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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.
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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.
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
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.
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 you will need 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
A4
A. This Child’s Health
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)
A1 In general, how would you describe this child’s health
(the one named above)?
b. Eating or swallowing because of
a health condition
Excellent
c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea
Very good
Good
Fair
d. Repeated or chronic physical pain,
including headaches or other back
or body pain
Poor
e. Toothaches
f. Bleeding gums
A2 How would you describe the condition of this child’s
teeth?
Excellent
g. Decayed teeth or cavities
A5
Very 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
Good
Fair
b. Serious difficulty walking or climbing
stairs
Poor
c. Difficulty dressing or bathing
d. Deafness or problems with hearing
e. Blindness or problems with seeing,
even when wearing glasses
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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?
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, does this child CURRENTLY have the
condition?
No
Yes
No
If yes, is it:
If yes, is it:
Mild
Moderate
Severe
Mild
Moderate
Severe
A12 Cystic Fibrosis?
A7 Arthritis?
Yes
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, does this child CURRENTLY have the
condition?
No
Yes
If yes, is it:
No
If yes, is it:
Mild
Moderate
Mild
Severe
Moderate
Severe
A13 Diabetes?
A8 Asthma?
Yes
Yes
No
If yes, does this child CURRENTLY have the
condition?
Yes
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
Moderate
Severe
A14 Down Syndrome?
A9 Blood Disorders (such as Sickle Cell Disease,
Thalassemia, or Hemophilia)?
Yes
Yes
No
No
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
Yes
Yes
No
No
If yes, is it:
If yes, is it:
Mild
Mild
Moderate
Moderate
Severe
Severe
A15 Epilepsy or Seizure Disorder?
A10 Brain injury, concussion or head injury?
Yes
Yes
No
No
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
Yes
Yes
No
No
If yes, is it:
If yes, is it:
Mild
Mild
Moderate
Moderate
Severe
Severe
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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.
Behavioral or Conduct Problems?
A16 Heart Condition?
Yes
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
Yes
If yes, is it:
Moderate
Severe
A17 Frequent or severe headaches, including migraine?
Mild
No
Yes
No
Yes
If yes, is it:
No
If yes, is it:
Mild
Moderate
Severe
Mild
Moderate
Severe
A24 Developmental Delay?
A18 Tourette Syndrome?
Yes
No
Yes
No
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
No
Yes
No
If yes, is it:
If yes, is it:
Mild
Moderate
Mild
Severe
Moderate
Severe
A25 Intellectual Disability (formerly known as Mental
A19 Anxiety Problems?
Yes
Severe
If yes, does this child CURRENTLY have the
condition?
No
Yes
Moderate
A23 Substance Abuse Disorder?
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, is it:
Mild
Yes
No
If yes, does this child CURRENTLY have the
condition?
Retardation)?
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, does this child CURRENTLY have the
condition?
No
Yes
If yes, is it:
No
If yes, is it:
Mild
Moderate
Severe
A20 Depression?
Mild
Moderate
Severe
A26 Speech or other language disorder?
Yes
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
If yes, does this child CURRENTLY have the
condition?
No
Yes
If yes, is it:
Moderate
Severe
A21 Other genetic or inherited condition?
Mild
Yes
If yes, does this child CURRENTLY have the
condition?
Severe
No
If yes, does this child CURRENTLY have the
condition?
No
Yes
If yes, is it:
Mild
Moderate
A27 Learning Disability?
No
Yes
No
If yes, is it:
Mild
Yes
No
No
If yes, is it:
Moderate
Severe
Mild
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A28 Has a doctor or other health care provider EVER told
A32
you that this child has...
Any other mental health condition?
Yes
Yes
No
A33
If yes, specify: C
If yes, does this child CURRENTLY have the
condition?
Yes
No
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
No
A34 Has a doctor or other health care provider EVER told
No
you that this child has Attention Deficit Disorder or
Attention Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?
If yes, is it:
Mild
Is this child CURRENTLY taking medication for Autism,
ASD, Asperger’s Disorder or PDD?
