National Survey of Children's Health Pretest

Appendix B -NSCH 2015 Pretest - Questionnaires

National Survey of Children's Health Pretest

OMB: 0607-0984

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Appendix B.
NSCH 2015 Pretest - Questionnaires
1. Screener Questionnaire*
2. Topical Questionnaires
a. 0 to 5 Year Old Children*
b. 6 to 11 Year Old Children*
c. 12 to 17 Year Old Children*
* A Spanish version will be created after OMB approval.

Screener Questionnaire

26005017

National Survey of Children’s Health
A study by the U.S. Department of Health and Human Services to
better understand the health issues being faced by children in the
United States today.

The U.S. Census Bureau is conducting the National Survey of Children’s Health on the behalf of the Department of Health and Human
Services (HHS) under Title 13, United States Code, Section 8(b), which allows the Census Bureau to conduct surveys on behalf of
other agencies, and Title 42, United States Code, Chapter 7, Title 5, which allows the HHS to collect information for the purpose of
understanding the health and well-being of children in the United States.
Any information you provide will be shared among a limited number of Census Bureau and HHS staff only for work-related purposes
identified above and as permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a) and in accordance with System of Records
Notice COMMERCE/Census-7, Other Agency Surveys and Reimbursables. By law, the information is kept confidential in accordance
with the Confidential Information Protection and Statistical Efficiency Act (CIPSEA), 44 U.S.C. 3501 note. This law requires the Census
Bureau and HHS to keep all information about you and your household strictly confidential, and also requires that the information
be used only for statistical purposes. In compliance with this law, all data released to the public are only in a statistical format. No
information that could personally identify you or your family is released. Violation of this law is a federal crime that is associated
with severe penalties, including a federal prison sentence of up to five years, a fine of up to $250,000, or both.
Participation in this survey is voluntary and there are no penalties for refusing to answer questions. However, your cooperation in
obtaining this much needed information is extremely important in order to ensure complete and accurate results.

NSCH-P-S1
(03/17/2015)

§;!S2¤

26005025

Start Here
Please answer all of the questions that apply, regardless of whether you have children 0-17 years old who usually live or stay
at this address.
For households with children, this survey should be completed by an adult who is familiar with their health and health care.
Thank you for helping us learn about the health and well-being of America’s children.
If you:
• Need help or have questions about completing this form
• Need Telephone Device for the Deaf (TDD) assistance
•¿NECESITA AYUDA? para completar su cuestionario
Please call: 1-800-845-8241. The telephone call is free.

In Your Home
1

Are there any youth or children 0-17 years old who usually live or stay at this address?
No
If No, STOP HERE after marking “No” and return this survey to us in the enclosed envelope. It is important that we
receive a response from every household selected for this study.
Yes

How many youth or children 0-17 years old usually live or stay at this address?

Number of children living or staying at this address

What is the primary language spoken in the household?
English
Spanish
Other Language (Please specify)

➜ Answer the remaining questions for each of the children 0-17 years old who usually live or stay
at this address.
Start with the YOUNGEST CHILD, who we call “Child 1” and continue with the next oldest until
you have answered the questions for all children who usually live or stay at this address.

NSCH-P-S1

§;!S:¤

26005033

CHILD 1

(Youngest)

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?
Yes

First name/initials/nickname of youngest child

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?

➜ NOTE: Answer BOTH question 1 about Hispanic

Yes

origin and question 2 about race. For this survey,
Hispanic origins are not races.

Yes

Is Child 1 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Yes, Mexican, Mexican American, Chicano

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Yes, Puerto Rican

Yes

Yes, another Hispanic, Latino, or Spanish origin

White

Vietnamese

Black or
African American

Other Asian

American Indian or
Alaska Native

Native Hawaiian

Asian Indian

Guamanian or
Chamorro

Chinese

Samoan

Filipino

Other Pacific Islander

Japanese

Some other race

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s race? Mark one or more boxes.

Yes
8

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?
Yes

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

Korean
3

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

Yes, Cuban

How old is this child in years?
Respond in months if less than 1 year.

Does this child need or get special therapy, such as
physical, occupational, or speech therapy?
Yes

If yes, is this because of ANY medical, behavioral,
or other health condition?
Years (or)

Months
Yes

Male
5

Female

How well does this child speak English?
(5 years old or older)
Very well

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s sex?

Yes

10 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?
Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

Not well
Not at all

Yes

NSCH-P-S1

;!SB¤

26005041

CHILD 2

(Next oldest)

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?
Yes

First name/initials/nickname of the next oldest child

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?

➜ NOTE: Answer BOTH question 1 about Hispanic

Yes

origin and question 2 about race. For this survey,
Hispanic origins are not races.

Yes

Is Child 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Yes, Mexican, Mexican American, Chicano

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Yes, Puerto Rican

Yes

Yes, another Hispanic, Latino, or Spanish origin

White

Vietnamese

Black or
African American

Other Asian

American Indian or
Alaska Native

Native Hawaiian

Asian Indian

Guamanian or
Chamorro

Chinese

Samoan

Filipino

Other Pacific Islander

Japanese

Some other race

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s race? Mark one or more boxes.

Yes
8

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?
Yes

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

Korean
3

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

Yes, Cuban

How old is this child in years?
Respond in months if less than 1 year.

Does this child need or get special therapy, such as
physical, occupational, or speech therapy?
Yes

If yes, is this because of ANY medical, behavioral,
or other health condition?
Years (or)

Months
Yes

Male
5

Female

How well does this child speak English?
(5 years old or older)
Very well

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s sex?

Yes

10 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?
Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

Not well
Not at all

Yes

NSCH-P-S1

;!SJ¤

26005058

CHILD 3

(Next oldest)

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?
Yes

First name/initials/nickname of the next oldest child

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?

➜ NOTE: Answer BOTH question 1 about Hispanic

Yes

origin and question 2 about race. For this survey,
Hispanic origins are not races.

Yes

Is Child 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Yes, Mexican, Mexican American, Chicano

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Yes, Puerto Rican

Yes

Yes, another Hispanic, Latino, or Spanish origin

White

Vietnamese

Black or
African American

Other Asian

American Indian or
Alaska Native

Native Hawaiian

Asian Indian

Guamanian or
Chamorro

Chinese

Samoan

Filipino

Other Pacific Islander

Japanese

Some other race

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s race? Mark one or more boxes.

Yes
8

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?
Yes

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

Korean
3

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

Yes, Cuban

How old is this child in years?
Respond in months if less than 1 year.

Does this child need or get special therapy, such as
physical, occupational, or speech therapy?
Yes

If yes, is this because of ANY medical, behavioral,
or other health condition?
Years (or)

Months
Yes

Male
5

Female

How well does this child speak English?
(5 years old or older)
Very well

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s sex?

Yes

10 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?
Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

Not well
Not at all

Yes

NSCH-P-S1

;!S[¤

26005066

CHILD 4

(Next oldest)

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?
Yes

First name/initials/nickname of the next oldest child

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?

➜ NOTE: Answer BOTH question 1 about Hispanic

Yes

origin and question 2 about race. For this survey,
Hispanic origins are not races.

Yes

Is Child 4 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Yes, Mexican, Mexican American, Chicano

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Yes, Puerto Rican

Yes

Yes, another Hispanic, Latino, or Spanish origin

White

Vietnamese

Black or
African American

Other Asian

American Indian or
Alaska Native

Native Hawaiian

Asian Indian

Guamanian or
Chamorro

Chinese

Samoan

Filipino

Other Pacific Islander

Japanese

Some other race

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s race? Mark one or more boxes.

Yes
8

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?
Yes

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

Korean
3

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

Yes, Cuban

How old is this child in years?
Respond in months if less than 1 year.

Does this child need or get special therapy, such as
physical, occupational, or speech therapy?
Yes

If yes, is this because of ANY medical, behavioral,
or other health condition?
Years (or)

Months
Yes

Male
5

Female

How well does this child speak English?
(5 years old or older)
Very well

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s sex?

Yes

10 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?
Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

Not well
Not at all

Yes

NSCH-P-S1

;!Sc¤

26005074

➜

If there are more than four children 0-17 years old who usually live or stay at this address, list the age and sex for
each. Do not repeat information for children already included in Child 1 through Child 4.

First name/initials/nickname

Child 5
▲

(Next oldest)

Age

Years (or)

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

First name/initials/nickname

Child 6
▲

(Next oldest)

Age

Years (or)

First name/initials/nickname

Child 7
▲

(Next oldest)

Age

Years (or)

First name/initials/nickname

Child 8
▲

(Next oldest)

Age

Years (or)

First name/initials/nickname

Child 9
▲

(Next oldest)

Age

Years (or)

First name/initials/nickname

Child 10
▲

(Next oldest)

Age

Years (or)

NSCH-P-S1

§;!Sk¤

26005082

Respondent Information
1

Respondent first name/initials/nickname

What is your telephone number?
Area code

Number

➜ Make sure you have:
• Listed all first names, initials, or nicknames of children 0-17 years old in the household
• Answered all questions for each child reported

➜ Place the completed questionnaire in the postage-paid return envelope. If the envelope has been
misplaced, please mail the questionnaire to:
U.S. Census Bureau
ATTN: DCB 60-A
1201 E. 10th Street
Jeffersonville, IN 47132-0001
You may also call 1-800-845-8241 to request a replacement envelope.

Public reporting burden for this collection of information is estimated to average 5 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. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:
Paperwork Project
, U.S. Census Bureau, 4600 Silver Hill Road, Room 7H054, Washington, DC 20233. You may e-mail comments to
DEMO.Paperwork@census.gov; use "Paperwork Project
" as the subject.

NSCH-P-S1

;!Ss¤

Topical Questionnaire – 0 to 5 Year Old Children

26015016

National Survey of Children’s Health
A study by the U.S. Department of Health and Human Services to
better understand the health issues being faced by children in the
United States today.

NSCH-P-T1
(03/17/2015)

§;"S1¤

26015024

Start Here

How well does each of these items describe this child?
Definitely Somewhat
true
true

Recently, you completed a survey that asked about the
children usually living or staying at this address.
Thank you for taking the time to complete that survey.

a. This child is affectionate
and tender with you

We now have some follow-up questions to ask about:

b. This child bounces back
quickly when things do not
go his or her way

Not
true

c. This child shows interest
and curiosity in learning
new things
These questions will collect more detailed information
on various aspects of this child’s health including his
or her health status, visits to health care providers,
health care costs, and health insurance coverage.

d. This child smiles and
laughs a lot
A4

We have selected only one child per household in an
effort to minimize the amount of time necessary to
complete the follow-up questions.

DURING THE PAST 12 MONTHS, has this child had
difficulty with or experienced any of the following?

The survey should be completed by an adult who is
familiar with this child’s health and health care.

Yes

b. Eating or swallowing because of
a health condition

Your participation is important. Thank you.

c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea

A. This Child’s Health

d. Repeated or chronic physical pain,
including headaches or other back
or body pain

A1 In general, how would you describe this child’s health

(the one named above)?
Excellent

e. Using his or her hands

Very good

f. Coordination or moving around

Good

g. Toothaches

Fair

h. Bleeding gums

Poor

A2 How would you describe the condition of this child’s

Yes

a. Breathing or other respiratory
problems (such as wheezing or
shortness of breath)

Decayed teeth or cavities

Does this child have any of the following?

teeth?
Excellent

a. Deafness or problems with hearing

Very good

b. Blindness or problems with seeing,
even when wearing glasses

Good
Fair
Poor

NSCH-P-T1

§;"S9¤

26015032

A6 Has a doctor or other health care provider EVER told

(Has a doctor or other health care provider EVER told
you that this child has...)

you that this child has...
Allergies (including food, drug, insect, or other)?
Yes

A11 Cerebral Palsy?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:

Mild

Moderate

Severe

Mild

Moderate

Severe

A12 Cystic Fibrosis?

A7 Arthritis?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:

Mild

Moderate

Severe

Mild

Moderate

Severe

A13 Diabetes?

A8 Asthma?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:

Mild

Moderate

Severe

Mild

Moderate

Severe

A14 Down Syndrome?

A9 Blood Disorders (such as sickle cell disease,

thalassemia, or hemophilia)?
Yes
Yes

If yes, does this child CURRENTLY have the condition?

