOOL_OTH). SPECIFY: ______________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

New 

PROGRAMMER INSTRUCTIONS

• GO TO ​TIME_STAMP_SEZ_ET.

SEZ03000/(SCHOOL_GRADE). What grade is {he/she} in?

Label	Code	Go To
PRESCHOOL	1	SEZ05000
KINDERGARTEN	2	SEZ05000
FIRST GRADE	3	SEZ05000
UNGRADED	4	SEZ05000
OTHER	-5
REFUSED	-1	SEZ05000
DON'T KNOW	-2	SEZ05000

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview 

SEZ04000/(SCHOOL_GRADE_OTH). SPECIFY: ___________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview 

SEZ05000. What month and year did {C_FNAME/the child} start in their current class?

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview (modified)

(BEGIN_SCHOOL_MM)

|___|___|

MONTH

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(BEGIN_SCHOOL_YYYY)  

|___|___|___|___|

         YEAR

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SEZ06000/(HRS_SCHOOL). How many hours each day does {he/she} spend in school?

 

|___|___|

HOURS

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview (modified)

SEZ07000/(DAYS_SCHOOL). How many days each week does {he/she} spend in school?

 

|___|

DAYS

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview (modified)

SEZ08000/(NAME_SCHOOL). What is the name of the school where {C_FNAME/the child} attends school?

 

NAME: _____________________________________

INTERVIEWER INSTRUCTIONS

• VERIFY SPELLING.

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview 

SEZ09000. What is the address of {SCHOOL NAME}?

INTERVIEWER INSTRUCTIONS

• VERIFY SPELLING.

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview 

(SCHOOL_STREET_ADDRESS_1) ​STREET ADDRESS 1: ____________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(SCHOOL_STREET_ADDRESS_2) ​STREET ADDRESS 2: _____________________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(SCHOOL_CITY) CITY: _____________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(SCHOOL_STATE) STATE: |___|___|

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(SCHOOL_ZIPCODE) ZIP CODE: |___|___|___|___|___|

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

PROGRAMMER INSTRUCTIONS

• DISPLAY RESPONSE PROVIDED IN NAME_SCHOOL AS ​"SCHOOL NAME".

SEZ10000/(SCHOOL_PRIVATE). Is the school public or private?

Label	Code	Go To
PUBLIC	1
PRIVATE	2
REFUSED	-1
DON’T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview (modified)

SEZ11000/(SCHOOL_VOUCHER). Did you use a voucher provided by the government to attend this school? 

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview 

SEZ12000/(NUM_STUDENTS_CLASS). How many students are in {C_FNAME/the child}'s class? 

 

|___|___|___|

NUMBER

SOURCE

New

SEZ13000/(NUM_TEACHERS_CLASS). How many teachers and teacher’s assistants usually work in {C_FNAME/the child}'s classroom? 

 

|___|___|

NUMBER

SOURCE

New 

SEZ14000/(TRANS_SCHOOL). How does {C_FNAME/the child} usually get to school? Does (he/she)…

Label	Code	Go To
Walk or ride a bike	1
Ride a bus	2
Is {he/she} dropped off by a parent, relative, or adult friend	3
Is {he/she} dropped off by {his/her} day care provider	4
REFUSED	-1
DON’T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, 1998-99 Kindergarten Cohort Spring Parent Interview 

SEZ15000/(COMMUTE_LENGTH_SCH). How many minutes does it usually take {C_FNAME/the child} to get to school?

 

l___l___l

MINUTES

SOURCE

New

SEZ16000/(DISTANCE_SCHOOL). About how far would you say it is from your home to the school {C_FNAME/the child} attends?

Label	Code	Go To
LESS THAN 1/8TH MILE (LESS THAN 3 BLOCKS)	1
1/8TH MILE TO ¼ MILES (3-5 BLOCKS	2
MORE THAN ¼ MILE, BUT LESS THAN ½ MILE (6-9 BLOCKS)	3
½ MILE TO LESS THAN 1 MILE (10-19 BLOCKS)	4
ONE MILE TO 2.5 MILES (LESS THAN 5 MINUTE DRIVE)	5
2.6 MILES TO 5 MILES (BETWEEN 5-10 MINUTE DRIVE)	6
5.1 MILES TO 7.5 MILES (BETWEEN 11 AND 15 MINUTE DRIVE)	7
7.6 MILES TO 10 MILES (BETWEEN 16 AND 20 MINUTE DRIVE), OR	8
11 MILES OR MORE (MORE THAN A 20 MINUTE DRIVE)?	9
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview (modified)

SEZ17000/(SPEC_ED). When a child with a disability or developmental delay receives special education and/or related services sponsored through your local education agency – that is, the school system – these services are initiated after a diagnosis of condition, or professional evaluation of the child, and development of an Individualized Education Program or "IEP" or an Individualized Family Service Program or "IFSP", which is discussed with and signed by the parent.

