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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 often does this child...
Always
Usually Sometimes
Never
a. Show interest and
curiosity in learning
new things?
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. Work to finish tasks
he or she starts?
We now have some follow-up questions to ask about:
c. Stay calm and in
control when faced
with a challenge?
d. Care about doing
well in school?
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.
e. Do 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.
The survey should be completed by an adult who is
familiar with this child’s health and health care.
f. Argue too much?
A4
Your participation is important. Thank you.
DURING THE PAST 12 MONTHS, how often was this
child bullied, picked on, or excluded by other children?
If the frequency changed throughout the year, report the
highest frequency.
Never (in the past 12 months)
1-2 times (in the past 12 months)
1-2 times per month
A. This Child’s Health
1-2 times per week
Almost every day
A1 In general, how would you describe this child’s health
(the one named above)?
Excellent
A5
Very good
Good
DURING THE PAST 12 MONTHS, how often did this
child bully others, pick on them, or exclude them?
If the frequency changed throughout the year, report the
highest frequency.
Never (in the past 12 months)
Fair
1-2 times (in the past 12 months)
Poor
1-2 times per month
A2 How would you describe the condition of this child’s
1-2 times per week
teeth?
Almost every day
Excellent
Very good
Good
Fair
Poor
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A6 DURING THE PAST 12 MONTHS, has this child had
FREQUENT or CHRONIC difficulty with any of the
following?
Yes
Has a doctor or other health care provider EVER told
you that this child has...
No
A10 Asthma?
a. Breathing or other respiratory
problems (such as wheezing or
shortness of breath)
Yes
No
If yes, does this child CURRENTLY have the
condition?
b. Eating or swallowing because of
a health condition
Yes
c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea
No
If yes, is it:
Mild
d. Repeated or chronic physical pain,
including headaches or other back
or body pain
Moderate
Severe
A11 Brain injury, concussion or head injury?
Yes
No
If yes, does this child CURRENTLY have the
condition?
e. Toothaches
f. Bleeding gums
Yes
g. Decayed teeth or cavities
If yes, is it:
No
Mild
A7 Does this child have any of the following?
Yes
No
Moderate
Severe
A12 Cerebral Palsy?
a. Serious difficulty concentrating,
remembering, or making decisions
because of a physical, mental, or
emotional condition
Yes
No
If yes, does this child CURRENTLY have the
condition?
b. Serious difficulty walking or climbing
stairs
Yes
No
If yes, is it:
c. Difficulty dressing or bathing
Mild
d. Difficulty doing errands alone, such
as visiting a doctor’s office or shopping,
because of a physical, mental, or
emotional condition
Yes
No
If yes, does this child CURRENTLY have the
condition?
f. Blindness or problems with seeing,
even when wearing glasses
Yes
A8 Allergies (including food, drug, insect, or other)?
No
If yes, is it:
Has a doctor or other health care provider EVER told
you that this child has...
Mild
Moderate
Severe
A14 Epilepsy or Seizure Disorder?
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
Severe
A13 Diabetes?
e. Deafness or problems with hearing
Yes
Moderate
No
If yes, does this child CURRENTLY have the
condition?
No
Yes
If yes, is it:
No
If yes, is it:
Mild
Moderate
Severe
A9 Arthritis?
Mild
Moderate
Severe
A15 Heart Condition?
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:
Mild
No
No
If yes, is it:
Moderate
Severe
Mild
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Moderate
Severe
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Has a doctor or other health care provider EVER told
you that this child has...
A16 Frequent or severe headaches, including migraine?
Has a doctor or other health care provider EVER told
you that this child has...
A21 Blood Disorders (such as Sickle Cell Disease,
Thalassemia, or Hemophilia)?
Yes
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
If yes, is it:
No
Mild
If yes, is it:
Mild
Moderate
Severe
Yes
Yes
Severe
No
If yes, was this child diagnosed with:
No
If yes, does this child CURRENTLY have the
condition?
Sickle Cell Disease?
Yes
No
Thalassemia?
Yes
No
Hemophilia?
Yes
No
Other Blood
Disorders?
Yes
No
No
If yes, is it:
Mild
Moderate
Severe
A22 Cystic Fibrosis?
A18 Anxiety Problems?