If yes, does this child CURRENTLY have the condition?
Yes

Yes

If yes, is it:

Mild

Moderate

Severe

Severe
A15 Epilepsy or seizure disorder?

A10

Brain injury, concussion or head injury?
Yes

Yes

If yes, does this child CURRENTLY have the condition?

If yes, does this child CURRENTLY have the condition?
Yes

Yes

If yes, is it:

If yes, is it:
Mild

Mild
Moderate

Moderate

Severe

Severe
A16 Genetic or inherited condition?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, is it:
Mild

NSCH-P-T1

Moderate

Severe

§;"SA¤

26015040

(Has a doctor or other health care provider EVER told
you that this child has...)

A22 Has a doctor, other health care provider, or educator

EVER told you that this child has...
Examples of educators are teachers and school nurses.

A17 Heart Condition?

Yes

Behavioral or Conduct Problems?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:
Mild

Moderate

If yes, is it:

Severe

Mild

Moderate

Severe

A18 Frequent or severe headaches, including migraine?

Yes

A23 Developmental Delay?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:
Mild

Moderate

If yes, is it:

Severe

Mild

Moderate

Severe

A19 Tourette Syndrome?

Yes

A24 Intellectual Disability (also known as Mental Retardation)?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:
Mild

Moderate

If yes, is it:

Severe

Mild
A20 Anxiety Problems?

Yes

Moderate

Severe

A25 Speech or other language disorder?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:

Mild

Moderate

Severe

A21 Depression?

Mild

Moderate

Severe

A26 Learning Disability?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:
Mild

If yes, is it:
Moderate

Severe

Mild

NSCH-P-T1

Moderate

Severe

§;"SI¤

26015057

A27 Has a doctor or other health care provider EVER told

A31 Is this child CURRENTLY taking medication for Autism,

you that this child has...

ASD or PDD?

Any Other Mental Health Condition?
Yes

Yes

If yes, specify:

A32 At any time DURING THE PAST 12 MONTHS, did this

child receive behavioral treatment for Autism, ASD or
PDD, such as training or an intervention that you or this
child received to help with his or her behavior?

Yes

If yes, does this child CURRENTLY have the
condition?

A33 Has a doctor or other health care provider EVER told

Yes

you that this child has Attention Deficit Disorder or
Attention Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?

If yes, is it:
Mild

Moderate

Severe

No ➔ SKIP to question A36

Yes

A28 Has a doctor or other health care provider EVER told

If yes, does this child CURRENTLY have the condition?

you that this child has Autism or Autism Spectrum
Disorder (ASD)? Include diagnoses of Asperger’s Disorder
or Pervasive Developmental Disorder (PDD).

Yes
If yes, is it:

No ➔ SKIP to question A33

Yes

Mild

Moderate

Severe

If yes, does this child CURRENTLY have the condition?
Yes

A34 Is this child CURRENTLY taking medication for ADD or

ADHD?

If yes, is it:
Mild

Yes
Moderate

Severe

A35 At anytime DURING THE PAST 12 MONTHS, did this

child receive behavioral treatment for ADD or ADHD,
such as training or an intervention that you or this
child received to help with his or her behavior?

A29 How old was this child when a doctor or other health

care provider FIRST told you that he or she had Autism,
ASD, or PDD?

Yes
Age in years

Don’t know

A36 DURING THE PAST 12 MONTHS, how often have this

child’s health conditions or problems affected his or her
ability to do things other children his or her age do?

A30 What type of doctor or other health care provider was

the FIRST to tell you that this child had Autism, ASD
or PDD? Mark ONE only.

This child does not have
any conditions ➔ SKIP to question B1

Primary Care Provider

Never

Specialist

Sometimes

School Psychologist/Counselor

Usually

Other Psychologist (Non-School)

Always

Psychiatrist
A37 To what extent do this child’s health conditions or

Other, specify:

problems affect his or her ability to do things?

Very little
Somewhat

Don’t know

A great deal

NSCH-P-T1

§;"SZ¤

26015065

B. This Child as an Infant
B1

Was this child born more than 3 weeks before his or
her due date?

How old was this child when he or she was FIRST fed
formula?
At birth
OR

Yes
days

No
OR
B2

How much did he or she weigh when born?
Provide your best estimate.
weeks
OR
pounds

ounces

OR
months
kilograms

grams

Check this box if child has never been fed formula
B3

Was this child EVER breastfed or fed breast milk?
B6

Yes
No ➔ SKIP to question B5
B4

How old was this child when he or she was FIRST fed
anything other than breast milk or formula? Include
juice, cow’s milk, sugar water, baby food, or anything else
that your child might have been given, even water.
At birth

If yes, how old was this child when he or she
COMPLETELY stopped breastfeeding or being fed
breast milk?

days
days

OR
weeks
weeks

OR
months
months

OR
Check this box if child has never been fed anything
other than breast milk or formula

Check this box if child is still breastfeeding
B7

What was the age of the mother when this child was
born?

Age in years

NSCH-P-T1

§;"Sb¤

26015073

C. Health Care Services
C1

DURING THE PAST 12 MONTHS, did this child see a
doctor, nurse, or other health care professional for
sick-child care, well-child check-ups, physical exams,
hospitalizations or any other kind of medical care?
Yes

Yes
No
C8

No ➔ SKIP to question C4
C2

If your child is YOUNGER THAN 9 MONTHS, please
SKIP to question C9 .
DURING THE PAST 12 MONTHS, did a doctor or other
health care provider have you or another caregiver fill
out a questionnaire about specific concerns or
observations you may have about this child’s
development, communication, or social behaviors?
Sometimes a child’s doctor or other health care provider
will ask a parent to do this at home or during a child’s visit.

If yes, DURING THE PAST 12 MONTHS, how many times
did this child visit a doctor, nurse, or other health care
professional to receive a preventive check-up?
A preventive check-up is when this child was not sick or
injured, such as an annual or sports physical, or well-child
visit.
0 visits ➔ SKIP to question C4

DURING THE PAST 12 MONTHS, did this child’s doctors
or other health care providers ask if you have concerns
about this child’s learning, development, or behavior?

Yes

If yes, and this child is 9-23 Months:

2 or more visits

Did the questionnaire ask about your concerns
or observations about: Mark ALL that apply.

Thinking about the LAST TIME you took this child for
a preventive check-up, about how long was the doctor
or health care provider who examined this child in the
room with you? Your best estimate is fine.

How this child talks or makes speech
sounds?
How this child interacts with you and
others?

Less than 10 minutes

If yes, and this child is 2-5 Years:

10-20 minutes

Did the questionnaire ask about your concerns
or observations about: Mark ALL that apply.

More than 20 minutes
C4

1 visit

Words and phrases this child uses and
understands?

What is this child’s CURRENT height?

feet

How this child behaves and gets along with
you and others?

inches

meters

Is there a place that this child USUALLY goes when
he or she is sick or you or another caregiver needs
advice about his or her health?

centimeters
Yes

How much does this child CURRENTLY weigh?
No ➔ SKIP to question C11
pounds

ounces

C10 If yes, where does this child USUALLY go?

Mark ONE only.

Doctor’s Office
kilograms
C6

Hospital Emergency Room

grams

Hospital Outpatient Department

Are you concerned about this child’s weight?
Yes, it’s too high

Clinic or Health Center

Yes, it’s too low

Retail Store Clinic or “Minute Clinic”

No, I am not concerned

School (Nurse’s Office, Athletic Trainer’s Office)
Some other place

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C11 Is there a place that this child USUALLY goes when

C17 If yes, DURING THE PAST 12 MONTHS, what

he or she needs routine preventive care, such as a
physical examination or well-child check-up?

preventive dental services did this child receive?
Mark ALL that apply.

Yes

Check-up

No ➔ SKIP to question C13

Cleaning
Instruction on tooth brushing and oral health care

C12 If yes, is this the same place this child goes when he

or she is sick?
X-Rays
Yes

Fluoride treatment

Sealant (plastic coatings on back teeth)

C13 Has this child EVER had his or her vision tested with

Don’t know

pictures, shapes, or letters?

C18 DURING THE PAST 12 MONTHS, has this child

Yes

received any treatment or counseling from a mental
health professional? Mental health professionals include
psychiatrists, psychologists, psychiatric nurses, and clinical
social workers.

No ➔ SKIP to question C15
C14 If yes, what kind of place or places did this child have

his or her vision tested? Mark ALL that apply.

Yes

Eye doctor or eye specialist (opthalmologist,
optometrist) office

No, but this child needed to see a mental health
professional

Pediatrician or other general doctor’s office

No, this child did not need to see a
mental health professional ➔ SKIP to question C20

Clinic or health center

C19 How much of a problem was it to get the mental health

treatment or counseling that this child needed?

School
Other, specify

Not a problem

Small problem
Big problem

C15 DURING THE PAST 12 MONTHS, did this child see a

dentist or other oral health care provider for any kind
of dental or oral health care?

C20 DURING THE PAST 12 MONTHS, has this child taken

any medication because of difficulties with his or her
emotions, concentration, or behavior?

Yes, saw a dentist
Yes, saw other oral health care provider

Yes

No ➔ SKIP to question C18

C16 If yes, DURING THE PAST 12 MONTHS, did this child

C21 DURING THE PAST 12 MONTHS, did this child see a

see a dentist or other oral health care provider for
preventive dental care, such as check-ups, dental
cleanings, dental sealants, or fluoride treatments?

specialist other than a mental health professional?
Specialists are doctors like surgeons, heart doctors, allergy
doctors, skin doctors, and others who specialize in one
area of health care.

No preventive visits in
the past 12 months ➔ SKIP to question C18

Yes

Yes, 1 visit

No, but this child needed to see a specialist

Yes, 2 or more visits

No, this child did not need to
see a specialist ➔ SKIP to question C23

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C27 DURING THE PAST 12 MONTHS, how often were you

C22 How much of a problem was it to get the specialist

frustrated in your efforts to get services for this child?

care that this child needed?
Not a problem

Never

Small problem

Sometimes

Big problem

Usually

C23 DURING THE PAST 12 MONTHS, did this child use any

type of alternative health care or treatment? Alternative
health care can include acupuncture, chiropractic care,
relaxation therapies, herbal supplements, and others.
Some therapies involve seeing a health care provider,
while others can be done on your own.

Always
C28 DURING THE PAST 12 MONTHS, how many times did

this child visit a hospital emergency room?
No visits

Yes

1 visit

2 or more visits

C24 DURING THE PAST 12 MONTHS, was there any time

when this child needed health care but it was not
received? By health care, we mean medical care as well
as other kinds of care like dental care, vision care, and
mental health services.

C29 Has this child EVER had a special education or early

intervention plan? Children receiving these services often
have an Individualized Family Service Plan or Individualized
Education Plan.
Yes

Yes

No ➔ SKIP to question C32

No ➔ SKIP to question C27

C30 If yes, how old was this child, in months, at the time of

C25 If yes, which types of care were not received?

the FIRST plan?

Mark ALL that apply.
Medical Care

Age in months

Dental Care
C31 Is this child CURRENTLY receiving services under one

Vision Care

of these plans?

Hearing Care

Yes

Mental Health Services

Other, specify:

C32 Has this child EVER received special services to meet

his or her developmental needs such as speech,
occupational, or behavioral therapy?
Yes

C26 Were these difficulties in getting services for this child

because:
Yes

a. This child was not eligible for the
services?

No ➔ SKIP to question D1

C33 If yes, how old was this child, in years, when he or she

began receiving these special services?

b. The services this child needed were
not available in your area?
c. There were problems getting an
appointment when this child needed
one?
d. There were problems with getting
transportation or child care?

Age in years
C34 Is this child CURRENTLY receiving these special

services?
Yes

e. The (clinic/doctor’s) office wasn’t
open when this child needed care?

f. There were issues related to cost?

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D. Experience with This
Child’s Health Care
Providers

Yes

D1 Do you have one or more persons you think of as this

child’s personal doctor or nurse? A personal doctor or
nurse is a health professional who knows this child well
and is familiar with this child’s health history. This can be
a general doctor, a pediatrician, a specialist doctor, a
nurse practitioner, or a physician’s assistant.

DURING THE PAST 12 MONTHS, were any decisions
needed about this child’s health care services or
treatment, such as whether to start or stop a
prescription or therapy services, get a referral to a
specialist, or have a medical procedure?