Moderate
Severe
No ➔ SKIP to question A37
Yes
A29 Has a doctor or other health care provider EVER told
you that this child has Autism or Autism Spectrum
Disorder (ASD)? Include diagnoses of Asperger’s Disorder
or Pervasive Developmental Disorder (PDD).
If yes, does this child CURRENTLY have the
condition?
Yes
No ➔ SKIP to question A34
Yes
If yes, is it:
If yes, does this child CURRENTLY have the
condition?
Yes
No
Mild
Moderate
Yes
Severe
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
Don’t know
A31 What type of doctor or other health care provider was
No
A36 At any time DURING THE PAST 12 MONTHS, did this
care provider FIRST told you that he or she had Autism,
ASD, Asperger’s Disorder or PDD?
No
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?
the FIRST to tell you that this child had Autism, ASD,
Asperger’s Disorder or PDD? Mark (X) ONE box.
Primary Care Provider
This child does not have any
health conditions ➔ SKIP to question B1
Specialist
Never
School Psychologist/Counselor
Sometimes
Other Psychologist (Non-School)
Usually
Psychiatrist
Always
Other, specify: C
Severe
ADHD?
A30 How old was this child when a doctor or other health
Age in years
Moderate
A35 Is this child CURRENTLY taking medication for ADD or
If yes, is it:
Mild
No
A38 To what extent do this child’s health conditions or
problems affect his or her ability to do things?
Very little
Don’t know
Somewhat
A great deal
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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
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
No
No ➔ SKIP to question C4
B2
How much did he or she weigh when born?
Answer in pounds and ounces OR kilograms and grams.
Provide your best estimate.
pounds AND
C2
ounces
OR
kilograms AND
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
grams
1 visit
B3
What was the age of the mother when this child was
born?
Age in years
2 or more visits
C3
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
10-20 minutes
More than 20 minutes
C4
What is this child’s CURRENT height?
feet AND
inches
OR
meters AND
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
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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 first?
Mark (X) ONE box.
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 (X) 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
Fluoride treatment
or she is sick?
Sealant (plastic coatings on back teeth)
Yes
Don’t know
No
C11 DURING THE PAST 2 YEARS, has this child had his or
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.
her vision tested with pictures, shapes, or letters?
Yes
No ➔ SKIP to question C13
Yes
No, but this child needed to see a mental health
professional
C12 If yes, what kind of place or places did this child have
his or her vision tested? Mark (X) ALL that apply.
Eye doctor or eye specialist (ophthalmologist,
optometrist) office
Pediatrician or other general doctor’s office
No, this child did not need to see a
mental health professional ➔ SKIP to question C18
C17 How difficult was it to get the mental health treatment
or counseling that this child needed?
Clinic or health center
Very difficult
School
Other, specify:
Somewhat difficult
C
Not difficult
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C18 DURING THE PAST 12 MONTHS, has this child taken
C24 Did any of the following reasons contribute to this child
not receiving needed health services? Mark (X) Yes or No
for each item.
any medication because of difficulties with his or her
emotions, concentration, or behavior?
Yes
Yes
a. This child was not eligible for the
services
No
b. The services this child needed were
not available in your area
C19 DURING THE PAST 12 MONTHS, did this child see a
No
c. There were problems getting an
appointment when this child needed
one
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 C21
C25
C20 How difficult was it to get the specialist care that this
DURING THE PAST 12 MONTHS, how often were you
frustrated in your efforts to get services for this child?
child needed?
Never
Very difficult
Sometimes
Somewhat difficult
Usually
Not difficult
Always
C21 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.
C26
DURING THE PAST 12 MONTHS, how many times did
this child visit a hospital emergency room?
None
Yes
1 time
No
2 or more times
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.
C27 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).
Yes
Yes
No ➔ SKIP to question C25
No ➔ SKIP to question C30
C23 If yes, which types of care were not received?
C28 If yes, how old was this child at the time of the FIRST
plan?
Mark (X) ALL that apply.
Medical Care
Years AND
Months
Dental Care
C29 Is this child CURRENTLY receiving services under one
Vision Care
of these plans?
