2 English Topical Questionnaire 1

Generic Clearance for Questionnaire Pretesting Research

NSCH T1_Cognitive Interviewing Version

NSCH Questionnaire Cognitive Testing

OMB: 0607-0725

Document [pdf]
Download: pdf | pdf
26018200
OMB No. 0607-0990: Approval Expires 05/31/2019

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

The U.S. Census Bureau is required by law to protect your information and is not permitted to publicly release your responses in
a way that could identify you or your household. 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. Title 42 U.S.C. Section 701(a)(2) allows HHS to collect information
for the purpose of understanding the health and well-being of children in the United States. Federal law protects your privacy and
keeps your answers confidential under 13 U.S.C. Section 9. Per the Federal Cybersecurity Enhancement Act of 2015, your data are
protected from cybersecurity risks through screening of the systems that transmit your data.
Any information you provide will be shared for the work-related purposes identified above and as permitted under the Privacy Act
of 1974 (5 U.S.C. Section 552a) and SORN COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame).
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-T1
(06/12/2017) Draft 2

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Start Here

A3

How true are each of the following statements about
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
If the name listed above is not correct or does not
correspond to a child living in this household, please
call 1-800-845-8241 for assistance.
We have selected only one child per household in an
effort to minimize the amount of time you will need to
complete the follow-up questions.

d. This child smiles and
laughs a lot
A4

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

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

No

Yes

No

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

Your participation is important. Thank you.
b. Eating or swallowing because of
a health condition
c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea
d. Repeated or chronic physical pain,
including headaches or other back
or body pain

A. This Child’s Health

e. Using his or her hands

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

(the one named above)?
f. Coordination or moving around
Excellent
g. Toothaches
Very good
h. Bleeding gums
Good
i.

Decayed teeth or cavities

Fair
Poor

A5

Does this child have any of the following?

a. Deafness or problems with hearing

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

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

This child does not have any teeth
Excellent

A6

Very good

Has a doctor or other health care provider EVER told
you that this child has...
Allergies (including food, drug, insect, or other)?

Good

Yes

Fair

If yes, does this child CURRENTLY have the
condition?

Poor

No

Yes

No

If yes, is it:
Mild

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2

Moderate

Severe

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

Has a doctor or other health care provider EVER told
you that this child has...
A13 Diabetes?

A7 Arthritis?

Yes

No

Yes

If yes, does this child CURRENTLY have the
condition?

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

No

Yes

No

If yes, is it:

If yes, is it:
Mild

Moderate

Severe

A8 Asthma?

Mild

Moderate

Severe

A14 Down Syndrome?

Yes

No

Yes

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

No

Yes
Moderate

Severe

A9 Blood Disorders (such as Sickle Cell Disease,

Mild

Yes

No

Moderate

Mild

Severe
Yes

No

No

If yes, is it:

If yes, is it:
Moderate

Mild

Severe

Moderate

Severe

A17 Frequent or severe headaches, including migraine?

A11 Cerebral Palsy?

Yes

No

Yes

Yes

No

No

If yes, is it:

If yes, is it:
Mild

No

If yes, does this child CURRENTLY have the
condition?

If yes, does this child CURRENTLY have the
condition?

Moderate

Mild

Severe

Moderate

Severe

A18 Tourette Syndrome?

A12 Cystic Fibrosis?

Yes

No

Yes

No

If yes, does this child CURRENTLY have the
condition?

If yes, does this child CURRENTLY have the
condition?

Yes

No

No

If yes, is it:

If yes, is it:
Mild

No

Yes

No

Yes

Severe

If yes, does this child CURRENTLY have the
condition?

If yes, does this child CURRENTLY have the
condition?

Mild

Moderate

A16 Heart Condition?

Brain injury, concussion or head injury?

Yes

No

If yes, is it:

If yes, is it:

Yes

No

Yes

No

Yes

Severe

If yes, does this child CURRENTLY have the
condition?

If yes, does this child CURRENTLY have the
condition?

Mild

Moderate

A15 Epilepsy or Seizure Disorder?

Thalassemia, or Hemophilia)?

Yes

No

If yes, is it:

Mild

Yes

No

If yes, does this child CURRENTLY have the
condition?