No ➔ SKIP to question D7
D6

If yes, DURING THE PAST 12 MONTHS, how often did
this child’s doctors or other health care providers:
Always

Yes, one person

Usually Sometimes Never

a. Discuss with you
the range of options
to consider for his
or her health care or
treatment?

Yes, more than one person
No

b. Make it easy for you
to raise concerns or
disagree with
recommendations
for this child’s health
care?

D2 DURING THE PAST 12 MONTHS, did this child need a

referral to see any doctors or receive any services?
Yes
No ➔ SKIP to question D4

c. Work with you to
decide together
which health care
and treatment
choices would be
best for this child?

D3 If yes, how much of a problem was it to get referrals?

Not a problem
Small problem
D7

Big problem
D4 Answer the following questions only if this child had a

Does anyone help you arrange or coordinate this
child’s care among the different doctors or services
that this child uses?
Yes

health care visit IN THE PAST 12 MONTHS. Otherwise,
SKIP to question E1 .

No
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers:
Always

a. Spend enough time
with this child?

Usually Sometimes

Did not see more than one
health care provider in
PAST 12 MONTHS ➔ SKIP to question D11

Never

b. Listen carefully to
you?
c. Show sensitivity to
your family’s values
and customs?
d. Provide the specific
information you
needed concerning
this child?

DURING THE PAST 12 MONTHS, have you felt that you
could have used extra help arranging or coordinating
this child’s care among the different health care
providers or services?
Yes
No ➔ SKIP to question D10

e. Help you feel like a
partner in this
child’s care?

If yes, DURING THE PAST 12 MONTHS, how often
did you get as much help as you wanted with
arranging or coordinating this child’s health care?
Usually
Sometimes
Never

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D10 Overall, how satisfied are you with the communication

among this child’s doctors and other health care
providers?

Indicate whether any of the following is a reason this
child was not covered by health insurance DURING
THE PAST 12 MONTHS:
Yes

Very satisfied

a. Change in employer or employment
status

Somewhat satisfied
Somewhat dissatisfied

b. Cancellation due to overdue
premiums

Very dissatisfied

c. Dropped coverage because it was
unaffordable
d. Dropped coverage because benefits
were inadequate

D11 DURING THE PAST 12 MONTHS, did this child’s health

care provider communicate with the child’s school, child
care provider, or special education program?
Yes

e. Dropped coverage because choice
of health care providers was
inadequate

No ➔ SKIP to question E1

f. Problems with application or
renewal process
g. Other, specify: C

Did not need health care
provider to communicate
with these providers ➔ SKIP to question E1
D12 If yes, overall, how satisfied are you with the health

care provider’s communication with the school, child
care provider, or special education program?

Is this child CURRENTLY covered by ANY kind of
health insurance or health coverage plan?

Very satisfied

Yes

Somewhat satisfied

No ➔ SKIP to question F1

Somewhat dissatisfied

Is this child covered by any of the following types of
health insurance or health coverage plans?

Very dissatisfied

Yes

a. Insurance through a current or
former employer or union

E. This Child’s Health
Insurance Coverage
E1

b. Insurance purchased directly
from an insurance company
c. Medicaid, Medical Assistance,
or any kind of government
assistance plan for those with
low incomes or a disability

DURING THE PAST 12 MONTHS, was this child EVER
covered by ANY kind of health insurance or health
coverage plan?

d. TRICARE or other military
health care

Yes, this child was covered
all 12 months ➔ SKIP to question E4

e. Indian Health Service

Yes, but this child had a gap in coverage
f. Other, specify: C
No

How often does this child’s health insurance offer
benefits or cover services that meet this child’s needs?
Always
Usually
Sometimes
Never

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How often does this child’s health insurance allow him
F2
or her to see the health care providers he or she needs?
Always

Yes

Usually
Sometimes

No
F3

Never
E7

DURING THE PAST 12 MONTHS, have you or other
family members:
Yes

a. Stopped working because of this
child’s health status?
b. Cut down on the hours you work
because of this child’s health or
health conditions?
c. Avoided changing jobs because of
concerns about maintaining health
insurance for this child?

Not including health insurance premiums or costs that
are covered by insurance, do you pay any money for
this child’s health care?
Yes
No ➔ SKIP to question E9

DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?

If yes, how often are these costs reasonable?
F4

Always
Usually

IN AN AVERAGE WEEK, how many hours do you or
other family members spend providing health care at
home for this child? Care might include changing
bandages, or giving medication and therapies when needed.
I did not provide any care

Sometimes

Less than 1 hour per week

Never

1-4 hours per week
E9

Answer the following question only if this child uses
mental or behavioral health services. Otherwise, SKIP
to question F1 .
Thinking specifically about this child’s mental or
behavioral health needs, how often does this child’s
health insurance offer benefits or cover services that
meet these needs?

5-10 hours per week
11 or more hours per week
F5

Always
Usually

I did not arrange or coordinate health or medical care

Sometimes

Less than 1 hour per week

Never

1-4 hours per week
5-10 hours per week

F. Providing for This
Child’s Health
F1

IN AN AVERAGE WEEK, how many hours do you or
other family members spend arranging or coordinating
health or medical care for this child, such as making
appointments or locating services?

How much money did you pay for this child’s medical
and health care DURING THE PAST 12 MONTHS? Do
not include health insurance premiums or costs that were
or will be reimbursed by insurance or another source.
$0 (No medical or health-related
expenses) ➔ SKIP to question F3
$1-$249

11 or more hours per week

G. This Child’s Learning
➜ Answer section G only if your child is AGE 3 OR
OLDER. Otherwise, SKIP to question
G1

Has this child started school? Include any formal home
schooling.

$250-$499

Yes

$500-$999

$1,000-$5,000
More than $5,000
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G2 Is this child learning to do things for him or herself?

How often can this child write his or her first name, even
if some of the letters aren’t quite right or are backwards?

Very well
All of the time
Somewhat
Most of the time
Poorly
Some of the time
Not at all
None of the time
G3 How confident are you that this child is ready to be in

school?

How high can this child count?

Very confident

Not at all

Mostly confident

Up to five

Somewhat confident

Up to ten

Not confident at all

Up to 20
Up to 50

G4 How often can this child recognize the beginning

sound of a word? For example, can this child tell you
that the word “ball” starts with the “buh” sound?
All of the time

Up to 100 or more
G10 How often can this child identify basic shapes such as

a triangle, circle, or square?

Most of the time

All of the time

Some of the time

Most of the time

None of the time

Some of the time

G5 About how many letters of the alphabet can this child

None of the time

recognize?
All of them

G11 How often is this child easily distracted?

All of the time
Most of them
Most of the time
Some of them
Some of the time
None of them
None of the time
G6 Can this child rhyme words?

G12 How often does this child keep working at something

until he or she is finished?

Yes

All of the time

Most of the time

G7 How often can this child explain things he or she has

seen or done so that you get a very good idea what
happened?

Some of the time

All of the time
Most of the time

None of the time
G13 When he or she is paying attention, how often can this

child follow instructions to complete a simple task?

Some of the time

All of the time

None of the time

Most of the time
Some of the time
None of the time

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G14 When this child holds a pencil, does he or she use

fingers to hold, or does he or she grip it in his or her
fist?

How often does this child go to bed at about the same
time on weeknights?
Always

Uses fingers
Usually
Grips in fist
Sometimes
Cannot hold a pencil
Rarely
G15 How often does this child play well with others?

Never

All of the time
H5

Most of the time

DURING THE PAST WEEK, how many hours of sleep
did this child get on an average weeknight?

Some of the time

Less than 6 hours

None of the time

6 hours

G16 Compared to other children his or her age, how much

7 hours

difficulty does this child have making or keeping
friends?

8 hours

No difficulty

9 hours

A little difficulty

10 hours

A lot of difficulty

11 or more hours

G17 Compared to other children his or her age, how often is

this child able to sit still?

Answer the next question only if this child is LESS THAN
12 MONTHS OLD. Otherwise, SKIP to question H7 .
In which position do you most often lay this baby down
to sleep now? Mark ONE only.

All of the time
Most of the time

On his or her side

Some of the time

On his or her back

None of the time

On his or her stomach

H. About You and This
Child

ON AN AVERAGE WEEKDAY, about how much time
does this child usually spend in front of a TV watching
TV programs, videos, or playing video games?
None

H1 Was this child born in the United States?

Yes ➔ SKIP to question H3

Less than 1 hour

1 hour
2 hours

H2 If no, how long has this child been living in the

United States?
3 hours
Years and

4 or more hours

Months

H3 How many times has this child moved to a new address

since he or she was born?

Number of times

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ON AN AVERAGE WEEKDAY, about how much time
does this child usually spend with computers, cell
phones, handheld video games, and other electronic
devices, doing things other than schoolwork?

H13 DURING THE PAST 12 MONTHS, was there someone

that you could turn to for day-to-day emotional support
with parenting or raising children?
Yes

None

No ➔ SKIP to question H15

Less than 1 hour

H14 If yes, did you receive emotional support from:
Yes

1 hour

a. Health care provider?

2 hours

b. Family member or close friend?

3 hours

c. Place of worship or religious
leader?

4 or more hours
H9

d. Support or advocacy group related
to specific health condition?

DURING THE PAST WEEK, how many days did you or
other family members read to this child?

e. Peer support group?

0 days
1-3 days

f. Counselor or other mental health
professional?

4-6 days

g. Other, specify:

Every day
H10 DURING THE PAST WEEK, how many days did you or

other family members tell stories or sing songs to this
child?

H15 Does this child receive care for at least 10 hours per

week from someone other than his or her parent or
guardian? This could be a day care center, preschool,
Head Start program, family child care home, nanny,
au pair, babysitter or relative.

0 days
1-3 days

Yes

4-6 days

No
H16 DURING THE PAST 12 MONTHS, did you or anyone in

Every day

the family have to quit a job, not take a job, or greatly
change your job because of problems with child care
for this child?

H11 In general, how well do you feel that you are coping

with the day-to-day demands of raising children?
Very well

Yes

Somewhat well

Not very well

I. About Your Family and
Household

Not at all
H12 DURING THE PAST MONTH, how often have you felt:
Never

Rarely Sometimes Usually Always

a. That this
child is much
harder to care
for than most
children his
or her age?

DURING THE PAST WEEK, on how many days did all the
family members who live in the household eat a meal
together?
0 days
1-3 days

b. That this
child does
things that
really bother
you a lot?

4-6 days
Every day

c. Angry with
this child?
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Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?

Yes

a. Sidewalks or walking paths?

No ➔ SKIP to question I4

b. A park or playground?

d. A library or bookmobile?

e. Litter or garbage on the street
or sidewalk?

When your family faces problems, how often are you
likely to do each of the following?
All of
the time

Most of
the time

Some of
the time

f. Poorly kept or rundown housing?

None of
the time

a. Talk together
about what to do

g. Vandalism such as broken
windows or graffiti?
I9

b. Work together to
solve our problems

a. People in this
neighborhood
help each other
out
b. We watch out for
each other’s
children in this
neighborhood

d. Stay hopeful
even in difficult
times
SINCE THIS CHILD WAS BORN, how often has it been
very hard to get by on your family’s income – hard to
cover the basics like food or housing?

c. This child is
safe in our
neighborhood

Never
Rarely

d. When we
encounter
difficulties, we
know where to
go for help in
our community

Somewhat often
Very often
I6

To what extent do you agree with these statements
about your neighborhood or community?
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

c. Know we have
strengths to draw on

The next question is about whether you were able to
afford the food you need. Which of these statements
best describes the food situation in your household
IN THE PAST 12 MONTHS?

I10

We could always afford to eat good nutritious meals.

The next questions are about events that may have
happened during this child’s life. These things can
happen in any family, but some people may feel
uncomfortable with these questions. You may skip
any questions you do not want to answer.
To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated

We could always afford enough to eat but not always
the kinds of food we should eat.
Sometimes we could not afford enough to eat.

b. Parent or guardian died
Often we could not afford enough to eat.
c. Parent or guardian served time in jail
I7

c. A recreation center, community
center, or boys’ and girls’ club?