Hearing Care
Yes
Mental Health Services
No
Other, specify: C
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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
D1
No ➔ SKIP to question D1
C31 If yes, how old was this child when he or she began
receiving these special services?
Years AND
Months
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
C32 Is this child CURRENTLY receiving these special
Yes, more than one person
services?
No
Yes
No
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
D3
If yes, how difficult was it to get referrals?
Very difficult
Somewhat difficult
Not difficult
D4
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:
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?
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D5 DURING THE PAST 12 MONTHS, did this child need
D10 DURING THE PAST 12 MONTHS, how satisfied were
any decisions to be made regarding his or her health
care, such as whether to get prescriptions, referrals,
or procedures?
you with the communication among this child’s doctors
and other health care providers?
Very satisfied
Yes
Somewhat satisfied
No ➔ SKIP to question D7
Somewhat dissatisfied
D6 If yes, DURING THE PAST 12 MONTHS, how often did
this child’s doctors or other health care providers:
Always
Very dissatisfied
Usually Sometimes Never
a. Discuss with you
the range of options
to consider for his
or her health care or
treatment?
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
b. Make it easy for you
to raise concerns or
disagree with
recommendations
for this child’s health
care?
c. Work with you to
decide together
which health care
and treatment
choices would be
best for this child?
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
Somewhat satisfied
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?
Somewhat dissatisfied
Very dissatisfied
Yes
No
Did not see more than one health care provider
in PAST 12 MONTHS
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
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E. This Child’s Health
Insurance Coverage
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
E1
DURING THE PAST 12 MONTHS, was this child EVER
covered by ANY kind of health insurance or health
coverage plan?
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
Yes, this child was covered
all 12 months ➔ SKIP to question E4
Yes, but this child had a gap in coverage
No
E2
No
a. Insurance through a current or
former employer or union
d. TRICARE or other military
health care
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
e. Indian Health Service
f. Other, specify: C
No
a. Change in employer or employment
status
b. Cancellation due to overdue
premiums
E5
c. Dropped coverage because it was
unaffordable
Always
d. Dropped coverage because benefits
were inadequate
Usually
e. Dropped coverage because choice
of health care providers was
inadequate
Sometimes
Never
f. Problems with application or
renewal process
g. Other, specify: C
How often does this child’s health insurance offer
benefits or cover services that meet this child’s needs?
E6
How often does this child’s health insurance allow him
or her to see the health care providers he or she needs?
Always
E3
Usually
Is this child CURRENTLY covered by ANY kind of
health insurance or health coverage plan?
Sometimes
Yes
Never
No ➔ SKIP to question F1
E7
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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F. Providing for This
Child’s Health
F1
F5
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.
This child does not need health care provided
on a weekly basis
No at home care is provided by me or other family
members
Less than 1 hour per week
$0 (No medical or health-related
expenses) ➔ SKIP to question F4
1-4 hours per week
$1-$249
5-10 hours per week
$250-$499
11 or more hours per week
F6
$500-$999
$1,000-$5,000
No health or medical care is arranged or coordinated
by me or other family members
How often are these costs reasonable?
Always
Less than 1 hour per week
Usually
1-4 hours per week
Sometimes
5-10 hours per week
Never
F3
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
More than $5,000
F2
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.
11 or more hours per week
DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?
G. This Child’s Schooling
and Activities
Yes
G1
No
F4
DURING THE PAST 12 MONTHS, have you or other
family members:
Yes
DURING THE PAST 12 MONTHS, about how many days
did this child miss school because of illness or injury?
Include days missed from any formal home schooling.
No missed school days
No
1-3 days
a. Stopped working because of this
child’s health or health conditions?
4-6 days
b. Cut down on the hours you work
because of this child’s health or
health conditions?
7-10 days
11 or more days
c. Avoided changing jobs because of
concerns about maintaining health
insurance for this child?
This child was not enrolled in school
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?
No times
1 time
2 or more times
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H. About You and This
Child
G3 SINCE STARTING KINDERGARTEN, has this child
repeated any grades?
