3 English Topical Questionnaire 2

Generic Clearance for Questionnaire Pretesting Research

NSCH T2_Cognitive Interviewing Version

NSCH Questionnaire Cognitive Testing

OMB: 0607-0725

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26028209
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-T2
(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.

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

NSCH-T2

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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

NSCH-T2

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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

NSCH-T2

4

Moderate

Severe

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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

NSCH-T2

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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

NSCH-T2

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26028142

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

NSCH-T2

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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

NSCH-T2

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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?

NSCH-T2

9

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Never

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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

NSCH-T2

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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

NSCH-T2

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26028092

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

NSCH-T2

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26028084

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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26028076

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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No

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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