If yes, does anyone smoke inside your home?
Yes

In your neighborhood, is there:

At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive:
Yes

d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home

a. Cash assistance from a government
welfare program?

e. Was a victim of violence or
witnessed violence in neighborhood

b. Food Stamps or Supplemental
Nutrition Assistance Program benefits?

f. Lived with anyone who was mentally
ill, suicidal, or severely depressed

c. Free or reduced-cost breakfasts or
lunches at school?

g. Lived with anyone who had a problem
with alcohol or drugs

d. Benefits from the Woman, Infants,
and Children (WIC) Program?

h. Treated or judged unfairly because
of his or her race or ethnic group

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J. About You

➜ Complete the questions for each of the two adults

8th grade or less

in the household who are this child’s primary
caregivers. If there is just one adult, provide
answers for that adult.

9th-12th grade; No diploma
High School Graduate or GED Completed

ADULT 1 (Respondent)
J1

Completed a vocational, trade, or business school
program

How are you related to this child?
Biological or Adoptive Parent

Some College Credit, but no Degree

Step-parent

Associate Degree (AA, AS)

Grandparent

Bachelor’s Degree (BA, BS, AB)

Foster Parent

Master’s Degree (MA, MS, MSW, MBA)

Aunt or Uncle

Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)

Other: Relative

Other: Non-Relative
J2

What is your sex?

Not married, but living with a partner
Never Married

Female

Divorced

What is your age?

Separated
Widowed

Age in years
J8
J4

Where were you born?

In general, how is your physical health?
Excellent

In the United States ➔ SKIP to question J6

Very Good

Outside of the United States
J5

What is your marital status?
Married

Male

What is the highest grade or year of school you have
completed? Mark ONE only.

Good

When did you come to live in the United States?

Fair

Year

Poor
J9

In general, how is your mental or emotional health?
Excellent
Very Good
Good
Fair
Poor

J10 Were you employed at least 50 out of the past 52 weeks?

Yes
No

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ADULT 2

J17 What is Adult 2’s marital status?

Married

J11 How is Adult 2 related to this child?

Biological or Adoptive Parent

Not married, but living with a partner

Step-parent

Never Married

Grandparent

Divorced

Foster Parent

Separated

Aunt or Uncle

Widowed

Other: Relative

J18 In general, how is Adult 2’s physical health?

Excellent

Other: Non-Relative

Very Good

J12 What is Adult 2’s sex?

Male

Good

Female

Fair

J13 What is Adult 2’s age?

Poor
J19 In general, how is Adult 2’s mental or emotional health?

Excellent

Age in years

Very Good

J14 Where was Adult 2 born?

In the United States ➔ SKIP to question J16

Good

Outside of the United States

Fair
Poor

J15 When did Adult 2 come to live in the United States?

Year

J20 Was Adult 2 employed at least 50 out of the past 52

weeks?
Yes
No

J16 What is the highest grade or year of school Adult 2 has

completed? Mark ONE only.
8th grade or less
9th-12th grade; No diploma
High School Graduate or GED Completed
Completed a vocational, trade, or business school
program
Some College Credit, but no Degree
Associate Degree (AA, AS)
Bachelor’s Degree (BA, BS, AB)
Master’s Degree (MA, MS, MSW, MBA)
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)

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J21 Income IN THE LAST CALENDAR YEAR

J22 The following question is about your income and is

(January 1 - December 31, 2014)
Mark (X) the “Yes” box for each type of income the family
received, and give your best estimate of the TOTAL
AMOUNT IN THE LAST CALENDAR YEAR. Mark (X) the
“No” box to show types of income NOT received.

very important. Think about your total combined
family income IN THE LAST CALENDAR YEAR for all
members of the family. What is that amount before
taxes? Include money from jobs, child support, social
security, retirement income, unemployment payments,
public assistance, and so forth. Also, include income from
interest, dividends, net income from business, farm, or
rent, and any other money income received.

a. Wages, salary, commissions, bonuses, or tips from all
jobs?
Yes

$
$

Total Amount

J23 How many people are living or staying at this address?

Include everyone who usually lives or stays at this address.
Do NOT include anyone who is living somewhere else for
more than two months, such as a college student living away
or someone in the Armed Forces on deployment.

b. Self-employment income from own nonfarm businesses
or farm business, including proprietorships and
partnerships?
Yes

Total Amount

No
Number of people

Total Amount
J24 How many of these people in your household are family

members? Family is defined as anyone related to this child
by blood, marriage, adoption, or through foster care.

c. Interest, dividends, net rental income, royalty income,
or income from estates and trusts?
Yes

No
Number of people

Total Amount

d. Social security or railroad retirement; retirement,
survivor, or disability pensions?
Yes

Total Amount

e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office?
Yes

Total Amount

f. Any other sources of income received regularly such as
Veterans’ (VA) payments, unemployment compensation,
child support, or alimony?
Yes

Total Amount

NSCH-P-T1

§;"T¥¤

26015206

Mailing Instructions
Thank you for your participation.
On behalf of the Department of Health and Human Services, we would like to thank you for the time and
effort you have spent sharing information about this child and your family.
Your answers are important to us and will help researchers, policymakers, and family advocates to better
understand the health and healthcare needs of children in our diverse population.
Place the completed questionnaire in the postage-paid return envelope. If the envelope has been
misplaced, mail the questionnaire to:
U.S. Census Bureau
ATTN: DCB 60-A
1201 E. 10th Street
Jeffersonville, IN 47132-0001
You may also call 1-800-845-8241 to request a replacement envelope.

Public reporting burden for this collection of information is estimated to average 30 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. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to: Paperwork Project
, U.S. Census Bureau, 4600 Silver Hill Road, Room 7H054, Washington, DC 20233. You may e-mail
comments to DEMO.Paperwork@census.gov; use "Paperwork Project
" as the subject.
NSCH-P-T1

§;"U’¤

Topical Questionnaire – 6 to 11 Year Old Children

26025015

National Survey of Children’s Health
A study by the U.S. Department of Health and Human Services to
better understand the health issues being faced by children in the
United States today.

NSCH-P-T2
(03/17/2015)

§;#S0¤

26025023

Start Here

How well does each of these items describe this child?
Definitely Somewhat
true
true

Recently, you completed a survey that asked about the
children usually living or staying at this address.
Thank you for taking the time to complete that survey.

Not
true

a. This child shows interest
and curiosity in learning
new things

We now have some follow-up questions to ask about:

b. This child works to finish
tasks he or she starts
c. This child stays calm and
in control when faced with
a challenge

These questions will collect more detailed information
on various aspects of this child’s health including his
or her health status, visits to health care providers,
health care costs, and health insurance coverage.

d. This child cares about
doing well in school

We have selected only one child per household in an
effort to minimize the amount of time necessary to
complete the follow-up questions.

f. This child is bullied,
picked on, or excluded by
other children

The survey should be completed by an adult who is
familiar with this child’s health and health care.

g. This child bullies others,
picks on them, or
excludes them

e. This child does all
required homework

Your participation is important. Thank you.

A. This Child’s Health

h. This child argues too
much
A4

A1 In general, how would you describe this child’s health

DURING THE PAST 12 MONTHS, has this child had
difficulty with or experienced any of the following?

Excellent

a. Breathing or other respiratory
problems (such as wheezing or
shortness of breath)

Very good

b. Eating or swallowing because of
a health condition

(the one named above)?

Yes

c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea

Good
Fair

d. Repeated or chronic physical pain,
including headaches or other back
or body pain

Poor

e. Toothaches

A2 How would you describe the condition of this child’s

teeth?
f. Bleeding gums
Excellent
g. Decayed teeth or cavities
Very good
A5

Does this child have any of the following?

Good
a. Serious difficulty concentrating,
remembering, or making decisions
because of a physical, mental, or
emotional condition

Fair
Poor

b. Serious difficulty walking or climbing
stairs
c. Difficulty dressing or bathing
d. Deafness or problems with hearing
e. Blindness or problems with seeing,
even when wearing glasses

NSCH-P-T2

§;#S8¤

26025031

A6 Has a doctor or other health care provider EVER told

(Has a doctor or other health care provider EVER told
you that this child has...)

you that this child has...
Allergies (including food, drug, insect, or other)?
Yes

A11 Cerebral Palsy?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:

Mild

Moderate

Severe

Mild

Moderate

Severe

A12 Cystic Fibrosis?

A7 Arthritis?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:

Mild

Moderate

Severe

Mild

Moderate

Severe

A13 Diabetes?

A8 Asthma?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:

Mild

Moderate

Severe

Mild

Moderate

Severe

A14 Down Syndrome?

A9 Blood Disorders (such as sickle cell disease,

thalassemia, or hemophilia)?
Yes
Yes

If yes, does this child CURRENTLY have the condition?

If yes, does this child CURRENTLY have the condition?
Yes

Yes

If yes, is it:

Mild

Moderate

Severe

Severe
A15 Epilepsy or seizure disorder?

A10

Brain injury, concussion or head injury?
Yes

Yes

If yes, does this child CURRENTLY have the condition?

If yes, does this child CURRENTLY have the condition?
Yes

Yes

If yes, is it:

If yes, is it:
Mild

Mild
Moderate

Moderate

Severe

Severe
A16 Genetic or inherited condition?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, is it:
Mild

NSCH-P-T2

Moderate

Severe

§;#S@¤

26025049

(Has a doctor or other health care provider EVER told
you that this child has...)

A22 Has a doctor, other health care provider, or educator

EVER told you that this child has...
Examples of educators are teachers and school nurses.

A17 Heart Condition?

Yes

Behavioral or Conduct Problems?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:
Mild

Moderate

If yes, is it:

Severe

Mild

Moderate

Severe

A18 Frequent or severe headaches, including migraine?

Yes

A23 Substance Abuse Disorder?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:
Mild

Moderate

If yes, is it:

Severe

Mild

Moderate

Severe

A19 Tourette Syndrome?

Yes

A24 Developmental Delay?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:
Mild

Moderate

If yes, is it:

Severe

Mild
A20 Anxiety Problems?

Yes

Moderate

Severe

A25 Intellectual Disability (also known as Mental Retardation)?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:

Mild

Moderate

Severe

A21 Depression?

Mild

Moderate

Severe

A26 Speech or other language disorder?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:
Mild

If yes, is it:
Moderate

Severe

Mild

Moderate

Severe

A27 Learning Disability?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, is it:
Mild
NSCH-P-T2

Moderate

Severe

§;#SR¤

26025056

A28 Has a doctor or other health care provider EVER told

A32

you that this child has...
Any Other Mental Health Condition?
Yes

Is this child CURRENTLY taking medication for Autism,
ASD or PDD?
Yes

No
A33

If yes, specify:

At any time DURING THE PAST 12 MONTHS, did this
child receive behavioral treatment for Autism, ASD or
PDD, such as training or an intervention that you or this
child received to help with his or her behavior?
Yes

If yes, does this child CURRENTLY have the
condition?

A34 Has a doctor or other health care provider EVER told

Yes

you that this child has Attention Deficit Disorder or
Attention Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?

If yes, is it:
Mild

Moderate

Severe

No ➔ SKIP to question A37

Yes

A29 Has a doctor or other health care provider EVER told

If yes, does this child CURRENTLY have the condition?

you that this child has Autism or Autism Spectrum
Disorder (ASD)? Include diagnoses of Asperger’s Disorder
or Pervasive Developmental Disorder (PDD).

Yes
If yes, is it:

No ➔ SKIP to question A34

Yes

Mild

Moderate

Severe

If yes, does this child CURRENTLY have the condition?
Yes

A35 Is this child CURRENTLY taking medication for ADD or

ADHD?

If yes, is it:
Mild

Yes
Moderate

Severe

A36 At anytime DURING THE PAST 12 MONTHS, did this

child receive behavioral treatment for ADD or ADHD,
such as training or an intervention that you or this
child received to help with his or her behavior?

A30 How old was this child when a doctor or other health

care provider FIRST told you that he or she had Autism,
ASD, or PDD?

Yes
Age in years

Don’t know

A37 DURING THE PAST 12 MONTHS, how often have this

child’s health conditions or problems affected his or her
ability to do things other children his or her age do?

A31 What type of doctor or other health care provider was

the FIRST to tell you that this child had Autism, ASD
or PDD? Mark ONE only.

This child does not have
any conditions ➔ SKIP to question B1

Primary Care Provider

Never
Specialist
Sometimes
School Psychologist/Counselor
Usually
Other Psychologist (Non-School)
Always
Psychiatrist
A38 To what extent do this child’s health conditions or

Other, specify: C

problems affect his or her ability to do things?
Very little
Somewhat

Don’t know

A great deal

NSCH-P-T2

§;#SY¤

26025064

B. This Child as an Infant
B1

Was this child born more than 3 weeks before his or
her due date?