Yes
Yes
No
Yes
Mild
No
Moderate
Severe
If yes, was this condition identified through a
blood test done shortly after birth? These tests
are sometimes called newborn screening.
If yes, is it:
Mild
No
If yes, is it:
If yes, does this child CURRENTLY have the
condition?
Moderate
Severe
A19 Depression?
Yes
No
A23 Other genetic or inherited condition?
Yes
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, specify: C
No
If yes, is it:
Is it:
Mild
A20
Moderate
Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
A17 Tourette Syndrome?
Yes
No
Moderate
Severe
Mild
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
A24 Substance Use Disorder?
No
If yes, is it:
Mild
Severe
Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Down Syndrome?
Yes
Moderate
Yes
Moderate
No
If yes, does this child CURRENTLY have the
disorder?
Severe
Yes
No
If yes, is it:
Mild
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Severe
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Has a doctor, other health care provider, or educator
EVER told you that this child has...
Examples of educators are teachers and school nurses.
A25 Behavioral or Conduct Problems?
Yes
Has a doctor or other health care provider EVER told
you that this child has...
A30
Yes
No
No
If yes, specify: C
If yes, does this child CURRENTLY have the
condition?
Yes
Any other mental health condition?
No
If yes, does this child CURRENTLY have the
condition?
If yes, is it:
Mild
Moderate
Severe
Yes
A26 Developmental Delay?
Yes
If yes, is it:
No
Mild
If yes, does this child CURRENTLY have the
condition?
Yes
No
A31
No
Moderate
Severe
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, is it:
Mild
Moderate
No ➔ SKIP to question A36 on page 6
Yes
Severe
If yes, does this child CURRENTLY have the
condition?
A27 Intellectual Disability (formerly known as Mental
Retardation)?
Yes
Yes
No
If yes, is it:
If yes, does this child CURRENTLY have the
disability?
Yes
No
Mild
A32
No
If yes, is it:
Mild
Moderate
Moderate
Severe
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?
Severe
Don’t know
Age in years
A28 Speech or other language disorder?
Yes
A33 What type of doctor or other health care provider was
No
the FIRST to tell you that this child had Autism, ASD,
Asperger’s Disorder or PDD? Mark (X) ONE box.
If yes, does this child CURRENTLY have the
condition?
Yes
Primary Care Provider
No
Specialist
If yes, is it:
Mild
Moderate
School Psychologist/Counselor
Severe
Other Psychologist (Non-School)
A29 Learning Disability?
Yes
Psychiatrist
No
If yes, does this child CURRENTLY have the
disability?
Yes
Other, specify: C
No
If yes, is it:
Mild
Don’t know
Moderate
Severe
A34 Is this child CURRENTLY taking medication for Autism,
ASD, Asperger’s Disorder or PDD?
Yes
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B. This Child as an Infant
A35 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
B1
No
Yes
No
A36 Has a doctor or other health care provider EVER told
you that this child has Attention Deficit Disorder or
Attention Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?
B2
No ➔ SKIP to question A39
Yes
Was this child born more than 3 weeks before his or
her due date?
How much did he or she weigh when born? Answer in
pounds and ounces OR kilograms and grams. Your best
estimate is fine.
If yes, does this child CURRENTLY have the
condition?
Yes
pounds AND
ounces
OR
No
If yes, is it:
kilograms AND
Mild
Moderate
A37 Is this child CURRENTLY taking medication for ADD or
B3
ADHD?
Yes
grams
Severe
What was the age of the mother when this child was
born? Your best estimate is fine.
No
Age in years
A38 At any time DURING THE PAST 12 MONTHS, did this
child receive behavioral treatment for ADD or ADHD,
such as training or an intervention that you or this
child received to help with his or her behavior?
C. Health Care Services
C1
Yes
No
A39 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?
Yes
This child does not have any
health conditions ➔ SKIP to question B1
Never
No ➔ SKIP to question C5 on page 7
C2
Sometimes
Usually
Always
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
A40 To what extent do this child’s health conditions or
1 visit
problems affect his or her ability to do things?
2 or more visits
Very little
Somewhat
DURING THE PAST 12 MONTHS, did this child see a
doctor, nurse, or other health care professional for
medical care (for example, preventive care, sick care,
hospitalizations)?