 

Is {C_FNAME/the child} receiving special education services related to either an IEP or an IFSP? 

Label	Code	Go To
YES	1
NO	2	SEZ21000
REFUSED	-1	SEZ21000
DON'T KNOW	-2	SEZ21000

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview 

PROGRAMMER INSTRUCTIONS

• IF SPEC_ED = 1, GO TO SPEC_EQUIP_SCHOOL.

• IF SPEC_ED = 2, -1 OR -2, AND
  
  

• IF SCHOOL_GRADE = 2, GO TO SEZ21000.

• IF SCHOOL_GRADE ≠ 2, GO TO INVITE_PARTY.

SEZ18000/(SPEC_EQUIP_SCHOOL). Does {C_FNAME/the child} currently use special equipment for children with special needs such as a wheelchair, communication board, or other assistive device?  

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, 1998-99 Kindergarten Cohort Fall Parent Interview 

SEZ19000/(WRITTEN_SPEC_NEEDS). Does {C_FNAME/the child} have a written accommodations plan for any special needs, as described under Section 504 of the Vocational Rehabilitation Act usually called a 504 plan? 

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Longitudinal Transition Study – 2 Parent Interview

SEZ20000/(SPEC_SERVICES). Were you the one who first asked for special services for {C_FNAME/the child} in school, or did school staff first suggest that {he/she} might need services?

Label	Code	Go To
PARENT ASKED	1
SCHOOL STAFF RECOMMENDED	2
SOMEONE ELSE RECOMMENDED	3
REFUSED	-1
DON’T KNOW	-2

SOURCE

National Longitudinal Transition Study – 2 Parent Interview 

PROGRAMMER INSTRUCTIONS

• IF SCHOOL_GRADE = 2, GO TO SEZ21000.

• IF SCHOOL_GRADE ≠ 2, GO TO INVITE_PARTY.

SEZ21000. Starting school can be a big change for children. These next few items are about how well that transition to school went for {C_FNAME/the child}, and how ready you thought {he/she} was for school.

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview 

SEZ22000/(ACAD_PREP_SCHOOL). How academically prepared do you think {C_FNAME/the child} was for kindergarten?  By academically prepared, we mean knowing things like letters and numbers, and being ready to learn. Would you say…

Label	Code	Go To
Very prepared	1
Somewhat prepared	2
Not at all prepared	3
REFUSED	-1
DON’T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview (modified)

SEZ23000/(SOC_PREP_SCHOOL). How socially prepared do you think {C_FNAME/the child} was for kindergarten?  By socially prepared, we mean being ready for the classroom environment, including being able to listen to and follow instructions, express {his/her} needs verbally, and play well with other children. Would you say…

Label	Code	Go To
Very prepared	1
Somewhat prepared	2
Not at all prepared	3
REFUSED	-1
DON’T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview (modified)

SEZ24000. Children sometimes have trouble adjusting to kindergarten. On average, {since this school year began/during the first two months of this school year}…

PROGRAMMER INSTRUCTIONS

• IF CURRENT MONTH AND YEAR < 2 MONTHS FROM BEGIN_SCHOOL_MM AND BEGIN_SCHOOL_YYYY DISPLAY FIRST BRACKETED PHRASE.

• OTHERWISE, DISPLAY SECOND BRACKETED PHRASE.

SEZ25000/(FREQ_COMPLAIN_SCH). How often did {C_FNAME/the child} complain about school?  Would you say more than once a week, once a week or less, or not at all?

Label	Code	Go To
MORE THAN ONCE A WEEK	1
ONCE A WEEK OR LESS	2
NOT AT ALL	3
REFUSED	-1
DON’T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview (modified)

SEZ26000/(FREQ_RELUCT_SCHOOL). How often was { C_FNAME/the child } reluctant to go to school?

