2 Questionnaire V2

Generic Clearance for Questionnaire Pretesting Research

Enclosure 6T1 nscht1_18_020818

2018 NSCH Usability Evaluation

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
(02/08/2018) Draft 7

§;"s!¤

26018192

Start Here

A3

How often...
Always

Usually Sometimes

Never

a. Is this child
affectionate and
tender with you?

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.

b. Does this child
bounce back
quickly when
things do not go
his or her way?

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

c. Does this child
show 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.

d. Does this child
smile and laugh?

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.
A4

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

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)
b. Eating or swallowing because of
a health condition
c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea

A. This Child’s Health

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

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

(the one named above)?
Excellent

e. Using his or her hands

Very good

f. Coordination or moving around

Good

g. Toothaches

Fair

h. Bleeding gums

Poor

i.

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

A5

Decayed teeth or cavities

Does this child have any of the following?

teeth?
This child does not have any teeth

a. Deafness or problems with hearing

Excellent

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

Very good
Good
Fair
Poor

NSCH-T1

2

§;"r}¤

26018184

Has a doctor or other health care provider EVER told
you that this child has...
A6

Allergies (including food, drug, insect, or other)?
Yes

Has a doctor or other health care provider EVER told
you that this child has...
A12 Epilepsy or Seizure Disorder?

No

Yes

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

If yes, does this child CURRENTLY have the
condition?

No

Yes

No

If yes, is it:

If yes, is it:
Mild

Moderate

Severe

A7 Arthritis?

Mild

Moderate

Severe

A13 Heart Condition?

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

Severe

A8 Asthma?

Mild

Moderate

Severe

A14 Frequent or severe headaches, including migraine?

Yes

No

Yes

Yes

No

Yes

Mild

Moderate

Severe

Mild

Yes

No

Severe

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

Moderate

Mild

Severe

Cerebral Palsy?
Yes

Moderate

A15 Tourette Syndrome?

A9 Brain injury, concussion or head injury?

Yes

No

If yes, is it:

If yes, is it:

Yes

No

If yes, does this child CURRENTLY have the
condition?

If yes, does this child CURRENTLY have the
condition?

A10

No

Moderate

Severe

A16 Anxiety Problems?

No

Yes

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

No

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

No

No

If yes, is it:

If yes, is it:
Mild

Moderate

Mild

Severe

A11 Diabetes?

Moderate

Severe

A17 Depression?

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

No

Moderate

Mild

Severe

NSCH-T1

3

Moderate

Severe

§;"ru¤

26018176

Has a doctor or other health care provider EVER told
you that this child has...
A18 Down Syndrome?

Yes

Has a doctor or other health care provider EVER told
you that this child has...
A21 Other genetic or inherited condition?

Yes

No

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

No

If yes, specify: C

No
Is it:

If yes, is it:
Mild

Moderate

Mild

Severe

Thalassemia, or Hemophilia)?

Yes

No

If yes, is it:
Mild

Moderate

No

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

Severe

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Yes

Severe

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.

A19 Blood Disorders (such as Sickle Cell Disease,

Yes

Moderate

A22 Behavioral or Conduct Problems?

Yes

No

No

If yes, does this child CURRENTLY have the
condition?

If yes, was this child diagnosed with:
Sickle Cell Disease?

Yes

No

Thalassemia?

Yes

No

Hemophilia?

Yes

No

Other Blood Disorders?

Yes

No

Yes

No

If yes, is it:
Mild

Yes

Yes

If yes, is it:

No

If yes, is it:
Moderate

Severe

If yes, was this condition identified through a
blood test done shortly after birth? These tests
are sometimes called newborn screening.
Yes

No

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

Mild

Severe

A23 Developmental Delay?

A20 Cystic Fibrosis?

Yes

Moderate

Mild

Moderate

Severe

A24 Intellectual Disability (formerly known as Mental

Retardation)?

No

Yes

No

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

No

If yes, is it:
Mild

NSCH-T1

4

Moderate

Severe

§;"rm¤

26018168

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

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

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

A25 Speech or other language disorder?

Yes

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

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.

No

Primary Care Provider

If yes, is it:
Mild

Moderate

Specialist

Severe

School Psychologist/Counselor

A26 Learning Disability?