If yes, is it:

A10

No

Moderate

Mild

Severe

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Moderate

Severe

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

Has a doctor, other health care provider, or educator
EVER told you that this child has...
Examples of educators are teachers and school nurses.

A19 Anxiety Problems?

A24 Intellectual Disability (formerly known as Mental

Yes

No

Retardation)?

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

Yes

No

If yes, does this child CURRENTLY have the
condition?

No

If yes, is it:

Yes

Mild

Moderate

No

If yes, is it:

Severe

Mild

A20 Depression?

Yes

Yes

If yes, does this child CURRENTLY have the
condition?

No

If yes, does this child CURRENTLY have the
condition?

No

If yes, is it:

Yes

Mild

Moderate

Severe

Mild

Moderate

Severe

A26 Learning Disability?

No

Yes

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

No

If yes, is it:

A21 Other genetic or inherited condition?

Yes

Severe

A25 Speech or other language disorder?

No

Yes

Moderate

No

If yes, does this child CURRENTLY have the
condition?

No

Yes

If yes, is it:

No

If yes, is it:
Mild

Moderate

Severe
Mild

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.

you that this child has...
Any other mental health condition?
Yes

No

No

If yes, specify: C

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

Severe

A27 Has a doctor or other health care provider EVER told

Behavioral or Conduct Problems?
Yes

Moderate

No
If yes, does this child CURRENTLY have the
condition?

If yes, is it:
Mild

Moderate

Severe

Yes

A23 Developmental Delay?

Yes

Mild

No

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

Severe

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

No

No ➔ SKIP to question A33

Yes
Moderate

Moderate

A28 Has a doctor or other health care provider EVER told

If yes, is it:
Mild

No

If yes, is it:

Severe

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

No

If yes, is it:
Mild

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Moderate

Severe

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

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?

care provider FIRST told you that he or she had Autism,
ASD, Asperger’s Disorder or PDD?

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

Don’t know

Age in years

Never

A30 What type of doctor or other health care provider was

the FIRST to tell you that this child had Autism, ASD,
Asperger’s Disorder or PDD? Mark (X) ONE box.

Sometimes

Primary Care Provider

Usually

Specialist

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

School Psychologist/Counselor

problems affect his or her ability to do things?

Other Psychologist (Non-School)

Very little

Psychiatrist
Other, specify:

Somewhat
C

A great deal

B. This Child as an Infant

Don’t know
A31 Is this child CURRENTLY taking medication for Autism,

B1

ASD, Asperger’s Disorder or PDD?
Yes

Yes

No

No

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

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

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

B2

How much did he or she weigh when born?
Answer in pounds and ounces OR kilograms and grams.
Provide your best estimate.

No

pounds AND

A33 Has a doctor or other health care provider EVER told

OR

you that this child has Attention Deficit Disorder or
Attention Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?
No ➔ SKIP to question A36

Yes

kilograms AND
B3

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

grams

What was the age of the mother when this child was
born?
Age in years

No
B4

If yes, is it:
Mild

ounces

Moderate

Severe

Was this child EVER breastfed or fed breast milk?
Yes
No ➔ SKIP to question B6

A34 Is this child CURRENTLY taking medication for ADD or

ADHD?
Yes

No

A35 At any time 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?
Yes

No

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B5

C. Health Care Services

If yes, how old was this child when he or she
COMPLETELY stopped breastfeeding or being fed
breast milk?
C1

days

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?

OR
Yes
weeks
OR

No ➔ SKIP to question C4
C2

months
OR

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.

Check this box if child is still breastfeeding
0 visits
B6

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

1 visit
2 or more visits

Check this box if child has never been fed formula
OR

C3

At birth
OR

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.
Less than 10 minutes

days
10-20 minutes

OR

More than 20 minutes
weeks

C4

What is this child’s CURRENT height?

OR
feet AND
months
B7

inches

OR

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.

meters AND
C5

centimeters

How much does this child CURRENTLY weigh?

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

pounds AND

ounces

OR

At birth
OR

kilograms AND
days

C6

grams

Are you concerned about this child’s weight?

OR
Yes, it’s too high
weeks

Yes, it’s too low

OR

No, I am not concerned
months

NSCH-T1

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C7 DURING THE PAST 12 MONTHS, did this child’s doctors C11 Is there a place that this child USUALLY goes when

or other health care providers ask if you have concerns
about this child’s learning, development, or behavior?