Yes
H1
Was this child born in the United States?
No
Yes ➔ SKIP to question H3
G4 DURING THE PAST 12 MONTHS, did this child
No
participate in:
Yes
No
a. A sports team or did he or she
take sports lessons after school
or on weekends?
H2
b. Any clubs or organizations after
school or on weekends?
c. Any other organized activities or
lessons, such as music, dance,
language, or other arts?
Years AND
H3
d. Any type of community service or
volunteer work at school, place of
worship, 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?
Months
How many times has this child moved to a new address
since he or she was born?
Number of times
H4
How often does this child go to bed at about the same
time on weeknights?
Always
G5 DURING THE PAST 12 MONTHS, how often did you
attend events or activities that this child participated in?
Usually
Always
Sometimes
Usually
Rarely
Sometimes
Never
Rarely
H5
DURING THE PAST WEEK, how many hours of sleep
did this child get on an average weeknight?
Never
Less than 6 hours
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?
6 hours
7 hours
0 days
8 hours
1-3 days
9 hours
4-6 days
10 hours
Every day
11 or more hours
G7 Compared to other children his or her age, how much
difficulty does this child have making or keeping
friends?
No difficulty
A little difficulty
A lot of difficulty
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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?
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
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?
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
H8
2 hours
a. Spouse?
3 hours
b. Other family member or close friend?
4 or more hours
c. Health care provider?
How well can you and this child share ideas or talk
about things that really matter?
d. Place of worship or religious leader?
e. Support or advocacy group related
to specific health condition?
Very well
f. Peer support group?
Somewhat well
H9
Not very well
g. Counselor or other mental health
professional?
Not well at all
h. Other person, specify:
C
How well do you think you are handling the day-to-day
demands of raising children?
Very well
Somewhat well
Not very well
Not at all
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26028068
I. About Your Family and
Household
I1
I6
All of
the time
DURING THE PAST WEEK, on how many days did all the
family members who live in the household eat a meal
together?
Some of
the time
None of
the time
b. Work together to
solve our problems
1-3 days
c. Know we have
strengths to draw on
4-6 days
d. Stay hopeful even
in difficult times
Every day
Most of
the time
a. Talk together
about what to do
0 days
I2
When your family faces problems, how often are you
likely to do each of the following?
I7
Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?
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?
Never
Yes
Rarely
No ➔ SKIP to question I4
I3
Somewhat often
If yes, does anyone smoke inside your home?
Yes
Very often
I8
No
I4
Which of these statements best describes your
household’s ability to afford the food you need DURING
THE PAST 12 MONTHS?
We could always afford to eat good nutritious meals.
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.
We could always afford enough to eat but not always
the kinds of food we should eat.
More than once a week
Sometimes we could not afford enough to eat.
Once a week
Often we could not afford enough to eat.
Once a month
I9
At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive:
Once every 2-5 months
I5
Yes
Once every 6 months
a. Cash assistance from a government
welfare program?
Once during the past 12 months
b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?
Never
c. Benefits from the Woman, Infants,
and Children (WIC) Program?
Don’t know
d. Free or reduced-cost breakfasts or
lunches at school?
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?
Yes
No
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No
26028050
I10 In your neighborhood, is/are there:
Yes
No
I13 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.
a. Sidewalks or walking paths?
b. A park or playground?
To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated
c. A recreation center, community
center, or boys’ and girls’ club?
d. A library or bookmobile?
b. Parent or guardian died
e. Litter or garbage on the street
or sidewalk?
c. Parent or guardian served time in jail
f. Poorly kept or rundown housing?
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home
g. Vandalism such as broken
windows or graffiti?
e. Was a victim of violence or
witnessed violence in his or her
neighborhood
I11 To what extent do you agree with these statements
about your neighborhood or community?
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree
f. Lived with anyone who was mentally
ill, suicidal, or severely depressed
a. People in this
neighborhood
help each other
out
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
b. We watch out for
each other’s
children in this
neighborhood
c. This child is
safe in our
neighborhood
d. When we
encounter
difficulties, we
know where to
go for help in
our community
e. This child is safe
at school
I12 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?