Yes

Don’t know

Age in years

No

Other Psychologist (Non-School)

No

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

Psychiatrist
Other, specify:

No

C

If yes, is it:
Mild

Moderate

Severe

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

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

ASD, Asperger’s Disorder or PDD?

A27 Any other mental health condition?

Yes

Yes

No

No

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

If yes, specify: C

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?

If yes, does this child CURRENTLY have the
condition?

Yes
Yes

A33 Has a doctor or other health care provider EVER told

If yes, is it:
Mild

Moderate

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

Severe

A28 Has a doctor or other health care provider EVER told

If yes, does this child CURRENTLY have the
condition?

No ➔ SKIP to question A33

Yes

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

No

If yes, is it:
Mild

No

If yes, is it:
Mild

No ➔ SKIP to question A36 on
page 6

Yes

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

No

No

Moderate

Severe

A34 Is this child CURRENTLY taking medication for ADD or

Moderate

ADHD?

Severe

Yes

NSCH-T1

5

No

§;"re¤

26018150

A35 At any time DURING THE PAST 12 MONTHS, did this

B5

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

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

No

days
OR

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?

weeks

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

OR

Never

months

Sometimes

OR

Usually

Check this box if child is still breastfeeding

Always

B6

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

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

problems affect his or her ability to do things?

Check this box if child has never been fed formula
OR

Very little

At birth

Somewhat

OR

A great deal

days
OR

B. This Child as an Infant
B1

weeks

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

OR

Yes
months

No
B2

How much did he or she weigh when born? Answer in
pounds and ounces OR kilograms and grams. Your best
estimate is fine.
pounds AND

B7

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

ounces

OR

At birth
kilograms AND
B3

grams

OR

What was the age of the mother when this child was
born? Your best estimate is fine.

days
OR

Age in years
B4

weeks

Was this child EVER breastfed or fed breast milk?
OR

Yes
No ➔ SKIP to question B6

months

NSCH-T1

6

§;"rS¤

26018143

C. Health Care Services

C7

C1 DURING THE PAST 12 MONTHS, did this child see a

Yes

doctor, nurse, or other health care professional for
medical care (for example, preventive care, sick care,
hospitalizations)?

No
C8

Yes
No ➔ SKIP to question C4
C2

C3

Has a doctor or other health care provider ever told you
that this child is overweight?

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

Yes
If yes, DURING THE PAST 12 MONTHS, how many times
did this child visit a doctor, nurse, or other health care
No
professional to receive a PREVENTIVE check-up?
A preventive check-up is when this child was not sick or
C9 Answer the following question only if this child is at
injured, such as an annual or sports physical, or well-child
least 9 months old. Otherwise skip to question C10 .
visit.
DURING THE PAST 12 MONTHS, did a doctor or other
health care provider have you or another caregiver fill
0 visits
out a questionnaire about observations or concerns you
may have about this child’s development, communication,
1 visit
or social behaviors? Sometimes a child’s doctor or other
health care provider will ask a parent to do this at home or
2 or more visits
during a child’s visit.
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.

Yes

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

Less than 10 minutes

How this child talks or makes speech sounds?

10-20 minutes

How this child interacts with you and others?

More than 20 minutes
C4

If yes, and this child is 2-5 Years:
Did the questionnaire ask about your concerns
or observations about: Mark (X) ALL that apply.
Words and phrases this child uses and
understands?

What is this child’s CURRENT height?
Your best estimate is fine.
feet AND

No

inches

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

OR

C10 Is there a place you or another caregiver USUALLY

meters AND
C5

take this child when he or she is sick or you need
advice about his or her health?

centimeters

Yes

How much does this child CURRENTLY weigh?
Your best estimate is fine.
pounds AND

ounces

No ➔ SKIP to question C12 on page 8
C11 If yes, where does this child USUALLY go first?

Mark (X) ONE box.
OR
Doctor’s Office
kilograms AND
C6

grams

Hospital Emergency Room
Hospital Outpatient Department

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

Clinic or Health Center

Yes, it’s too low

Retail Store Clinic or “Minute Clinic”

No, I am not concerned

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

NSCH-T1

7

§;"rL¤

26018135

C12 Is there a place that this child USUALLY goes when

C18 If yes, DURING THE PAST 12 MONTHS, what

preventive dental service(s) did this child receive?
Mark (X) ALL that apply.