C3
A great deal
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
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C4
At his or her LAST MEDICAL CARE VISIT, did this
child have a chance to speak with a doctor or other
health care provider privately, without you or another
caregiver in the room?
C10 If yes, where does this child USUALLY go first?
Mark (X) ONE box.
Doctor’s Office
Yes
Hospital Emergency Room
No
Hospital Outpatient Department
Clinic or Health Center
C5 What is this child’s CURRENT height?
Your best estimate is fine.
Retail Store Clinic or “Minute Clinic”
feet AND
inches
School (Nurse’s Office, Athletic Trainer’s Office)
OR
Some other place
meters AND
centimeters
C11 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?
C6 How much does this child CURRENTLY weigh?
Your best estimate is fine.
Yes
No ➔ SKIP to question C13
pounds
OR
C12 If yes, is this the same place this child goes when he
or she is sick?
kilograms
Yes
C7 Are you concerned about this child’s weight?
Yes, it’s too high
No
C13 DURING THE PAST 12 MONTHS, has this child had his
or her vision tested, such as with letters, pictures, or
shapes?
Yes, it’s too low
No, I am not concerned
Yes
No ➔ SKIP to question C15 on page 8
C8 Has a doctor or other health care provider ever told
you that this child is overweight?
C14 If yes, where was this child’s vision tested? Mark (X)
Yes
ALL that apply.
Eye doctor or eye specialist (ophthalmologist,
optometrist) office
No
Pediatrician or other general doctor’s office
C9 Is there a place you or another caregiver USUALLY
take this child when he or she is sick or you need
advice about his or her health?
Clinic or health center
Yes
School
No ➔ SKIP to question C11
Other, specify:
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C15 DURING THE PAST 12 MONTHS, did this child see a
C20 DURING THE PAST 12 MONTHS, has this child taken
any medication because of difficulties with his or her
emotions, concentration, or behavior?
dentist or other oral health care provider for any kind
of dental or oral health care?
Yes, saw a dentist
Yes
Yes, saw other oral health care provider
No
No ➔ SKIP to question C18
C21 DURING THE PAST 12 MONTHS, did this child see a
specialist other than a mental health professional?
Specialists are doctors like surgeons, heart doctors, allergy
doctors, skin doctors, and others who specialize in one
area of health care.
C16 If yes, DURING THE PAST 12 MONTHS, did this child
see a dentist or other oral health care provider for
preventive dental care, such as check-ups, dental
cleanings, dental sealants, or fluoride treatments?
Yes
No preventive visits in
the past 12 months ➔ SKIP to question C18
No, but this child needed to see a specialist
Yes, 1 visit
No, this child did not need to
see a specialist ➔ SKIP to question C23
Yes, 2 or more visits
C22 How difficult was it to get the specialist care that this
child needed?
C17 If yes, DURING THE PAST 12 MONTHS, what
Very difficult
preventive dental service(s) did this child receive?
Mark (X) ALL that apply.
Somewhat difficult
Check-up
Not difficult
Cleaning
It was not possible to obtain care
Instruction on tooth brushing and oral health care
C23 DURING THE PAST 12 MONTHS, did this child use any
type of alternative health care or treatment? Alternative
health care can include acupuncture, chiropractic care,
relaxation therapies, herbal supplements, and others.
Some therapies involve seeing a health care provider,
while others can be done on your own.
X-Rays
Fluoride treatment
Sealant (plastic coatings on back teeth)
Yes
Don’t know
C18 DURING THE PAST 12 MONTHS, has this child
received any treatment or counseling from a mental
health professional? Mental health professionals include
psychiatrists, psychologists, psychiatric nurses, and clinical
social workers.
No
C24 DURING THE PAST 12 MONTHS, was there any time
when this child needed health care but it was not
received? By health care, we mean medical care as well
as other kinds of care like dental care, vision care, and
mental health services.
Yes
Yes
No, but this child needed to see a mental health
professional
No ➔ SKIP to question C27 on page 9
C25 If yes, which types of care were not received?
No, this child did not need to see a
mental health professional ➔ SKIP to question C20
Mark (X) ALL that apply.