Label	Code	Go To
MORE THAN ONCE A WEEK	1
ONCE A WEEK OR LESS	2
NOT AT ALL	3
REFUSED	-1
DON’T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview (modified)

SEZ27000/(FREQ_PRETEND_SICK). How often did {he/she} pretend to be sick to stay home from school?

Label	Code	Go To
MORE THAN ONCE A WEEK	1
ONCE A WEEK OR LESS	2
NOT AT ALL	3
REFUSED	-1
DON’T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview 

SEZ28000/(FREQ_SAY_GOOD). How often did {he/she} say good things about school?

Label	Code	Go To
MORE THAN ONCE A WEEK	1
ONCE A WEEK OR LESS	2
NOT AT ALL	3
REFUSED	-1
DON’T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview 

SEZ29000/(FREQ_SAY_LIKE_TEACH). How often did {C_FNAME/the child} say {he/she} liked {his/her} teacher?

Label	Code	Go To
MORE THAN ONCE A WEEK	1
ONCE A WEEK OR LESS	2
NOT AT ALL	3
REFUSED	-1
DON’T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview 

SEZ30000/(FREQ_LOOK_FORWARD_SCH). How often did {he/she} look forward to going to school?

Label	Code	Go To
MORE THAN ONCE A WEEK	1
ONCE A WEEK OR LESS	2
NOT AT ALL	3
REFUSED	-1
DON’T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview 

SEZ31000/(INVITE_PARTY). During the past 12 months, has {he/she} been invited by friends to social activities like over to their home or to a party?  

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Longitudinal Transition Study – 2 Parent Interview 

SEZ32000/(NUM_FRIENDS). How many friends does {C_FNAME/the child} have? Would you say...

Label	Code	Go To
None	1
1 or 2 friends	2
3 to 5 friends	3
More than 5 friends	4
REFUSED	-1
DON’T KNOW	-2

SOURCE

Fragile X Survey 

SEZ33000/(BULLY_SCHOOL). Has {C_FNAME/the child} been bullied [in school] this year?  By bullied, we mean has there been a time when someone else has done things like called {C_FNAME/the child} names, teased or laughed at {him/her}, left {him/her} out, threatened, or physically hurt {him/her}?  

Label	Code	Go To
YES	1
NO	2	MET_TEACHER
REFUSED	-1	MET_TEACHER
DON'T KNOW	-2	MET_TEACHER

SOURCE

New 

SEZ34000/(BULLY_FREQ). How often has this happened?  Would you say…

Label	Code	Go To
Once or twice	1
Three to ten times	2
More than ten times	3
REFUSED	-1
DON’T KNOW	-2

SOURCE

New 

SEZ35000/(MET_TEACHER). Have you met {C_FNAME/the child}’s teacher yet? 

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort Kindergarten 2006 Parent Interview (modified)

SEZ36000. Since the beginning of this school year, have you or the other adults in your household…

SOURCE

Early Childhood Longitudinal Study, 1998-99 Kindergarten Cohort Fall Parent Interview 

SEZ37000/(ATTEND_OPEN_HOUSE). Attended an open house or a back-to-school night?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, 1998-99 Kindergarten Cohort Fall Parent Interview 

SEZ38000/(ATTEND_PTA_MTG). Attended a meeting of a PTA, PTO, or Parent-Teacher Student Organization?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, 1998-99 Kindergarten Cohort Fall Parent Interview 

SEZ39000/(ATTEND_ADVIS_GRP). Gone to a meeting of a parent advisory group or policy council?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, 1998-99 Kindergarten Cohort Fall Parent Interview

SEZ40000/(ATTEN_PAR_TEAC_CONF). Gone to a regularly-scheduled parent-teacher conference with {C_FNAME/the child}'s teacher or meeting with {C_FNAME/the child}'s teacher?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, 1998-99 Kindergarten Cohort Fall Parent Interview 

SEZ41000/(ATTEND_SCH_EVENT). Attended a school or class event, such as a play, sports event, or science fair?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, 1998-99 Kindergarten Cohort Fall Parent Interview 

SEZ42000/(VOLUNTEER_SCHOOL). Acted as a volunteer at the school or served on a committee?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, 1998-99 Kindergarten Cohort Fall Parent Interview 

SEZ43000/(FUNDRAISE_SCHOOL). Participated in fundraising for (C_FNAME/the child)'s school?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, 1998-99 Kindergarten Cohort Fall Parent Interview 

(TIME_STAMP_SEZ_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

CHILD DEMOGRAPHICS

(TIME_STAMP_CD_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

CD01000. These next questions ask about {C_FNAME/the child}.