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

Check-up

No ➔ SKIP to question C14

Cleaning
Instruction on tooth brushing and oral health care

C13 If yes, is this the same place this child goes when he

or she is sick?
X-Rays
Yes
Fluoride treatment
No
Sealant (plastic coatings on back teeth)
C14 DURING THE PAST 12 MONTHS, has this child had his

or her vision tested, such as with pictures, shapes, or
letters?

Don’t know
C19 DURING THE PAST 12 MONTHS, has this child

Yes

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

No ➔ SKIP to question C16
C15 If yes, where was this child’s vision tested?

Yes

Mark (X) ALL that apply.
Eye doctor or eye specialist (ophthalmologist,
optometrist) office

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

Pediatrician or other general doctor’s office

No, this child did not need to see a
mental health professional ➔ SKIP to question C21

Clinic or health center

C20 How difficult was it to get the mental health treatment

or counseling that this child needed?
School
Very difficult
Other, specify:

C

Somewhat difficult
Not difficult

C16 DURING THE PAST 12 MONTHS, did this child see a

It was not possible to obtain care

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

C21 DURING THE PAST 12 MONTHS, has this child taken

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

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

Yes

No ➔ SKIP to question C19
C17 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?

No
C22 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.

No preventive visits in
the past 12 months ➔ SKIP to question C19

Yes
Yes, 1 visit
No, but this child needed to see a specialist
Yes, 2 or more visits
No, this child did not need to see
a specialist ➔ SKIP to question C24 on page 9

NSCH-T1

8

§;"rD¤

26018127

C23 How difficult was it to get the specialist care that this

C28 DURING THE PAST 12 MONTHS, how often were you

child needed?

frustrated in your efforts to get services for this child?

Very difficult

Never

Somewhat difficult

Sometimes

Not difficult

Usually

It was not possible to obtain care

Always

C24 DURING THE PAST 12 MONTHS, did this child use any

C29 DURING THE PAST 12 MONTHS, how many times did

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.

this child visit a hospital emergency room?
None
1 time

Yes

2 or more times

No

C30 DURING THE PAST 12 MONTHS, was this child

admitted to the hospital to stay for at least one night?

C25 DURING THE PAST 12 MONTHS, was there any time

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

Yes
No
C31 Has this child EVER had a special education or early

Yes

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

No ➔ SKIP to question C28
C26 If yes, which types of care were not received?

Yes

Mark (X) ALL that apply.

No ➔ SKIP to question C34

Medical Care
Dental Care

C32 If yes, how old was this child at the time of the FIRST

plan?
Vision Care
Years AND

Hearing Care

C33 Is this child CURRENTLY receiving services under one

Mental Health Services
Other, specify:

Months

of these plans?
Yes

C

No
C27 Did any of the following reasons contribute to this child C34 Has this child EVER received special services to meet

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

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

No

Yes

a. This child was not eligible for the
services
b. The services this child needed were
not available in your area

No ➔ SKIP to question D1 on page 10
C35 If yes, how old was this child when he or she began

receiving these special services?

c. There were problems getting an
appointment when this child needed
one
d. There were problems with getting
transportation or child care

Years AND

Months

C36 Is this child CURRENTLY receiving these special

services?

e. The clinic or doctor’s office wasn’t
open when this child needed care

Yes

f. There were issues related to cost

No

NSCH-T1

9

§;"r<¤

26018119

D. Experience with This
Child’s Health Care
Providers

D6

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

Usually Sometimes Never

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

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

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

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

Yes, one person
Yes, more than one person

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

No
D2 DURING THE PAST 12 MONTHS, did this child need a

referral to see any doctors or receive any services?
Yes
D7

No ➔ SKIP to question D4

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?

D3 How difficult was it to get referrals?

No
Very difficult
Yes
Somewhat difficult
Did not see more than one health care provider
in PAST 12 MONTHS

Not difficult
D8

It was not possible to get a referral
D4 Answer the following questions only if this child has had

a health care visit IN THE PAST 12 MONTHS. Otherwise
skip to Section E on page 11.

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

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

Usually Sometimes

No ➔ SKIP to question D10

Never

a. Spend enough time
with this child?

D9

b. Listen carefully to
you?

Usually

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

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?

Sometimes
Never
D10 DURING THE PAST 12 MONTHS, how satisfied were

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

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

Very satisfied

D5 DURING THE PAST 12 MONTHS, did this child need

Somewhat satisfied

any decisions to be made regarding his or her health
care, such as whether to get prescriptions, referrals,
or procedures?