C. Health Care Services
C1

Yes

No
B2

No ➔ SKIP to question C4

How much did he or she weigh when born?
Provide your best estimate.
C2

pounds

ounces

kilograms

grams

1 visit
B3

What was the age of the mother when this child was
born?

2 or more visits
C3

Age in years

What is this child’s CURRENT height?

feet

inches

meters
C5

centimeters

How much does this child CURRENTLY weigh?

pounds
OR

kilograms
C6

Are you concerned about this child’s weight?
Yes, it’s too high
Yes, it’s too low
No, I am not concerned

NSCH-P-T2

§;#Sa¤

26025072

C7 Is there a place that this child USUALLY goes when

C13 DURING THE PAST 12 MONTHS, did this child see a

dentist or other oral health care provider for any kind
of dental or oral health care?

he or she is sick or you or another caregiver needs
advice about his or her health?
Yes

Yes, saw a dentist

No ➔ SKIP to question C9

Yes, saw other oral health care provider
No ➔ SKIP to question C16

C8 If yes, where does this child USUALLY go?

Mark ONE only.
C14 If yes, DURING THE PAST 12 MONTHS, did this child

Doctor’s Office

see a dentist or other oral health care provider for
preventive dental care, such as check-ups, dental
cleanings, dental sealants, or fluoride treatments?

Hospital Emergency Room
Hospital Outpatient Department

No preventive visits in
the past 12 months ➔ SKIP to question C16

Clinic or Health Center

Yes, 1 visit
Retail Store Clinic or “Minute Clinic”
Yes, 2 or more visits
School (Nurse’s Office, Athletic Trainer’s Office)
C15 If yes, DURING THE PAST 12 MONTHS, what

preventive dental services did this child receive?
Mark ALL that apply.

Some other place
C9

Is there a place that this child USUALLY goes when
he or she needs routine preventive care, such as a
physical examination or well-child check-up?

Check-up
Cleaning

Yes
Instruction on tooth brushing and oral health care
No ➔ SKIP to question C11
X-Rays
C10 If yes, is this the same place this child goes when he

or she is sick?

Fluoride treatment

Yes

Sealant (plastic coatings on back teeth)

Don’t know

C11 DURING THE PAST 2 YEARS, has this child had his or

her vision tested with pictures, shapes, or letters?

C16 DURING THE PAST 12 MONTHS, has this child

received any treatment or counseling from a mental
health professional? Mental health professionals include
psychiatrists, psychologists, psychiatric nurses, and clinical
social workers.

Yes
No ➔ SKIP to question C13

Yes

C12 If yes, what kind of place or places did this child have

his or her vision tested? Mark ALL that apply.
No, but this child needed to see a mental health
professional

Eye doctor or eye specialist (opthalmologist,
optometrist) office

No, this child did not need to see a
mental health professional ➔ SKIP to question C18

Pediatrician or other general doctor’s office
Clinic or health center

C17 How much of a problem was it to get the mental health

treatment or counseling that this child needed?

School
Other, specify

Not a problem
C

Small problem
Big problem

NSCH-P-T2

§;#Si¤

26025080

C18 DURING THE PAST 12 MONTHS, has this child taken

C24 Were these difficulties in getting services for this child

because:

any medication because of difficulties with his or her
emotions, concentration, or behavior?

Yes

a. This child was not eligible for the
services?

b. The services this child needed were
not available in your area?
c. There were problems getting an
appointment when this child needed
one?

C19 DURING THE PAST 12 MONTHS, did this child see a

specialist other than a mental health professional?
Specialists are doctors like surgeons, heart doctors, allergy
doctors, skin doctors, and others who specialize in one
area of health care.

d. There were problems with getting
transportation or child care?

Yes

e. The (clinic/doctor’s) office wasn’t
open when this child needed care?

No, but this child needed to see a specialist
No, this child did not need to
see a specialist ➔ SKIP to question C21

f. There were issues related to cost?
C25

C20 How much of a problem was it to get the specialist

DURING THE PAST 12 MONTHS, how often were you
frustrated in your efforts to get services for this child?
Never

care that this child needed?
Not a problem

Sometimes

Small problem

Usually

Big problem

Always

C21 DURING THE PAST 12 MONTHS, did this child use any

C26

1 visit
2 or more visits
C27 Has this child EVER had a special education or early

intervention plan? Children receiving these services often
have an Individualized Family Service Plan or Individualized
Education Plan.

C22 DURING THE PAST 12 MONTHS, was there any time

when this child needed health care but it was not
received? By health care, we mean medical care as well
as other kinds of care like dental care, vision care, and
mental health services.

Yes
No ➔ SKIP to question C30

Yes
No ➔ SKIP to question C25

DURING THE PAST 12 MONTHS, how many times did
this child visit a hospital emergency room?
No visits

Yes
No

C28 If yes, how old was this child, in months, at the time of

the FIRST plan?

C23 If yes, which types of care were not received?

Mark ALL that apply.
Age in months
Medical Care
Dental Care

C29 Is this child CURRENTLY receiving services under one

of these plans?

Vision Care

Yes

Hearing Care

Mental Health Services
Other, specify: C

NSCH-P-T2

§;#Sq¤

26025098

D. Experience with This
Child’s Health Care
Providers

C30 Has this child EVER received special services to meet

his or her developmental needs such as speech,
occupational, or behavioral therapy?
Yes
No ➔ SKIP to question D1

C31 If yes, how old was this child, in years, when he or she

began receiving these special services?

Age in years

Do you have one or more persons you think of as this
child’s personal doctor or nurse? A personal doctor or
nurse is a health professional who knows this child well
and is familiar with this child’s health history. This can be
a general doctor, a pediatrician, a specialist doctor, a
nurse practitioner, or a physician’s assistant.
Yes, one person
Yes, more than one person

C32 Is this child CURRENTLY receiving these special

services?
No
Yes
D2

DURING THE PAST 12 MONTHS, did this child need a
referral to see any doctors or receive any services?
Yes
No ➔ SKIP to question D4

If yes, how much of a problem was it to get referrals?
Not a problem
Small problem
Big problem

Answer the following questions only if this child had a
health care visit IN THE PAST 12 MONTHS. Otherwise,
SKIP to question E1 .
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers:
Always

Usually Sometimes

a. Spend enough time
with this child?
b. Listen carefully to
you?
c. Show sensitivity to
your family’s values
and customs?
d. Provide the specific
information you
needed concerning
this child?
e. Help you feel like a
partner in this
child’s care?

NSCH-P-T2

§;#S¥¤

Never

26025106

D5 DURING THE PAST 12 MONTHS, were any decisions

D10 Overall, how satisfied are you with the communication

needed about this child’s health care services or
treatment, such as whether to start or stop a
prescription or therapy services, get a referral to a
specialist, or have a medical procedure?

among this child’s doctors and other health care
providers?
Very satisfied

Yes

Somewhat satisfied

No ➔ SKIP to question D7

Somewhat dissatisfied
Very dissatisfied

D6 If yes, DURING THE PAST 12 MONTHS, how often did

this child’s doctors or other health care providers:
Always

Usually Sometimes Never

D11 DURING THE PAST 12 MONTHS, did this child’s health

care provider communicate with the child’s school, child
care provider, or special education program?

a. Discuss with you
the range of options
to consider for his
or her health care or
treatment?
b. Make it easy for you
to raise concerns or
disagree with
recommendations
for this child’s health
care?

Yes
No ➔ SKIP to question E1
Did not need health care
provider to communicate
with these providers ➔ SKIP to question E1
D12 If yes, overall, how satisfied are you with the health

care provider’s communication with the school, child
care provider, or special education program?

c. Work with you to
decide together
which health care
and treatment
choices would be
best for this child?

Very satisfied
Somewhat satisfied

D7 Does anyone help you arrange or coordinate this

Somewhat dissatisfied

child’s care among the different doctors or services
that this child uses?

Very dissatisfied

Yes
No
Did not see more than one
health care provider in
PAST 12 MONTHS ➔ SKIP to question D11
D8 DURING THE PAST 12 MONTHS, have you felt that you

could have used extra help arranging or coordinating
this child’s care among the different health care
providers or services?
Yes
No ➔ SKIP to question D10
D9 If yes, DURING THE PAST 12 MONTHS, how often

did you get as much help as you wanted with
arranging or coordinating this child’s health care?
Usually
Sometimes
Never

NSCH-P-T2

§;#T’¤

26025114

E. This Child’s Health
Insurance Coverage

How often does this child’s health insurance offer
benefits or cover services that meet this child’s needs?
Always

DURING THE PAST 12 MONTHS, was this child EVER
covered by ANY kind of health insurance or health
coverage plan?

Usually
Sometimes

Yes, this child was covered
all 12 months ➔ SKIP to question E4

Never

Yes, but this child had a gap in coverage
E6

No
E2

Indicate whether any of the following is a reason this
child was not covered by health insurance DURING
THE PAST 12 MONTHS:
Yes
No

How often does this child’s health insurance allow him
or her to see the health care providers he or she needs?
Always
Usually

a. Change in employer or employment
status

Sometimes

b. Cancellation due to overdue
premiums

Never

c. Dropped coverage because it was
unaffordable

d. Dropped coverage because benefits
were inadequate

Not including health insurance premiums or costs that
are covered by insurance, do you pay any money for
this child’s health care?
Yes

e. Dropped coverage because choice
of health care providers was
inadequate

No ➔ SKIP to question E9

f. Problems with application or
renewal process

g. Other, specify: C

If yes, how often are these costs reasonable?
Always
Usually

Sometimes

Is this child CURRENTLY covered by ANY kind of
health insurance or health coverage plan?

Never

Yes
E9

No ➔ SKIP to question F1
E4

Is this child covered by any of the following types of
health insurance or health coverage plans?
Yes

a. Insurance through a current or
former employer or union

Always

b. Insurance purchased directly
from an insurance company
c. Medicaid, Medical Assistance,
or any kind of government
assistance plan for those with
low incomes or a disability

Usually
Sometimes
Never

d. TRICARE or other military
health care
e. Indian Health Service
f. Other, specify: C

NSCH-P-T2

§;#T/¤

26025122

F. Providing for This
Child’s Health
F1

IN AN AVERAGE WEEK, how many hours do you or
other family members spend arranging or coordinating
health or medical care for this child, such as making
appointments or locating services?
I did not arrange or coordinate health or medical care
Less than 1 hour per week
1-4 hours per week

$0 (No medical or health-related
expenses) ➔ SKIP to question F3

5-10 hours per week
$1-$249
11 or more hours per week
$250-$499
$500-$999

G. This Child’s Schooling
and Activities

$1,000-$5,000
More than $5,000
F2

DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?

No missed school days
1-3 days

Yes

4-6 days

No
F3

DURING THE PAST 12 MONTHS, about how many days
did this child miss school because of illness or injury?

7-10 days

DURING THE PAST 12 MONTHS, have you or other
family members:
Yes

11 or more days

DURING THE PAST 12 MONTHS, how many times has
this child’s school contacted you or another adult in
your household about any problems he or she is
having with school?
No times
1 time

2 or more times
G3

I did not provide any care

SINCE STARTING KINDERGARTEN, has this child
repeated any grades?

Less than 1 hour per week

Yes

1-4 hours per week

5-10 hours per week
11 or more hours per week

NSCH-P-T2

§;#T7¤

26025130

H. About You and This
Child

G4 DURING THE PAST 12 MONTHS, did this child

participate in:
a. A sports team or did he or she
take sports lessons after school
or on weekends?

Yes

No
H1

Was this child born in the United States?

b. Any clubs or organizations after
school or on weekends?

Yes ➔ SKIP to question H3

c. Any other organized activities or
lessons, such as music, dance,
language, or other arts?

No
H2

d. Any type of community service or
volunteer work at school, church, or
in the community?
e. Any paid work, including regular
jobs as well as babysitting, cutting
grass, or other occasional work?

If no, how long has this child been living in the United
States?

Years and
H3

G5 DURING THE PAST 12 MONTHS, how often did you

Months

How many times has this child moved to a new address
since he or she was born?

attend events or activities that this child participated in?
Number of times

Always
Usually

Sometimes

How often does this child go to bed at about the same
time on weeknights?