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

Yes

Yes

No

No ➔ SKIP to question C13

C8 If this 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.
Yes

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

or she is sick?
Yes
No
C13 Has this child EVER had his or her vision tested with

pictures, shapes, or letters?
Yes

No

No ➔ SKIP to question C15

If yes, and this child is 9-23 Months:
Did the questionnaire ask about your concerns
or observations about: Mark (X) ALL that apply.

C14 If yes, what kind of place or places did this child have

his or her vision tested? Mark (X) ALL that apply.
How this child talks or makes speech sounds?

Eye doctor or eye specialist (ophthalmologist,
optometrist) office

How this child interacts with you and others?

Pediatrician or other general doctor’s office

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

Clinic or health center

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

School

Words and phrases this child uses and
understands?

Other, specify:

C

How this child behaves and gets along with
you and others?
C9 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?

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?

Yes

Yes, saw a dentist

No ➔ SKIP to question C11

Yes, saw other oral health care provider

C10 If yes, where does this child USUALLY go first?

No ➔ SKIP to question C18

Mark (X) ONE box.
Doctor’s Office

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

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 C18

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)
Some other place

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C17 If yes, DURING THE PAST 12 MONTHS, what

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.

preventive dental services did this child receive?
Mark (X) ALL that apply.
Check-up
Cleaning

Yes

Instruction on tooth brushing and oral health care
X-Rays

No
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.

Fluoride treatment
Sealant (plastic coatings on back teeth)

Yes

Don’t know

No ➔ SKIP to question C27

C18 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.

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

Mark (X) ALL that apply.
Medical Care

Yes
Dental Care

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

Vision Care

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

Hearing Care

C19 How difficult was it to get the mental health treatment or

Mental Health Services

counseling that this child needed?
Very difficult

Other, specify:

C

Somewhat difficult
Not difficult

C26 Did any of the following reasons contribute to this child

not receiving needed health services? Mark (X) Yes or No
for each item.

C20 DURING THE PAST 12 MONTHS, has this child taken

Yes

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

b. The services this child needed were
not available in your area

No

c. There were problems getting an
appointment when this child needed
one

C21 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 C23

No

a. This child was not eligible for the
services

C27 DURING THE PAST 12 MONTHS, how often were you

frustrated in your efforts to get services for this child?

C22 How difficult was it to get the specialist care that this

Never

child needed?
Very difficult

Sometimes

Somewhat difficult

Usually

Not difficult

Always

NSCH-T1

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D. Experience with This
Child’s Health Care
Providers

C28 DURING THE PAST 12 MONTHS, how many times did

this child visit a hospital emergency room?
None
1 time

D1

2 or more times
C29 Has this child EVER had a special education or early

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

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

Yes, more than one person

No ➔ SKIP to question C32

No

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

D2

plan?

DURING THE PAST 12 MONTHS, did this child need a
referral to see any doctors or receive any services?
Yes

Years AND

Months
No ➔ SKIP to question D4

C31 Is this child CURRENTLY receiving services under one

of these plans?

D3

If yes, how difficult was it to get referrals?

Yes

Very difficult

No

Somewhat difficult
Not difficult

C32 Has this child EVER received special services to meet

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

D4

Yes

Answer the following questions only if this child had a
health care visit IN THE PAST 12 MONTHS.
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?

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

receiving these special services?

b. Listen carefully to
you?
Years AND

Months

c. Show sensitivity to
your family’s values
and customs?

C34 Is this child CURRENTLY receiving these special

services?

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

Yes
No

e. Help you feel like a
partner in this
child’s care?
D5

DURING THE PAST 12 MONTHS, did this child need
any decisions to be made regarding his or her health
care, such as whether to get prescriptions, referrals,
or procedures?
Yes
No ➔ SKIP to question D7

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26018119

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

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?

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

Usually Sometimes Never

Yes

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?