Medical Care
C19 How difficult was it to get the mental health treatment
or counseling that this child needed?
Dental Care
Very difficult
Vision Care
Somewhat difficult
Hearing Care
Not difficult
Mental Health Services
It was not possible to obtain care
Other, specify:
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C26 Did any of the following reasons contribute to this child C32 Is this child CURRENTLY receiving services under one
not receiving needed health services? Mark (X) Yes or No
for each item.
Yes
of these plans?
No
Yes
a. This child was not eligible for the
services
No
b. The services this child needed were
not available in your area
C33 Has this child EVER received special services to meet
c. There were problems getting an
appointment when this child needed
one
his or her developmental needs such as speech,
occupational, or behavioral therapy?
Yes
d. There were problems with getting
transportation or child care
e. The clinic or doctor’s office wasn’t
open when this child needed care
No ➔ SKIP to question D1
C34 If yes, how old was this child when he or she began
receiving these special services?
f. There were issues related to cost
C27 DURING THE PAST 12 MONTHS, how often were you
Years AND
frustrated in your efforts to get services for this child?
Months
C35 Is this child CURRENTLY receiving these special
Never
services?
Sometimes
Yes
Usually
No
Always
D. Experience with This
Child’s Health Care
Providers
C28 DURING THE PAST 12 MONTHS, how many times did
this child visit a hospital emergency room?
None
D1
1 time
2 or more times
C29 DURING THE PAST 12 MONTHS, was this child admitted
to the hospital to stay for at least one night?
Do you have one or more persons you think of as this
child’s personal doctor or nurse? A personal doctor or
nurse is a health professional who knows this child well
and is familiar with this child’s health history. This can be
a general doctor, a pediatrician, a specialist doctor, a
nurse practitioner, or a physician’s assistant.
Yes, one person
Yes
Yes, more than one person
No
No
C30 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).
D2
DURING THE PAST 12 MONTHS, did this child need a
referral to see any doctors or receive any services?
Yes
Yes
No ➔ SKIP to question C33
No ➔ SKIP to question D4 on page 10
C31 If yes, how old was this child at the time of the FIRST
D3
plan?
How difficult was it to get referrals?
Very difficult
Years AND
Somewhat difficult
Months
Not difficult
It was not possible to get a referral
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D4 Answer the following questions only if this child has
D8
had a health care visit IN THE PAST 12 MONTHS.
Otherwise skip to Section E on page 11.
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers...
Always
Usually Sometimes
Yes
Never
a. Spend enough time
with this child?
DURING THE PAST 12 MONTHS, have you felt that you
could have used extra help arranging or coordinating
this child’s care among the different health care
providers or services?
No ➔ SKIP to question D10
D9
b. Listen carefully to
you?
c. Show sensitivity to
your family’s values
and customs?
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
d. Provide the specific
information you
needed concerning
this child?
Never
D10 DURING THE PAST 12 MONTHS, how satisfied were
e. Help you feel like a
partner in this
child’s care?
you with the communication among this child’s doctors
and other health care providers?
Very satisfied
D5 DURING THE PAST 12 MONTHS, did this child need
any decisions to be made regarding his or her health
care, such as whether to get prescriptions, referrals,
or procedures?
Somewhat satisfied
Somewhat dissatisfied
Yes
Very dissatisfied
No ➔ SKIP to question D7
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?
D6 If yes, DURING THE PAST 12 MONTHS, how often did
this child’s doctors or other health care providers...
Always
Yes
Usually Sometimes Never
a. Discuss with you
the range of options
to consider for his
or her health care or
treatment?
b. Make it easy for you
to raise concerns or
disagree with
recommendations
for this child’s health
care?
No ➔ SKIP to question D13
Did not need health care
provider to communicate
with these providers ➔ SKIP to question D13
D12 If yes, during this time, how satisfied were you with the
health care provider’s communication with the school,
child care provider, or special education program?
Very satisfied
c. Work with you to
decide together
which health care
and treatment
choices would be
best for this child?
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 satisfied
Somewhat dissatisfied
Very dissatisfied
D13 Do any of this child’s doctors or other health care
providers treat only children?