Rarely

Always

Never

Usually
Sometimes

G6 DURING THE PAST WEEK, on how many days did

this child exercise, play a sport, or participate in
physical activity for at least 60 minutes?

Rarely
Never

0 days
1-3 days

4-6 days

DURING THE PAST WEEK, how many hours of sleep
did this child get on an average weeknight?
Less than 6 hours

Every day

6 hours

G7 Compared to other children his or her age, how much

7 hours

difficulty does this child have making or keeping
friends?

8 hours

No difficulty

9 hours

A little difficulty

10 hours

A lot of difficulty

11 or more hours

NSCH-P-T2

§;#T?¤

26025148

ON AN AVERAGE WEEKDAY, about how much time
does this child usually spend in front of a TV watching
TV programs, videos, or playing video games?

H10 DURING THE PAST MONTH, how often have you felt:
Never

3 hours

a. That this
child is much
harder to care
for than most
children his
or her age?
b. That this
child does
things that
really bother
you a lot?

4 or more hours

c. Angry with
this child?

None
Less than 1 hour
1 hour
2 hours

ON AN AVERAGE WEEKDAY, about how much time
does this child usually spend with computers, cell
phones, handheld video games, and other electronic
devices, doing things other than schoolwork?

Rarely Sometimes Usually Always

H11 DURING THE PAST 12 MONTHS, was there someone

that you could turn to for day-to-day emotional support
with parenting or raising children?
Yes

None
No ➔ SKIP to question I1
Less than 1 hour
1 hour

H12 If yes, did you receive emotional support from:
Yes

2 hours

a. Health care provider?

3 hours

b. Family member or close friend?

4 or more hours

c. Place of worship or religious
leader?
d. Support or advocacy group related
to specific health condition?

How well can you and this child share ideas or talk
about things that really matter?

e. Peer support group?

Very well
Somewhat well

f. Counselor or other mental health
professional?

Not very well

g. Other, specify:

Not at all
H9

In general, how well do you feel that you are coping
with the day-to-day demands of raising children?
Very well
Somewhat well
Not very well
Not at all

NSCH-P-T2

§;#TQ¤

26025155

I. About Your Family and
Household
I1

DURING THE PAST WEEK, on how many days did all the
family members who live in the household eat a meal
together?

We could always afford to eat good nutritious meals.
We could always afford enough to eat but not always
the kinds of food we should eat.

1-3 days

Sometimes we could not afford enough to eat.

4-6 days

Often we could not afford enough to eat.
I7

Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?

Yes

c. Free or reduced-cost breakfasts or
lunches at school?

If yes, does anyone smoke inside your home?

d. Benefits from the Woman, Infants,
and Children (WIC) Program?

Yes
I8

Most of
the time

Some of
the time

In your neighborhood, is there:
a. Sidewalks or walking paths?

When your family faces problems, how often are you
likely to do each of the following?
All of
the time

b. A park or playground?

None of
the time

a. Talk together
about what to do

c. A recreation center, community
center, or boys’ and girls’ club?

b. Work together to
solve our problems

d. A library or bookmobile?
e. Litter or garbage on the street
or sidewalk?

c. Know we have
strengths to draw on

f. Poorly kept or rundown housing?

d. Stay hopeful
even in difficult
times
I5

Yes

b. Food Stamps or Supplemental
Nutrition Assistance Program benefits?

No ➔ SKIP to question I4

At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive:
a. Cash assistance from a government
welfare program?

Yes

The next question is about whether you were able to
afford the food you need. Which of these statements
best describes the food situation in your household
IN THE PAST 12 MONTHS?

0 days

Every day
I2

g. Vandalism such as broken
windows or graffiti?

SINCE THIS CHILD WAS BORN, how often has it been
very hard to get by on your family’s income – hard to
cover the basics like food or housing?
Never
Rarely
Somewhat often
Very often

NSCH-P-T2

§;#TX¤

26025163

To what extent do you agree with these statements
about your neighborhood or community?

I11 The next questions are about events that may have

happened during this child’s life. These things can
happen in any family, but some people may feel
uncomfortable with these questions. You may skip
any questions you do not want to answer.

Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

a. People in this
neighborhood
help each other
out

To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated

b. We watch out for
each other’s
children in this
neighborhood

b. Parent or guardian died

c. This child is
safe in our
neighborhood

c. Parent or guardian served time in jail
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home

d. When we
encounter
difficulties, we
know where to
go for help in
our community

e. Was a victim of violence or
witnessed violence in neighborhood
f. Lived with anyone who was mentally
ill, suicidal, or severely depressed

e. This child is safe
at school

g. Lived with anyone who had a problem
with alcohol or drugs

I10 Other than you or other adults in your home, is there at

least one other adult in this child’s school, neighborhood,
or community who knows this child well and who he or
she can rely on for advice or guidance?

h. Treated or judged unfairly because
of his or her race or ethnic group

Yes
No

NSCH-P-T2

§;#T‘¤

26025171

J. About You

➜ Complete the questions for each of the two adults

8th grade or less

in the household who are this child’s primary
caregivers. If there is just one adult, provide
answers for that adult.

9th-12th grade; No diploma
High School Graduate or GED Completed

ADULT 1 (Respondent)
J1

Completed a vocational, trade, or business school
program

How are you related to this child?
Biological or Adoptive Parent

Some College Credit, but no Degree

Step-parent

Associate Degree (AA, AS)

Grandparent

Bachelor’s Degree (BA, BS, AB)

Foster Parent

Master’s Degree (MA, MS, MSW, MBA)

Aunt or Uncle

Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)

Other: Relative

Other: Non-Relative
J2

What is your sex?

Not married, but living with a partner
Never Married

Female

Divorced

What is your age?

Separated
Widowed

Age in years
J8
J4

Where were you born?

In general, how is your physical health?
Excellent

In the United States ➔ SKIP to question J6

Very Good

Outside of the United States
J5

What is your marital status?
Married

Male

What is the highest grade or year of school you have
completed? Mark ONE only.

Good

When did you come to live in the United States?

Fair

Year

Poor
J9

In general, how is your mental or emotional health?
Excellent
Very Good
Good
Fair
Poor

J10

Were you employed at least 50 out of the past 52 weeks?
Yes
No

NSCH-P-T2

§;#Th¤

26025189

ADULT 2

J17 What is Adult 2’s marital status?

Married

J11 How is Adult 2 related to this child?

Biological or Adoptive Parent

Not married, but living with a partner

Step-parent

Never Married

Grandparent

Divorced

Foster Parent

Separated

Aunt or Uncle

Widowed

Other: Relative

J18 In general, how is Adult 2’s physical health?

Excellent

Other: Non-Relative

Very Good

J12 What is Adult 2’s sex?

Male

Good

Female

Fair

J13 What is Adult 2’s age?

Poor
J19 In general, how is Adult 2’s mental or emotional health?

Excellent

Age in years

Very Good

J14 Where was Adult 2 born?

In the United States ➔ SKIP to question J16

Good

Outside of the United States

Fair
Poor

J15 When did Adult 2 come to live in the United States?

Year

J20 Was Adult 2 employed at least 50 out of the past 52

weeks?
Yes
No

J16 What is the highest grade or year of school Adult 2 has

NSCH-P-T2

§;#Tz¤

26025197

J21 Income IN THE LAST CALENDAR YEAR

J22 The following question is about your income and is

a. Wages, salary, commissions, bonuses, or tips from all
jobs?
Yes

$
$

Total Amount

J23 How many people are living or staying at this address?

b. Self-employment income from own nonfarm businesses
or farm business, including proprietorships and
partnerships?
Yes

Total Amount

No
Number of people

Total Amount
J24 How many of these people in your household are family

members? Family is defined as anyone related to this child
by blood, marriage, adoption, or through foster care.

c. Interest, dividends, net rental income, royalty income,
or income from estates and trusts?
Yes

No
Number of people

Total Amount

d. Social security or railroad retirement; retirement,
survivor, or disability pensions?
Yes

Total Amount

e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office?
Yes

Total Amount

f. Any other sources of income received regularly such as
Veterans’ (VA) payments, unemployment compensation,
child support, or alimony?
Yes

Total Amount

NSCH-P-T2

§;#T¿¤

26025205

§;#U&¤

Topical Questionnaire – 12 to 17 Year Old Children

26035014

National Survey of Children’s Health
A study by the U.S. Department of Health and Human Services to
better understand the health issues being faced by children in the
United States today.

NSCH-P-T3
(03/17/2015)

§;$S/¤

26035022

Start Here

How well does each of these items describe this child?
Definitely Somewhat
true
true

Recently, you completed a survey that asked about the
children usually living or staying at this address.
Thank you for taking the time to complete that survey.

a. This child shows interest
and curiosity in learning
new things
b. This child works to finish
tasks he or she starts

We now have some follow-up questions to ask about:

c. This child stays calm and
in control when faced with
a challenge
d. This child cares about
doing well in school

e. This child does all
required homework

We have selected only one child per household in an
effort to minimize the amount of time necessary to
complete the follow-up questions.

f. This child is bullied,
picked on, or excluded by
other children

The survey should be completed by an adult who is
familiar with this child’s health and health care.

g. This child bullies others,
picks on them, or
excludes them

Your participation is important. Thank you.

h. This child argues too
much

A. This Child’s Health

Not
true

A1 In general, how would you describe this child’s health

DURING THE PAST 12 MONTHS, has this child had
difficulty with or experienced any of the following?
Yes

Yes

a. Breathing or other respiratory
problems (such as wheezing or
shortness of breath)
b. Eating or swallowing because of
a health condition

(the one named above)?
Excellent
Very good

c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea

Good
Fair

d. Repeated or chronic physical pain,
including headaches or other back
or body pain

Poor

e. Toothaches
A2 How would you describe the condition of this child’s

teeth?

f. Bleeding gums

Excellent
Very good

g. Decayed teeth or cavities
A5

Good

Does this child have any of the following?
a. Serious difficulty concentrating,
remembering, or making decisions
because of a physical, mental, or
emotional condition

Fair
Poor

b. Serious difficulty walking or climbing
stairs
c. Difficulty dressing or bathing
d. Difficulty doing errands alone, such
as visiting a doctor’s office or shopping,
because of a physical, mental, or
emotional condition
e. Deafness or problems with hearing
f. Blindness or problems with seeing,
even when wearing glasses

NSCH-P-T3

§;$S7¤

26035030

A6 Has a doctor or other health care provider EVER told

(Has a doctor or other health care provider EVER told
you that this child has...)

you that this child has...
Allergies (including food, drug, insect, or other)?
Yes

A11 Cerebral Palsy?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:

Mild

Moderate

Severe

Mild

Moderate

Severe

A12 Cystic Fibrosis?

A7 Arthritis?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:

Mild

Moderate

Severe

Mild

Moderate

Severe

A13 Diabetes?

A8 Asthma?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:

Mild

Moderate

Severe

Mild

Moderate

Severe

A14 Down Syndrome?

A9 Blood Disorders (such as sickle cell disease,

thalassemia, or hemophilia)?
Yes
Yes

If yes, does this child CURRENTLY have the condition?

If yes, does this child CURRENTLY have the condition?
Yes

Yes

If yes, is it:

Mild

Moderate

Severe

Severe
A15 Epilepsy or seizure disorder?

A10 Brain injury, concussion or head injury?

Yes

If yes, does this child CURRENTLY have the condition?

If yes, does this child CURRENTLY have the condition?
Yes

Yes

If yes, is it:

If yes, is it:
Mild

Mild
Moderate

Moderate

Severe

Severe
A16 Genetic or inherited condition?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, is it:
Mild

NSCH-P-T3

Moderate

Severe

§;$S?¤

26035048

(Has a doctor or other health care provider EVER told
you that this child has...)

A22 Has a doctor, other health care provider, or educator

EVER told you that this child has...
Examples of educators are teachers and school nurses.

A17 Heart Condition?

Yes

Behavioral or Conduct Problems?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:
Mild

Moderate

If yes, is it:

Severe

Mild

Moderate

Severe

A18 Frequent or severe headaches, including migraine?

Yes

A23 Substance Abuse Disorder?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:
Mild

Moderate

If yes, is it:

Severe

Mild

Moderate

Severe

A19 Tourette Syndrome?