CD02000/(BABY_ETHNIC_ORIGIN). Is {C_FNAME/the child} of Hispanic, Latino/a or Spanish origin?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Office of Minority Health Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status

PROGRAMMER INSTRUCTIONS

• IF BABY_ETHNIC_ORIGIN=1, GO TO  BABY_EHTNIC_ORIGIN_1.

• IF BABY_EHTNIC_ORIGIN≠1, AND

• IF MODE=CAPI,GO TO BABY_RACE_NEW.

• IF MODE=CATI, GO TO BABY_RACE_1​.

CD03000/(BABY_ETHNIC_ORIGIN_1). Is {C_FNAME/the child} one or more of the following?

INTERVIEWER INSTRUCTIONS

• SELECT ALL THAT APPLY.

• PROBE: Anything else?

Label	Code	Go To
Mexican, Mexican American, Chicano/a	1
Puerto Rican	2
Cuban	3
Another Hispanic, Latino/a, or Spanish origin	4
OTHER	-5
REFUSED	-1
DON’T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Office of Minority Health Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status

PROGRAMMER INSTRUCTIONS

• IF BABY_ETHNIC_ORIGIN_1=ANY COMBINATION OF 1 THROUGH 4, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING BABY_EHTNIC_ORIGIN_1.

• IF BABY_ETHNIC_ORIGIN_1=-5 OR ANY COMBINATION OF 1 THROUGH 4 AND-5, GO TO BABY_EHTNIC_ORIGIN_1_OTH.

• IF BABY_EHTNIC_ORIGIN_1=-1 OR-2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PROGRAMMER INSTRUCTIONS FOLLOWING BABY_EHTNIC_ORIGIN_1​.

CD04000/(BABY_ETHNIC_ORIGIN_1_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Office of Minority Health Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status

PROGRAMMER INSTRUCTIONS

• IF MODE=CAPI, GO TO BABY_RACE_NEW​.

• IF MODE=CATI, GO TO BABY_RACE_1.

CD05000/(BABY_RACE_NEW). What is {C_FNAME/the child}’s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• SELECT ALL THAT APPLY.

• CODE “SOME OTHER RACE” ONLY IF VOLUNTEERED.

• PROBE: Anything else?

Label	Code	Go To
WHITE	1
BLACK OR AFRICAN AMERICAN	2
AMERICAN INDIAN OR ALASKA NATIVE	3
ASIAN INDIAN	4
CHINESE	5
FILIPINO	6
JAPANESE	7
KOREAN	8
VIETNAMESE	9
OTHER ASIAN	10
NATIVE HAWAIIAN	11
GUAMANIAN OR CHAMORRO	12
SAMOAN	13
OTHER PACIFIC ISLANDER	14
SOME OTHER RACE	-5
REFUSED	-1
DON’T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Office of Minority Health Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status

PROGRAMMER INSTRUCTIONS

• IF BABY_RACE_NEW=ANY COMBINATION OF 1 THROUGH 14, GO TO ​ENGLISH_WELL_CHILD.

• IF BABY_RACE_NEW=-5 OR ANY COMBINATION OF 1 THROUGH 14 AND -5, GO TO BABY_RACE_NEW_OTH.

• IF BABY_RACE_NEW=-1 OR -2, DO NOT ALLOW ANY OTHER RESONSES AND GO TO ENGLISH_WELL_CHILD. 

CD06000/(BABY_RACE_NEW_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Office of Minority Health Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status

PROGRAMMER INSTRUCTIONS

• GO TO ENGLISH_WELL_CHILD​.

CD07000/(BABY_RACE_1). What is {C_FNAME/the child}’s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• SELECT ALL THAT APPLY.

• CODE “SOME OTHER RACE” ONLY IF VOLUNTEERED.

• PROBE: Anything else?