Somewhat dissatisfied

Yes

Very dissatisfied

No ➔ SKIP to question D7
NSCH-T1

10

§;"r4¤

26018101

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

E3

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

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

Yes

No ➔ SKIP to question F1 on page 12

No ➔ SKIP to question E1
E4

Did not need health care
provider to communicate
with these providers ➔ SKIP to question E1

Is this child CURRENTLY 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

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?

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

Very satisfied
Somewhat satisfied
Somewhat dissatisfied

d. TRICARE or other military
health care

Very dissatisfied

e. Indian Health Service

E. This Child’s Health
Insurance Coverage
E1

E2

f. Other, specify: C

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

E5

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

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

Always

Yes, but this child had a gap in coverage

Usually

No

Sometimes

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

Never
E6

No

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

a. Change in employer or employment
status

Always

b. Cancellation due to overdue
premiums

Usually

c. Dropped coverage because it was
unaffordable

Sometimes

d. Dropped coverage because benefits
were inadequate

Never

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

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?

f. Problems with application or
renewal process

This child does not use mental or behavioral
health services

g. Other, specify: C

Always
Usually
Sometimes
Never

NSCH-T1

11

§;"r"¤

26018093

F. Providing for This
Child’s Health
F1

F5

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.
This child does not need health care provided
on a weekly basis

Including co-pays and amounts reimbursed 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.

Less than 1 hour per week
1-4 hours per week
5-10 hours per week

$0 (No medical or health-related
expenses) ➔ SKIP to question F4

11 or more hours per week
$1-$249
F6

$250-$499
$500-$999

F2

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?

$1,000-$5,000

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

More than $5,000

Less than 1 hour per week
1-4 hours per week

How often are these costs reasonable?
Always

5-10 hours per week

Usually

11 or more hours per week

Sometimes

G. This Child’s Learning

Never
F3

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

Answer the following question only if this child is at
least 1 year old. Otherwise skip to H1 on page 15.
G1

Yes

Yes

No

a. Say at least one word, such as "hi"
or "dog"?

No
F4

Is this child able to do the following...
Mark (X) Yes or No for each item.

b. Use 2 words together, such as
"car go"?

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

c. Use 3 words together in a sentence,
such as, "Mommy come now."?

No

a. Left a job or taken a leave of
absence because of this child’s
health or health conditions?

d. Ask questions like "who," "what,"
"when," "where"?

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

e. Ask questions like "why" and "how"?
f. Tell a story with a beginning,
middle, and end?

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

g. Understand the meaning of the
word "no"?
h. Follow a verbal direction without
hand gestures, such as "Wash your
hands."?
i.

Point to things in a book when
asked?
j. Follow 2-step directions, such as
"Get your shoes and put them in the
basket."?
k. Understand words such as "in,"
"on," and "under"?

NSCH-T1

12

§;"q

¤

26018085

G2 Is this child 3 years old or older?

G8 Can this child rhyme words?

Yes

Yes

No ➔ SKIP to question H1 on page 15

No

G3 Has this child started school? Include any formal

G9 How often can this child explain things he or she has seen

home schooling.

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

Yes, preschool

Always

Yes, kindergarten

Most of the time

Yes, first grade

About half the time

No

Sometimes
Never

G4 Are you concerned about how this child is learning to

do things for him or herself?
G10 How often can this child write his or her first name, even

Yes, somewhat concerned

if some of the letters aren’t quite right or are backwards?

Yes, very concerned

Always

No

Most of the time
About half the time

G5 How confident are you that this child is ready to be in

school?
Sometimes
Completely confident
Never
Mostly confident
G11 How high can this child count?

Somewhat confident
This child cannot count
Not at all confident
Up to five
G6 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?

Up to ten
Up to 20

Always

Up to 50

Most of the time

Up to 100 or more

About half the time
Sometimes

G12 How often can this child identify basic shapes such as

a triangle, circle, or square?

Never

Always

G7 About how many letters of the alphabet can this child

Most of the time

recognize?

About half the time

All of them

Sometimes

Most of them

Never

About half of them
Some of them
None of them

NSCH-T1

13

§;"qv¤

26018077

G13 Can this child identify the colors red, yellow, blue,

G19 How often does this child become angry or anxious

and green by name?

when going from one activity to another?