Yes

A24 Developmental Delay?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:
Mild

Moderate

If yes, is it:

Severe

Mild
A20 Anxiety Problems?

Yes

Moderate

Severe

A25 Intellectual Disability (also known as Mental Retardation)?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:

Mild

Moderate

Severe

A21 Depression?

Mild

Moderate

Severe

A26 Speech or other language disorder?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, does this child CURRENTLY have the condition?

Yes

If yes, is it:
Mild

If yes, is it:
Moderate

Severe

Mild

Moderate

Severe

A27 Learning Disability?

Yes

If yes, does this child CURRENTLY have the condition?
Yes

If yes, is it:
Mild
NSCH-P-T3

Moderate

Severe

§;$SQ¤

26035055

A28 Has a doctor or other health care provider EVER told

A32

you that this child has...
Any Other Mental Health Condition?
Yes

Is this child CURRENTLY taking medication for Autism,
ASD or PDD?
Yes

No
A33

If yes, specify:

If yes, does this child CURRENTLY have the
condition?

A34 Has a doctor or other health care provider EVER told

Yes

you that this child has Attention Deficit Disorder or
Attention Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?

If yes, is it:
Mild

Moderate

Severe

No ➔ SKIP to question A37

Yes

A29 Has a doctor or other health care provider EVER told

If yes, does this child CURRENTLY have the condition?

you that this child has Autism or Autism Spectrum
Disorder (ASD)? Include diagnoses of Asperger’s Disorder
or Pervasive Developmental Disorder (PDD).

Yes
If yes, is it:

No ➔ SKIP to question A34

Yes

Mild

Moderate

Severe

If yes, does this child CURRENTLY have the condition?
Yes

A35 Is this child CURRENTLY taking medication for ADD or

ADHD?

If yes, is it:
Mild

Yes
Moderate

Severe

A36 At anytime DURING THE PAST 12 MONTHS, did this

child receive behavioral treatment for ADD or ADHD,
such as training or an intervention that you or this
child received to help with his or her behavior?

A30 How old was this child when a doctor or other health

care provider FIRST told you that he or she had Autism,
ASD, or PDD?

Yes
Age in years

Don’t know

A37 DURING THE PAST 12 MONTHS, how often have this

child’s health conditions or problems affected his or her
ability to do things other children his or her age do?

A31 What type of doctor or other health care provider was

the FIRST to tell you that this child had Autism, ASD
or PDD? Mark ONE only.

This child does not have
any conditions ➔ SKIP to question B1

Primary Care Provider

Never
Specialist
Sometimes
School Psychologist/Counselor
Usually
Other Psychologist (Non-School)
Always
Psychiatrist
A38 To what extent do this child’s health conditions or

Other, specify: C

problems affect his or her ability to do things?
Very little
Somewhat

Don’t know

A great deal

NSCH-P-T3

§;$SX¤

26035063

B. This Child as an Infant
B1

Was this child born more than 3 weeks before his or
her due date?

Less than 10 minutes

Yes

10-20 minutes

No
B2

More than 20 minutes

How much did he or she weigh when born?
Provide your best estimate.
C4

pounds

ounces

At his or her LAST preventive check-up, did this child
have a chance to speak with a doctor or other health
care provider privately, without you or another adult in
the room?
Yes

kilograms

grams
C5

What is this child’s CURRENT height?

What was the age of the mother when this child was
born?
feet
OR

Age in years

meters

C. Health Care Services
C1

centimeters

How much does this child CURRENTLY weigh?

pounds
OR

Yes
No ➔ SKIP to question C5
C2

inches

kilograms

If yes, DURING THE PAST 12 MONTHS, how many times
did this child visit a doctor, nurse, or other health care C7
professional to receive a preventive check-up?
A preventive check-up is when this child was not sick or
injured, such as an annual or sports physical, or well-child
visit.
0 visits ➔ SKIP to question C5

Are you concerned about this child’s weight?
Yes, it’s too high
Yes, it’s too low
No, I am not concerned

1 visit
2 or more visits

NSCH-P-T3

§;$S‘¤

26035071

C8 Is there a place that this child USUALLY goes when

C14 DURING THE PAST 12 MONTHS, did this child see a

dentist or other oral health care provider for any kind
of dental or oral health care?

he or she is sick or you or another caregiver needs
advice about his or her health?
Yes

Yes, saw a dentist

No ➔ SKIP to question C10

Yes, saw other oral health care provider
No ➔ SKIP to question C17

C9 If yes, where does this child USUALLY go?

Mark ONE only.
C15 If yes, DURING THE PAST 12 MONTHS, did this child

Doctor’s Office

see a dentist or other oral health care provider for
preventive dental care, such as check-ups, dental
cleanings, dental sealants, or fluoride treatments?

Hospital Emergency Room
Hospital Outpatient Department

No preventive visits in
the past 12 months ➔ SKIP to question C17

Clinic or Health Center

Yes, 1 visit
Retail Store Clinic or “Minute Clinic”
Yes, 2 or more visits
School (Nurse’s Office, Athletic Trainer’s Office)
C16 If yes, DURING THE PAST 12 MONTHS, what

preventive dental services did this child receive?
Mark ALL that apply.

Some other place
C10 Is there a place that this child USUALLY goes when

Check-up

he or she needs routine preventive care, such as a
physical examination or well-child check-up?

Cleaning
Yes
Instruction on tooth brushing and oral health care
No ➔ SKIP to question C12
X-Rays
C11 If yes, is this the same place this child goes when he

or she is sick?

Fluoride treatment

Yes

Sealant (plastic coatings on back teeth)

Don’t know

C12 DURING THE PAST 2 YEARS, has this child had his or

her vision tested with pictures, shapes, or letters?

C17 DURING THE PAST 12 MONTHS, has this child

received any treatment or counseling from a mental
health professional? Mental health professionals include
psychiatrists, psychologists, psychiatric nurses, and clinical
social workers.

Yes
No ➔ SKIP to question C14

Yes

C13 If yes, what kind of place or places did this child have

his or her vision tested? Mark ALL that apply.
No, but this child needed to see a mental health
professional

Eye doctor or eye specialist (opthalmologist,
optometrist) office

No, this child did not need to see a
mental health professional ➔ SKIP to question C19

Pediatrician or other general doctor’s office
Clinic or health center

C18 How much of a problem was it to get the mental health

treatment or counseling that this child needed?

School
Other, specify

Not a problem
C

Small problem
Big problem

NSCH-P-T3

§;$Sh¤

26035089

C19 DURING THE PAST 12 MONTHS, has this child taken

C25 Were these difficulties in getting services for this child

because:

any medication because of difficulties with his or her
emotions, concentration, or behavior?

Yes

a. This child was not eligible for the
services?

b. The services this child needed were
not available in your area?
c. There were problems getting an
appointment when this child needed
one?

C20 DURING THE PAST 12 MONTHS, did this child see a

specialist other than a mental health professional?
Specialists are doctors like surgeons, heart doctors, allergy
doctors, skin doctors, and others who specialize in one
area of health care.

d. There were problems with getting
transportation or child care?

Yes

e. The (clinic/doctor’s) office wasn’t
open when this child needed care?

No, but this child needed to see a specialist

f. There were issues related to cost?

No, this child did not need to
see a specialist ➔ SKIP to question C22

C26 DURING THE PAST 12 MONTHS, how often were you

frustrated in your efforts to get services for this child?

C21 How much of a problem was it to get the specialist

Never

care that this child needed?
Not a problem

Sometimes

Small problem

Usually

Big problem

Always

C22 DURING THE PAST 12 MONTHS, did this child use any

C27 DURING THE PAST 12 MONTHS, how many times did

this child visit a hospital emergency room?
No visits
1 visit

Yes

2 or more visits

C28 Has this child EVER had a special education or early

intervention plan? Children receiving these services often
have an Individualized Family Service Plan or Individualized
Education Plan.

C23 DURING THE PAST 12 MONTHS, was there any time

when this child needed health care but it was not
received? By health care, we mean medical care as well
as other kinds of care like dental care, vision care, and
mental health services.

Yes
No ➔ SKIP to question C31

Yes
No ➔ SKIP to question C26

C29 If yes, how old was this child, in months, at the time of

the FIRST plan?

C24 If yes, which types of care were not received?

Mark ALL that apply.
Medical Care

Age in months

Dental Care
C30 Is this child CURRENTLY receiving services under one

of these plans?

Vision Care
Hearing Care

Yes

Mental Health Services

Other, specify:

NSCH-P-T3

§;$Sz¤

26035097

C31 Has this child EVER received special services to meet

his or her developmental needs such as speech,
occupational, or behavioral therapy?
Yes

Answer the following questions only if this child had a
health care visit IN THE PAST 12 MONTHS. Otherwise,
SKIP to question D13 .
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers:

No ➔ SKIP to question D1

Always

Usually Sometimes

Never

a. Spend enough time
with this child?

C32 If yes, how old was this child, in years, when he or she

began receiving these special services?

b. Listen carefully to
you?
c. Show sensitivity to
your family’s values
and customs?

Age in years
C33 Is this child CURRENTLY receiving these special

d. Provide the specific
information you
needed concerning
this child?

services?
Yes

e. Help you feel like a
partner in this
child’s care?

D. Experience with This
Child’s Health Care
Providers
D1

If yes, DURING THE PAST 12 MONTHS, how often did
this child’s doctors or other health care providers:

Yes, one person

Always

Yes, more than one person

No
D2

b. Make it easy for you
to raise concerns or
disagree with
recommendations
for this child’s health
care?

DURING THE PAST 12 MONTHS, did this child need a
referral to see any doctors or receive any services?
Yes
No ➔ SKIP to question D4

Usually Sometimes Never

a. Discuss with you
the range of options
to consider for his
or her health care or
treatment?

c. Work with you to
decide together
which health care
and treatment
choices would be
best for this child?

If yes, how much of a problem was it to get referrals?
Not a problem
Small problem
Big problem

NSCH-P-T3

§;$S¿¤

26035105

D7 Does anyone help you arrange or coordinate this

D13 Do any of this child’s doctors or other health care

providers treat only children?

child’s care among the different doctors or services
that this child uses?

Yes

No ➔ SKIP to question D15

No
Did not see more than one
health care provider in
PAST 12 MONTHS ➔ SKIP to question D11

D14 If yes, have they talked with you about having this child

eventually see doctors or other health care providers
who treat adults?
Yes

D8 DURING THE PAST 12 MONTHS, have you felt that you

could have used extra help arranging or coordinating
this child’s care among the different health care
providers or services?

No
D15 Has this child’s doctor or other health care provider

actively worked with this child to:

Yes

No ➔ SKIP to question D10

Don’t
know

a. Think about and plan for his
or her future. For example, by
taking time to discuss future
plans about education, work,
relationships, and development
of independent living skills?

D9 If yes, DURING THE PAST 12 MONTHS, how often

did you get as much help as you wanted with
arranging or coordinating this child’s health care?
Usually

b. Make positive choices about
his or her health. For example,
by eating healthy, getting
regular exercise, not using
tobacco, alcohol or other drugs,
or delaying sexual activity?

Sometimes
Never
D10 Overall, how satisfied are you with the communication

c. Gain skills to manage his or
her health and health care.
For example, by understanding
current health needs, knowing
what to do in a medical
emergency, or taking
medications he or she may need?

among this child’s doctors and other health care
providers?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied

d. Understand the changes in
health care that happen at
age 18. For example, by
understanding changes in privacy,
consent, access to information, or
decision-making?

Very dissatisfied
D11 DURING THE PAST 12 MONTHS, did this child’s health

care provider communicate with the child’s school, child
care provider, or special education program?

D16 Have this child’s doctors or other health care providers

worked with you and this child to create a written plan
to meet his or her health goals and needs?

Yes
No ➔ SKIP to question D13

Yes

Did not need health care
provider to communicate
with these providers ➔ SKIP to question D13

No ➔ SKIP to question D20

D12 If yes, overall, how satisfied are you with the health

care provider’s communication with the school, child
care provider, or special education program?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

NSCH-P-T3

§;$T&¤

26035113

E. This Child’s Health
Insurance Coverage

D17 If yes, does this plan identify specific health goals for

this child and any health needs or problems this child
may have and how to get these needs met?
Yes

DURING THE PAST 12 MONTHS, was this child EVER
covered by ANY kind of health insurance or health
coverage plan?
Yes, this child was covered
all 12 months ➔ SKIP to question E4

D18 Did you and this child receive a written copy of this

plan of care?