No ➔ SKIP to question E1
Did not need health care
provider to communicate
with these providers ➔ SKIP to question E1
D12 If yes, during this time, how satisfied were you with the

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

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

Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

D7 DURING THE PAST 12 MONTHS, did anyone help you

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

E. This Child’s Health
Insurance Coverage

No
Yes

E1

Did not see more than one health care provider
in PAST 12 MONTHS

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

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, but this child had a gap in coverage
No

Yes
E2

No ➔ SKIP to question D10

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

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

a. Change in employer or employment
status

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

b. Cancellation due to overdue
premiums

Sometimes

c. Dropped coverage because it was
unaffordable

Never

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

D10 DURING THE PAST 12 MONTHS, how satisfied were

you with the communication among this child’s doctors
and other health care providers?
Very satisfied

f. Problems with application or
renewal process

Somewhat satisfied

g. Other, specify: C

Somewhat dissatisfied
Very dissatisfied

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No

26018101

E3

F. Providing for This
Child’s Health

Is this child CURRENTLY covered by ANY kind of
health insurance or health coverage plan?
Yes
F1

No ➔ SKIP to question F1
E4

Is this child covered by any of the following types of
health insurance or health coverage plans?
Mark (X) Yes or No for EACH item.
Yes

No

a. Insurance through a current or
former employer or union

Including co-pays and amounts from Health Savings
Accounts (HSA) and Flexible Spending Accounts
(FSA), how much money did you pay for this child’s
medical, health, dental, and vision 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 F4

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

$500-$999

d. TRICARE or other military
health care

$1,000-$5,000

e. Indian Health Service

More than $5,000

f. Other, specify: C

$1-$249
$250-$499

F2

How often are these costs reasonable?
Always
Usually

E5

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

Sometimes

Always
Usually

Never
F3

Sometimes

Yes

Never
E6

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

No

How often does this child’s health insurance allow him
or her to see the health care providers he or she needs?
F4

Always

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

Usually

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

Sometimes

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

Never
E7

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

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?
This child does not use mental or behavioral
health services
Always
Usually
Sometimes
Never

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No

26018093

F5

IN AN AVERAGE WEEK, how many hours do you or
G4 How confident are you that this child is ready to be in
school?
other family members spend providing health care at
home for this child? Care might include changing
Completely confident
bandages, or giving medication and therapies when needed.
This child does not need health care provided
on a weekly basis

Mostly confident
Somewhat confident

No at home care is provided by me or other family
members

Not at all confident
Less than 1 hour per week

G5 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?

1-4 hours per week

F6

5-10 hours per week

Always

11 or more hours per week

Most of the time
About half the time

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?
This child does not need health care coordinated
on a weekly basis

Sometimes
Never
G6 About how many letters of the alphabet can this child

recognize?
No health or medical care is arranged or coordinated
by me or other family members

All of them

Less than 1 hour per week

Most of them

1-4 hours per week

About half of them

5-10 hours per week

Some of them

11 or more hours per week

None of them
G7 Can this child rhyme words?

G. This Child’s Learning

Yes
No

G1 Is this child 3 years old or older?

Yes

G8

No ➔ SKIP to question H1

How often can this child explain things he or she has seen
or done so that you get a very good idea what happened?
Always

G2 Has this child started school? Include any formal

Most of the time

home schooling.
About half the time
Yes, preschool
Sometimes
Yes, kindergarten
Never
Yes, first grade
G9

No

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

G3 Are you concerned about how this child is learning to

do things for him or herself?

Most of the time

Yes, somewhat concerned

About half the time

Yes, very concerned

Sometimes

No

Never

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G10 How high can this child count?

G15 When this child is paying attention, how often can he

or she follow instructions to complete a simple task?
This child cannot count
Always
Up to five
Most of the time
Up to ten
About half the time
Up to 20
Sometimes
Up to 50
Never
Up to 100 or more
G16 How does this child usually hold a pencil?
G11 How often can this child identify basic shapes such as

a triangle, circle, or square?

Uses fingers to hold the pencil

Always

Grips the pencil in his or her fist

Most of the time

This child cannot hold a pencil

About half the time

G17 How often does this child play well with others?

Sometimes

Always

Never

Most of the time
About half the time

G12 Can this child identify the colors red, yellow, blue,

and green by name?
Sometimes
Yes, all of them
Never
Yes, some of them
G18 How often does this child become angry or anxious

when going from one activity to another?

No, none of them
G13 How often is this child easily distracted?