Yes
No
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26028043
J. About You
J6
➜ Complete the questions for up to two adults in the
8th grade or less
household who are this child’s primary caregivers.
If there is just one adult primary caregiver, provide
answers for that adult.
9th-12th grade; No diploma
High School Graduate or GED Completed
ADULT 1 (Respondent)
J1
J3
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)
Other: Relative
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
Other: Non-Relative
J2
What is the highest grade or level of school you have
completed? Mark (X) ONE box.
J7
What is your sex?
What is your marital status?
Married
Male
Not married, but living with a partner
Female
Never Married
What is your age?
Divorced
Separated
Age in years
Widowed
J4
Where were you born?
In the United States ➔ SKIP to question J6
J8
In general, how is your physical health?
Excellent
Outside of the United States
Very Good
J5
When did you come to live in the United States?
Good
Year
Fair
Poor
J9
In general, how is your mental or emotional health?
Excellent
Very Good
Good
Fair
Poor
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26028035
J10 Were you employed at least 50 out of the past
J18 What is the highest grade or level of school Adult 2 has
52 weeks?
completed? Mark (X) ONE box.
Yes
8th grade or less
No
9th-12th grade; No diploma
J11 Have you ever served on active duty in the
High School Graduate or GED Completed
U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
Completed a vocational, trade, or business school
program
Never served in the military ➔ SKIP to question J13
Some College Credit, but no Degree
Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question J13
Associate Degree (AA, AS)
Now on active duty
Bachelor’s Degree (BA, BS, AB)
On active duty in the past, but not now
Master’s Degree (MA, MS, MSW, MBA)
J12 Were you deployed at any time during this child’s life?
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
Yes
J19 What is Adult 2’s marital status?
No
Married
ADULT 2
Not married, but living with a partner
J13 How is Adult 2 related to this child?
Never Married
There is only one primary adult
caregiver for this child ➔ SKIP to question K1
Divorced
Biological or Adoptive Parent
Separated
Step-parent
Widowed
Grandparent
J20 In general, how is Adult 2’s physical health?
Foster Parent
Excellent
Other: Relative
Very Good
Other: Non-Relative
Good
J14 What is Adult 2’s sex?
Fair
Male
Poor
Female
J21 In general, how is Adult 2’s mental or emotional health?
J15 What is Adult 2’s age?
Excellent
Age in years
Very Good
J16 Where was Adult 2 born?
Good
In the United States ➔ SKIP to question J18
Fair
Outside of the United States
Poor
J17 When did Adult 2 come to live in the United States?
Year
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26028027
J22 Was Adult 2 employed at least 50 out of the past
K3
52 weeks?
Yes
No
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.
a. Wages, salary, commissions, bonuses, or tips for
all jobs.
J23 Has Adult 2 ever served on active duty in the
Yes ➔
U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
$
.00
b. Self-employment income from own nonfarm
businesses or farm business, including
proprietorships and partnerships.
Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question K1
Now on active duty
Yes ➔
On active duty in the past, but not now
$
,
,
.00
Loss
TOTAL AMOUNT
in the last calendar year
No
J24 Was Adult 2 deployed at any time during this child’s life?
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Yes
Yes ➔
No
$
,
,
.00
Loss
TOTAL AMOUNT
in the last calendar year
No
K. Household Information
d. Social security or railroad retirement; retirement,
survivor, or disability pensions.
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.
Yes ➔
$
,
,
.00
TOTAL AMOUNT
in the last calendar year
No
e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office.
Number of people
K2
,
TOTAL AMOUNT
in the last calendar year
No
Never served in the military ➔ SKIP to question K1
K1
,
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.
Yes ➔
$
,
.00
TOTAL AMOUNT
in the last calendar year
No
Number of people
,
f. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support, or alimony.
Yes ➔
$
,
.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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26028019
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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| File Type | application/pdf |
| File Modified | 2017-06-12 |
| File Created | 2017-06-12 |