Yes, all of them

Always

Yes, some of them

Most of the time

No, none of them

About half the time

G14 How often is this child easily distracted?

Sometimes

Always
Most of the time

Never
G20 How often does this child show concern when others

are hurt or unhappy?

About half the time

Always
Sometimes
Most of the time
Never
About half the time
G15 How often does this child keep working at something

until he or she is finished?

Sometimes

Always
Most of the time

Never
G21 When excited or all wound up, how often can this child

calm down quickly?

About half the time

Always
Sometimes
Most of the time
Never
About half the time
G16 When this child is paying attention, how often can he

Sometimes

or she follow instructions to complete a simple task?
Always
Most of the time

Never
G22 How often does this child lose control of his or her

temper when things do not go his or her way?

About half the time

Always
Sometimes
Most of the time
Never
About half the time
G17 How does this child usually hold a pencil?

Sometimes

Uses fingers to hold the pencil

Never

Grips the pencil in his or her fist
This child cannot hold a pencil

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

difficulty does this child have making or keeping
friends?

G18 How often does this child play well with others?

A lot of difficulty

Always

A little difficulty

Most of the time

No difficulty

About half the time
Sometimes
Never
NSCH-T1

14

§;"qn¤

26018069

G24 Compared to other children his or her age, how often

H6

is this child able to sit still?

Answer the next question only if this child is LESS THAN
12 MONTHS OLD. Otherwise, SKIP to question H7 .
In which position do you most often lay this baby down
to sleep now? Mark (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 MOST WEEKDAYS, about how much time did this
child spend in front of a TV, computer, cellphone or
other electronic device watching programs, playing
games, accessing the internet or using social media?
Do not include time spent doing schoolwork.
Less than 1 hour

H1 Was this child born in the United States?

1 hour

Yes ➔ SKIP to question H3

2 hours

No

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

United States?
Years AND

4 or more hours
Months

H8

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

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

since he or she was born?

1-3 days
Number of times
4-6 days
H4 How often does this child go to bed at about the same

Every day

time on weeknights?
Always

H9

Usually

DURING THE PAST WEEK, how many days did you or
other family members tell stories or sing songs to this
child?

Sometimes

0 days

Rarely

1-3 days

Never

4-6 days
Every day

H5 DURING THE PAST WEEK, how many hours of sleep

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

H10 How well do you think you are handling the day-to-day

demands of raising children?

Less than 7 hours

Very well
7 hours
Somewhat well
8 hours
Not very well
9 hours
Not at all
10 hours
11 hours
12 or more hours

NSCH-T1

15

§;"qf¤

26018051

I. About Your Family and
Household

H11 DURING THE PAST MONTH, how often have you

felt...

Never

Rarely Sometimes Usually Always

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

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

c. Angry with
this child?

Every day

H12 DURING THE PAST 12 MONTHS, was there someone

I2

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

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

Yes

No ➔ SKIP to question I4

No ➔ SKIP to question H14
H13 If yes, did you receive emotional support from...
Yes

I3

If yes, does anyone smoke inside your home?
Yes

No

No

a. Spouse or domestic partner?
b. Other family member or close friend?

I4

c. Health care provider?

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.

d. Place of worship or religious leader?

More than once a week

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

Once a week

f. Peer support group?

Once a month

g. Counselor or other mental health
professional?

Once every 2-5 months

h. Other person, specify:

Once every 6 months
C

Once during the past 12 months
Never
H14 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.

Don’t know
I5

Yes

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

No

H15 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?
Yes
No

NSCH-T1

16

§;"qT¤

26018044

I6

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

I10 In your neighborhood, is/are there...

Yes

None of
the time

No

a. Sidewalks or walking paths?

a. Talk together
about what to do

b. A park or playground?

b. Work together to
solve our problems

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

c. Know we have
strengths to draw on

d. A library or bookmobile?

d. Stay hopeful
even in difficult
times

e. Litter or garbage on the street
or sidewalk?
f. Poorly kept or rundown housing?

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?
Never

g. Vandalism such as broken
windows or graffiti?
I11 To what extent do you agree with these statements

about your neighborhood or community?
Rarely

Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

Somewhat often

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

Very often
I8

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.

c. This child is
safe in our
neighborhood

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

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

Sometimes we could not afford enough to eat.
Often we could not afford enough to eat.
I9

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

I12 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.