Always

Always

Most of the time

Most of the time

About half the time

About half the time

Sometimes

Sometimes

Never

Never

G19 How often does this child show concern when others

are hurt or unhappy?
G14 How often does this child keep working at something

until he or she is finished?

Always

Always

Most of the time

Most of the time

About half the time

About half the time

Sometimes

Sometimes

Never

Never

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G20 When excited or all wound up, how often can this child

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

calm down quickly?

since he or she was born?

Always

Number of times

Most of the time
H4 How often does this child go to bed at about the same

time on weeknights?

About half the time
Sometimes

Always

Never

Usually
Sometimes

G21 How often does this child lose control of his or her

temper when things do not go his or her way?

Rarely

Always

Never

Most of the time
H5 DURING THE PAST WEEK, how many hours of sleep

did this child get during an average day (count both
nighttime sleep and naps)?

About half the time
Sometimes

Less than 7 hours

Never

7 hours

G22 Compared to other children his or her age, how much

8 hours

difficulty does this child have making or keeping
friends?

9 hours

A lot of difficulty

10 hours

A little difficulty

11 hours

No difficulty

12 or more hours

G23 Compared to other children his or her age, how often

is this child able to sit still?

H6

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 (X) ONE box.

Always
Most of the time

On his or her side

About half the time

On his or her back

Sometimes

On his or her stomach

Never

H7

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
Less than 1 hour

H1 Was this child born in the United States?

Yes ➔ SKIP to question H3

1 hour

No

2 hours
3 hours

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

United States?
Years AND

4 or more hours
Months

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H8

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

H9

2 hours

a. Spouse?

3 hours

b. Other family member or close friend?

4 or more hours

c. Health care provider?

No

d. Place of worship or religious leader?

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

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

1-3 days

f. Peer support group?

4-6 days

g. Counselor or other mental health
professional?

Every day

h. Other person, specify:

C

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
4-6 days

Yes

Every day

No

H11 How well do you think you are handling the day-to-day

demands of raising children?

H16 DURING THE PAST 12 MONTHS, did you or anyone in

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

Very well
Somewhat well

Yes

Not very well

No

Not at all

I. About Your Family and
Household

H12 DURING THE PAST MONTH, how often have you felt:
Never

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

Rarely Sometimes Usually Always
I1

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

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

1-3 days
4-6 days
Every day

c. Angry with
this child?
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I2

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

I8

Which of these statements best describes your
household’s ability to afford the food you need
DURING THE PAST 12 MONTHS?

Yes
We could always afford to eat good nutritious meals.
No ➔ SKIP to question I4
I3

I4

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

If yes, does anyone smoke inside your home?
Yes

Sometimes we could not afford enough to eat.

No

Often we could not afford enough to eat.

DURING THE PAST 12 MONTHS, how often were
pesticides used inside your residence to control for
insects? If the frequency changed throughout the year,
report the highest frequency.

I9

More than once a week

a. Cash assistance from a government
welfare program?

Once a week

b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?

Once a month
Once every 2-5 months

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

Once every 6 months

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

Yes

No

Yes

No

I10 In your neighborhood, is/are there:

Once during the past 12 months
Never

a. Sidewalks or walking paths?

Don’t know
I5

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

b. A park or playground?

DURING THE PAST 12 MONTHS, other than in a shower
or bathtub, have you seen any mold, mildew or other
signs of water damage on walls or other surfaces inside
your home?

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

Yes
e. Litter or garbage on the street
or sidewalk?

No
I6

f. Poorly kept or rundown housing?

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

g. Vandalism such as broken
windows or graffiti?

None of
the time

a. Talk together
about what to do

I11 To what extent do you agree with these statements

about your neighborhood or community?

b. Work together to
solve our problems

Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

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

c. Know we have
strengths to draw on
d. Stay hopeful
even in difficult
times
I7

SINCE THIS CHILD WAS BORN, how often has it been
very hard to cover the basics, like food and housing,
on your family’s income?

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
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I12 The next questions are about events that may have

J4

Where were you born?