Yes, but this child had a gap in coverage

Yes

No
E2
D19 Is this plan CURRENTLY up-to-date for this child?

Indicate whether any of the following is a reason this
child was not covered by health insurance DURING
THE PAST 12 MONTHS:
Yes

Yes

a. Change in employer or employment
status

b. Cancellation due to overdue
premiums

D20 Eligibility for health insurance often changes in young

adulthood. Do you know how this child will be insured
as he or she becomes an adult?

c. Dropped coverage because it was
unaffordable

Yes ➔ SKIP to question E1

d. Dropped coverage because benefits
were inadequate

e. Dropped coverage because choice
of health care providers was
inadequate

D21 If no, has anyone discussed with you how to obtain or

keep some type of health insurance coverage as this
child becomes an adult?

f. Problems with application or
renewal process

Yes

g. Other, specify: C

No
E3

Is this child CURRENTLY covered by ANY kind of
health insurance or health coverage plan?
Yes
No ➔ SKIP to question F1

Is this child covered by any of the following types of
health insurance or health coverage plans?
Yes

a. Insurance through a current or
former employer or union
b. Insurance purchased directly
from an insurance company
c. Medicaid, Medical Assistance,
or any kind of government
assistance plan for those with
low incomes or a disability
d. TRICARE or other military
health care
e. Indian Health Service
f. Other, specify: C

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F. Providing for This
Child’s Health

How often does this child’s health insurance offer
benefits or cover services that meet this child’s needs?
Always
Usually

Sometimes

$0 (No medical or health-related
expenses) ➔ SKIP to question F3

Never
E6

How often does this child’s health insurance allow him
or her to see the health care providers he or she needs?

$1-$249

Always

$250-$499

Usually

$500-$999

Sometimes

$1,000-$5,000

Never

More than $5,000

Not including health insurance premiums or costs that
are covered by insurance, do you pay any money for
this child’s health care?

DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?

Yes
Yes
No ➔ SKIP to question E9
No
E8

If yes, how often are these costs reasonable?
Always

DURING THE PAST 12 MONTHS, have you or other
family members:
Yes

Usually

a. Stopped working because of this
child’s health status?

Sometimes

b. Cut down on the hours you work
because of this child’s health or
health conditions?

Never
E9

c. Avoided changing jobs because of
concerns about maintaining health
insurance for this child?

Answer the following question only if this child uses
mental or behavioral health services. Otherwise, SKIP
to question F1 .
Thinking about this child’s mental or behavioral health
needs, how often does this child’s health insurance
offer benefits or cover services that meet these needs?

Always

Usually

Less than 1 hour per week

Sometimes

1-4 hours per week

Never

5-10 hours per week
11 or more hours per week

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IN AN AVERAGE WEEK, how many hours do you or
other family members spend arranging or coordinating
health or medical care for this child, such as making
appointments or locating services?

G4 DURING THE PAST 12 MONTHS, did this child

participate in:
Yes

a. A sports team or did he or she
take sports lessons after school
or on weekends?

I did not arrange or coordinate health or medical care
Less than 1 hour per week

b. Any clubs or organizations after
school or on weekends?

1-4 hours per week

c. Any other organized activities or
lessons, such as music, dance,
language, or other arts?

5-10 hours per week

d. Any type of community service or
volunteer work at school, church, or
in the community?

11 or more hours per week

e. Any paid work, including regular
jobs as well as babysitting, cutting
grass, or other occasional work?

G. This Child’s Schooling
and Activities

G5 DURING THE PAST 12 MONTHS, how often did you

attend events or activities that this child participated in?

G1 DURING THE PAST 12 MONTHS, about how many days

did this child miss school because of illness or injury?
Always
No missed school days
Usually
1-3 days
Sometimes
4-6 days
Rarely
7-10 days
Never
11 or more days
G6
G2 DURING THE PAST 12 MONTHS, how many times has

this child’s school contacted you or another adult in
your household about any problems he or she is
having with school?

DURING THE PAST WEEK, on how many days did
this child exercise, play a sport, or participate in
physical activity for at least 60 minutes?
0 days

No times

1-3 days

1 time

4-6 days

2 or more times

Every day

G3 SINCE STARTING KINDERGARTEN, has this child

repeated any grades?

Compared to other children his or her age, how much
difficulty does this child have making or keeping
friends?

Yes
No difficulty
No
A little difficulty
A lot of difficulty

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H. About You and This
Child
H1

H6 ON AN AVERAGE WEEKDAY, about how much time

does this child usually spend in front of a TV watching
TV programs, videos, or playing video games?
None

Was this child born in the United States?
Yes ➔ SKIP to question H3

Less than 1 hour

1 hour

If no, how long has this child been living in the
United States?

2 hours
3 hours

Years and
H3

4 or more hours

Months

How many times has this child moved to a new address
since he or she was born?

H7 ON AN AVERAGE WEEKDAY, about how much time

does this child usually spend with computers, cell
phones, handheld video games, and other electronic
devices, doing things other than schoolwork?

Number of times
H4

None

How often does this child go to bed at about the same
time on weeknights?

Less than 1 hour
1 hour

Always
2 hours
Usually
3 hours
Sometimes
4 or more hours
Rarely
H8

Never
H5

How well can you and this child share ideas or talk
about things that really matter?
Very well

DURING THE PAST WEEK, how many hours of sleep
did this child get on an average weeknight?

Somewhat well
Less than 6 hours
Not very well
6 hours
Not at all
7 hours
8 hours

In general, how well do you feel that you are coping
with the day-to-day demands of raising children?

9 hours

Very well

10 hours

Somewhat well

11 or more hours

Not very well
Not at all

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I. About Your Family and
Household

H10 DURING THE PAST MONTH, how often have you felt:
Never

Rarely Sometimes Usually Always

a. That this
child is much
harder to care
for than most
children his
or her age?

b. That this
child does
things that
really bother
you a lot?

DURING THE PAST WEEK, on how many days did all the
family members who live in the household eat a meal
together?
0 days
1-3 days
4-6 days

c. Angry with
this child?

Every day

H11 DURING THE PAST 12 MONTHS, was there someone

that you could turn to for day-to-day emotional support
with parenting or raising children?

Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?
Yes

Yes
No ➔ SKIP to question

No ➔ SKIP to question I4
I1
I3

Yes

H12 If yes, did you receive emotional support from:
Yes

If yes, does anyone smoke inside your home?

a. Health care provider?
I4

b. Family member or close friend?

All of
the time

c. Place of worship or religious
leader?

Most of
the time

Some of
the time

None of
the time

a. Talk together
about what to do

d. Support or advocacy group related
to specific health condition?

b. Work together to
solve our problems

e. Peer support group?

c. Know we have
strengths to draw on

f. Counselor or other mental health
professional?
g. Other, specify:

When your family faces problems, how often are you
likely to do each of the following?

d. Stay hopeful
even in difficult
times

SINCE THIS CHILD WAS BORN, how often has it been
very hard to get by on your family’s income – hard to
cover the basics like food or housing?
Never
Rarely
Somewhat often
Very often

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The next question is about whether you were able to
afford the food you need. Which of these statements
best describes the food situation in your household
IN THE PAST 12 MONTHS?

To what extent do you agree with these statements
about your neighborhood or community?
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

a. People in this
neighborhood
help each other
out

We could always afford to eat good nutritious meals.
We could always afford enough to eat but not always
the kinds of food we should eat.

b. We watch out for
each other’s
children in this
neighborhood

Sometimes we could not afford enough to eat.
Often we could not afford enough to eat.
I7

c. This child is
safe in our
neighborhood

At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive:
Yes

d. When we
encounter
difficulties, we
know where to
go for help in
our community

a. Cash assistance from a government
welfare program?
b. Food Stamps or Supplemental
Nutrition Assistance Program benefits?

e. This child is safe
at school

c. Free or reduced-cost breakfasts or
lunches at school?
I10

d. Benefits from the Woman, Infants,
and Children (WIC) Program?
I8

Other than you or other adults in your home, is there at
least one other adult in this child’s school, neighborhood,
or community who knows this child well and who he or
she can rely on for advice or guidance?

In your neighborhood, is there:
Yes

Yes

a. Sidewalks or walking paths?
b. A park or playground?

No
I11

c. A recreation center, community
center, or boys’ and girls’ club?
d. A library or bookmobile?

The next questions are about events that may have
happened during this child’s life. These things can
happen in any family, but some people may feel
uncomfortable with these questions. You may skip any
questions you do not want to answer.
To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated

e. Litter or garbage on the street
or sidewalk?
f. Poorly kept or rundown housing?
g. Vandalism such as broken
windows or graffiti?

b. Parent or guardian died
c. Parent or guardian served time in jail
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home
e. Was a victim of violence or
witnessed violence in neighborhood
f. Lived with anyone who was mentally
ill, suicidal, or severely depressed
g. Lived with anyone who had a problem
with alcohol or drugs
h. Treated or judged unfairly because
of his or her race or ethnic group

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J. About You

➜ Complete the questions for each of the two adults

8th grade or less

in the household who are this child’s primary
caregivers. If there is just one adult, provide
answers for that adult.

9th-12th grade; No diploma
High School Graduate or GED Completed

ADULT 1 (Respondent)
J1

Completed a vocational, trade, or business school
program

How are you related to this child?
Biological or Adoptive Parent

Some College Credit, but no Degree

Step-parent

Associate Degree (AA, AS)

Grandparent

Bachelor’s Degree (BA, BS, AB)

Foster Parent

Master’s Degree (MA, MS, MSW, MBA)

Aunt or Uncle

Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)

Other: Relative

Other: Non-Relative
J2

What is your sex?

Not married, but living with a partner
Never Married

Female

Divorced

What is your age?

Separated
Widowed

Age in years
J8
J4

Where were you born?

In general, how is your physical health?
Excellent

In the United States ➔ SKIP to question J6

Very Good

Outside of the United States
J5

What is your marital status?
Married

Male

What is the highest grade or year of school you have
completed? Mark ONE only.

Good

When did you come to live in the United States?

Fair

Year

Poor
J9

In general, how is your mental or emotional health?
Excellent
Very Good
Good
Fair
Poor

J10

Were you employed at least 50 out of the past 52 weeks?
Yes
No

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ADULT 2

J17 What is Adult 2’s marital status?

Married

J11 How is Adult 2 related to this child?

Biological or Adoptive Parent

Not married, but living with a partner

Step-parent

Never Married

Grandparent

Divorced

Foster Parent

Separated

Aunt or Uncle

Widowed

Other: Relative

J18 In general, how is Adult 2’s physical health?

Excellent

Other: Non-Relative

Very Good

J12 What is Adult 2’s sex?

Male

Good

Female

Fair

J13 What is Adult 2’s age?

Poor
J19 In general, how is Adult 2’s mental or emotional health?

Age in years

Excellent
Very Good

J14 Where was Adult 2 born?

In the United States ➔ SKIP to question J16

Good

Outside of the United States

Fair
Poor

J15 When did Adult 2 come to live in the United States?

Year

J20 Was Adult 2 employed at least 50 out of the past 52

weeks?
Yes
No

J16 What is the highest grade or year of school Adult 2 has

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J21 Income IN THE LAST CALENDAR YEAR

J22 The following question is about your income and is

a. Wages, salary, commissions, bonuses, or tips from all
jobs?
Yes

$
$

Total Amount

J23 How many people are living or staying at this address?

b. Self-employment income from own nonfarm businesses
or farm business, including proprietorships and
partnerships?
Yes

Total Amount

No
Number of people

Total Amount
J24 How many of these people in your household are family

members? Family is defined as anyone related to this child
by blood, marriage, adoption, or through foster care.

c. Interest, dividends, net rental income, royalty income,
or income from estates and trusts?
Yes

No
Number of people

Total Amount

d. Social security or railroad retirement; retirement,
survivor, or disability pensions?
Yes

Total Amount

e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office?
Yes

Total Amount

f. Any other sources of income received regularly such as
Veterans’ (VA) payments, unemployment compensation,
child support, or alimony?
Yes

Total Amount

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File Type	application/pdf
Author	Leah Nicole Meyer
File Modified	2015-04-29
File Created	2015-03-20