No

a. Cash assistance from a government
welfare program?

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

b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?
c. Free or reduced-cost breakfasts or
lunches at school?

b. Parent or guardian died

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

c. Parent or guardian served time in jail
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home
e. Was a victim of violence or
witnessed violence in his or her
neighborhood
f. Lived with anyone who was mentally
ill, suicidal, or severely depressed
g. Lived with anyone who had a problem
with alcohol or drugs
h. Treated or judged unfairly because
of his or her race or ethnic group
NSCH-T1

17

§;"qM¤

26018036

J. Child’s Caregivers

J7

Married

➜ 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.
J1

Not married, but living with a partner
Never Married

How are you related to this child?

Divorced

Biological or Adoptive Parent

Separated

Step-parent
Grandparent

Widowed
J8

Foster Parent

In general, how is your physical health?
Excellent

Other: Relative

Very Good

Other: Non-Relative
J2

What is your marital status?

Good

What is your sex?

Fair

Male

Poor

Female
J9
J3

What is your age?

Excellent

Age in years
J4

J5

In general, how is your mental or emotional health?

Very Good

Where were you born?

Good

In the United States ➔ SKIP to question J6

Fair

Outside of the United States

Poor

When did you come to live in the United States?

J10

Year

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

J6

What is the highest grade or level of school you have
completed? Mark (X) ONE box.

J11

8th grade or less

Have you ever served on active duty in the
U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.

9th-12th grade; No diploma

Never served in the
military ➔ SKIP to question J13 on page 19

High School Graduate or GED Completed

Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question J13 on page 19

Completed a vocational, trade, or business school
program

Now on active duty
On active duty in the past, but not now

Some College Credit, but no Degree
Associate Degree (AA, AS)

J12

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

Bachelor’s Degree (BA, BS, AB)

No

Master’s Degree (MA, MS, MSW, MBA)
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
NSCH-T1

18

§;"qE¤

26018028

Questions J13 - J24 ask about another adult primary
caregiver who may be in the household in addition to
yourself.

J19 What is this primary caregiver’s marital status?

Married

J13 How is this adult primary caregiver in the household

Not married, but living with a partner

related to this child?
There is only one primary adult caregiver for
this child ➔ SKIP to question K1 on page 20

Never Married

Biological or Adoptive Parent

Divorced

Step-parent

Separated

Grandparent

Widowed

Foster Parent

J20 In general, how is this primary caregiver’s physical

health?

Other: Relative

Excellent

Other: Non-Relative

Very Good

J14 What is this primary caregiver’s sex?

Good

Male

Fair

Female

Poor

J15 What is this primary caregiver’s age?

J21 In general, how is this primary caregiver’s mental or

emotional health?
Age in years

Excellent

J16 Where was this primary caregiver born?

Very Good

In the United States ➔ SKIP to question J18

Good

Outside of the United States

Fair

J17 When did this primary caregiver come to live in the

United States?
Year

Poor
J22 Was this primary caregiver employed at least 50 out of

the past 52 weeks?
Yes
J18 What is the highest grade or level of school this primary

caregiver has completed? Mark (X) ONE box.
8th grade or less

No
J23 Has this primary caregiver ever served on active duty in

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

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

Never served in the
military ➔ SKIP to question K1 on page 20

Completed a vocational, trade, or business school
program

Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question K1 on page 20

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)

J24 Was this primary caregiver 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

NSCH-T1

19

§;"q=¤

26018010

K. Household Information
K1

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 ➔

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 ➔

Number of people

$

,

$

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

$

,

.00

,

No

$

,

$

.00

,

.00

,

,

.00

TOTAL AMOUNT
in the last calendar year

The following question is about your 2017 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

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

,

Loss

TOTAL AMOUNT
in the last calendar year

No

$

No
K4

.00

,

,

TOTAL AMOUNT
in the last calendar year

Yes ➔

TOTAL AMOUNT
in the last calendar year

No

.00

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

Income in 2017
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.
Yes ➔

,

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

No

K3

,

TOTAL AMOUNT
in the last calendar year

No

Number of people
K2

$

Loss

TOTAL AMOUNT
in the last calendar year

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.

NSCH-T1

20

§;"q+¤


File Typeapplication/pdf
File Modified2018-02-08
File Created2018-02-07

© 2024 OMB.report | Privacy Policy