Label	Code	Go To
White	1
Black or African American	2
American Indian or Alaska native,	3
Asian	4
Native Hawaiian or other Pacific Islander	5
SOME OTHER RACE	-5
REFUSED	-1
DON’T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Office of Minority Health Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status

PROGRAMMER INSTRUCTIONS

• IF BABY_RACE_1=ANY COMBINATION OF 1 THROUGH 3, GO TO ENGLISH_WELL_CHILD.

• IF BABY_RACE_1=4 OR ANY COMBINATION OF 4 AND 1, 2, 3 AND/OR 5, GO TO BABY_RACE_2.

• IF BABY_RACE_1=5 OR ANY COMBINATION OF 5 AND 1 THORUGH 3, GO TO BABY_RACE_3.

• IF BABY_RACE_1=-5 OR ANY COMBINATION OF 1 THROUGH 5 AND -5, GO TO BABY_RACE_1_OTH.

• IF BABY_RACE_1=-1 OR -2, DO NOT ALLOW OTHER RESPONSES AND GO TO ENGLISH_WELL_CHILD.  

CD08000/(BABY_RACE_1_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Office of Minority Health Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status

PROGRAMMER INSTRUCTIONS

• IF BABY_RACE_1=4 OR 4 AND ANY COMBINATION OF 1, 2, 3, AND/OR 5, GO TO BABY_RACE_2. 

• IF BABY_RACE_1=5 OR 5 AND ANY COMBINATION OF 1 THROUGH 3, GO TO BABY_RACE_3.

• OTHERWISE, GO TO ENGLISH_WELL_CHILD.

CD09000/(BABY_RACE_2). What is {C_FNAME/the child}’s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY. 

Label	Code	Go To
Asian Indian	1
Chinese	2
Filipino	3
Japanese	4
Korean	5
Vietnamese	6
Other Asian	7
REFUSED	-1
DON’T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Office of Minority Health Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status

PROGRAMMER INSTRUCTIONS

• IF BABY_RACE_1=ANY COMBINATION WITH 4 AND 5 ,GO TO BABY_RACE_3.

• OTHERWISE, GO TO ENGLISH_WELL_CHILD.

CD10000/(BABY_RACE_3). What is {C_FNAME/the child}’s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY. 

Label	Code	Go To
Native Hawaiian	1
Guamanian or Chamorro	2
Samoan	3
Other Pacific Islander	4
REFUSED	-1
DON’T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Office of Minority Health Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status

CD11000/(ENGLISH_WELL_CHILD). How well does {C_FNAME/the child} speak English? Would you say…

Label	Code	Go To
Very well	1
Well	2
Not well	3
Not at all	4
REFUSED	-1
DON’T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

CD12000/(HH_NONENGLISH_NEW_CHILD). Does{C_FNAME/the child} speak a language other than English at home?

Label	Code	Go To
YES	1
NO	2	DIFF_HEAR_CHILD
REFUSED	-1	DIFF_HEAR_CHILD
DON'T KNOW	-2	DIFF_HEAR_CHILD

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

CD13000/(OTHER_LANG_CHILD). What is this language?

Label	Code	Go To
Spanish	1	DIFF_HEAR_CHILD
Other Language	-5
REFUSED	-1	DIFF_HEAR_CHILD
DON’T KNOW	-2	DIFF_HEAR_CHILD

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

CD14000/(OTHER_LANG_CHILD_OTH ). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

CD15000/(DIFF_HEAR_CHILD). Is {C_FNAME/the child} deaf or does {he/she} have serious difficulty hearing?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

CD15100/(DIFF_SEE_CHILD). Is {C_FNAME/the child} blind or does {he/she} have serious difficulty seeing, even when wearing glasses?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

CD16000/(DIFF_CONCENTRATE_CHILD). Because of a physical, mental, or emotional condition, does {C_FNAME/the child} have serious difficulty concentrating, remembering, or making decisions?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

CD17000/(DIFF_WALK_CHILD). Does {C_FNAME/the child} have serious difficulty walking or climbing stairs?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

CD18000/(DIFF_DRESS_CHILD). Does {C_FNAME/the child} have difficulty dressing or bathing?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act

CD19000/(PARTICIPANT_SEX). WHAT IS THE SEX OF THE CHILD?

INTERVIEWER INSTRUCTIONS

• DO NOT ADMINISTER THIS QUESTION TO THE RESPONDENT

Label	Code	Go To
MALE	1
FEMALE	2
REFUSED	-1
DON'T KNOW	-2

(TIME_STAMP_CD_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.