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

In the United States ➔ SKIP to question J6
Outside of the United States
J5

When did you come to live in the United States?
Year

b. Parent or guardian died
c. Parent or guardian served time in jail

J6

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

What is the highest grade or level of school you have
completed? Mark (X) ONE box.
8th grade or less
9th-12th grade; No diploma

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

High School Graduate or GED Completed

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

Completed a vocational, trade, or business school
program

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

Some College Credit, but no Degree

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

Associate Degree (AA, AS)
Bachelor’s Degree (BA, BS, AB)

J. About You

Master’s Degree (MA, MS, MSW, MBA)

➜ Complete the questions for up to two adults in the
household who are this child’s primary caregivers.
If there is just one adult primary caregiver, provide
answers for that adult.

Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
J7

Married

ADULT 1 (Respondent)
J1

Not married, but living with a partner

How are you related to this child?

Never Married

Biological or Adoptive Parent

Divorced

Step-parent

Separated

Grandparent

Widowed

Foster Parent
Other: Relative

J8

Very Good

What is your sex?

Good

Male

Fair

Female
J3

In general, how is your physical health?
Excellent

Other: Non-Relative
J2

What is your marital status?

Poor

What is your age?
Age in years

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J9

In general, how is your mental or emotional health?

J16 Where was Adult 2 born?

Excellent

In the United States ➔ SKIP to question J18

Very Good

Outside of the United States

Good

J17 When did Adult 2 come to live in the United States?

Year

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

J18 What is the highest grade or level of school Adult 2 has

Yes

completed? Mark (X) ONE box.

No

8th grade or less
9th-12th grade; No diploma

J11 Have you ever served on active duty in the

U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.

High School Graduate or GED Completed

Never served in the military ➔ SKIP to question J13

Completed a vocational, trade, or business school
program

Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question J13

Some College Credit, but no Degree

Now on active duty

Associate Degree (AA, AS)

On active duty in the past, but not now

Bachelor’s Degree (BA, BS, AB)

J12 Were you deployed at any time during this child’s life?

Master’s Degree (MA, MS, MSW, MBA)

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

No

J19 What is Adult 2’s marital status?

ADULT 2

Married

J13 How is Adult 2 related to this child?

Not married, but living with a partner

There is only one primary adult
caregiver for this child ➔ SKIP to question K1

Never Married

Biological or Adoptive Parent
Divorced
Step-parent
Separated
Grandparent
Widowed
Foster Parent
J20 In general, how is Adult 2’s physical health?

Other: Relative
Excellent
Other: Non-Relative
Very Good
J14 What is Adult 2’s sex?

Good

Male

Fair

Female

Poor

J15 What is Adult 2’s age?

Age in years

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26018028

K3

Very Good

Income in 2016
Mark (X) the "Yes" box for each type of income this child’s
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.

Good

a. Wages, salary, commissions, bonuses, or tips for
all jobs.

J21 In general, how is Adult 2’s mental or emotional health?

Excellent

Fair

Yes ➔

Poor

$

,

.00

TOTAL AMOUNT
in the last calendar year

No

J22 Was Adult 2 employed at least 50 out of the past

,

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

52 weeks?
Yes

Yes ➔

No

$

U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.

.00

Loss

TOTAL AMOUNT
in the last calendar year

No

J23 Has Adult 2 ever served on active duty in the

,

,

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

Never served in the military ➔ SKIP to question K1
Yes ➔
Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question K1

$

Yes ➔

J24 Was Adult 2 deployed at any time during this child’s life?

Yes

$

,

.00

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

K. Household Information

Yes ➔
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.

$

,

,

.00

TOTAL AMOUNT
in the last calendar year

No

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

Number of people
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.

,

TOTAL AMOUNT
in the last calendar year

No

No

K2

Loss

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

On active duty in the past, but not now

K1

.00

TOTAL AMOUNT
in the last calendar year

No

Now on active duty

,

,

Yes ➔

$

Number of people

,

.00

TOTAL AMOUNT
in the last calendar year

No
K4

,

The following question is about your 2016 income.
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 businesses, farm, or rent, and any other money income
received.

$

,

.00

,

TOTAL AMOUNT
in the last calendar year

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Mailing Instructions
Thank you for your participation.
On behalf of the U.S. 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 health care 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 0607-0990,
U.S. Census Bureau, 4600 Silver Hill Road, Room 8H590, Washington, DC 20233. You may e-mail comments to
DEMO.Paperwork@census.gov; use "Paperwork Project 0607-0990" as the subject.

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