Yes
Yes
No
No ➔ SKIP to question D15 on page 11
Did not see more than one health care provider
in PAST 12 MONTHS
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D14 If yes, have they talked with you about when this child
D20 Eligibility for health insurance often changes in young
will need to see doctors or other health care providers
who treat adults?
adulthood. Do you know how this child will be insured
as he or she becomes an adult?
Yes
Yes ➔ SKIP to question E1
No
No
D15 Has this child’s doctor or other health care provider
actively worked with this child to:
Yes
No
D21 If no, has anyone discussed with you how to obtain or
keep some type of health insurance coverage as this
child becomes an adult?
Don’t
know
a. Make positive choices about
his or her health. For example,
by eating healthy, getting
regular exercise, not using
tobacco, alcohol or other drugs,
or delaying sexual activity?
b. Gain skills to manage his or
her health and health care.
For example, by understanding
current health needs, knowing
what to do in a medical
emergency, or taking
medications he or she may need?
Yes
No
E. This Child’s Health
Insurance Coverage
E1
Yes, this child was covered
all 12 months ➔ SKIP to question E4 on page 12
c. Understand the changes in
health care that happen at
age 18. For example, by
understanding changes in privacy,
consent, access to information, or
decision-making?
D16 Did you and this child receive a summary of your
child’s medical history (for example, medical conditions,
allergies, medications, immunizations)?
DURING THE PAST 12 MONTHS, was this child EVER
covered by ANY kind of health insurance or health
coverage plan?
Yes, but this child had a gap in coverage
No
E2
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
Yes
a. Change in employer or employment
status
No
b. Cancellation due to overdue
premiums
D17 Have this child’s doctors or other health care providers
worked with you and this child to create a plan of care
to meet his or her health goals and needs?
c. Dropped coverage because it was
unaffordable
d. Dropped coverage because benefits
were inadequate
Yes
e. Dropped coverage because choice
of health care providers was
inadequate
No ➔ SKIP to question D20
D18 If yes, do you and this child have access to this plan of
care?
f. Problems with application or
renewal process
Yes
g. Other, specify: C
No
D19 Does this plan of care address transition to doctors and
other health care providers who treat adults?
E3
Yes
Is this child CURRENTLY covered by ANY kind of
health insurance or health coverage plan?
Yes
No
No ➔ SKIP to question F1 on page 12
No, child already sees providers who treat adults
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E4
F. Providing for This
Child’s Health
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
F1
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
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.
$0 (No medical or health-related
expenses) ➔ SKIP to question F4
d. TRICARE or other military
health care
$1-$249
e. Indian Health Service
$250-$499
f. Other, specify: C
$500-$999
$1,000-$5,000
E5
How often does this child’s health insurance offer
benefits or cover services that meet this child’s needs?
Always
More than $5,000
F2
Always
Usually
Usually
Sometimes
Sometimes
Never
E6
How often does this child’s health insurance allow him
or her to see the health care providers he or she needs?
Never
F3
Always
DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?
Usually
Yes
Sometimes
No
Never
E7
How often are these costs reasonable?
F4
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?
DURING THE PAST 12 MONTHS, have you or other
family members...
Yes
a. Left a job or taken a leave of
absence because of this child’s
health or health conditions?
This child does not use mental or behavioral
health services
b. Cut down on the hours you work
because of this child’s health or
health conditions?
Always
c. Avoided changing jobs because of
concerns about maintaining health
insurance for this child?
Usually
Sometimes
Never
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No
26038083
F5
IN AN AVERAGE WEEK, how many hours do you or
G3 SINCE STARTING KINDERGARTEN, has this child
other family members spend providing health care at
repeated any grades?
home for this child? Care might include changing
bandages, or giving medication and therapies when needed.
Yes
This child does not need health care provided at home
No
on a weekly basis
Less than 1 hour per week
G4 DURING THE PAST 12 MONTHS, how often did you
attend events or activities that this child participated in?
1-4 hours per week
Always
5-10 hours per week
Usually
11 or more hours per week
Sometimes
F6
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
Rarely
Never
G5 DURING THE PAST 12 MONTHS, did this child
participate in...
Less than 1 hour per week
Yes
1-4 hours per week
5-10 hours per week
b. Any clubs or organizations after
school or on weekends?
11 or more hours per week
c. Any other organized activities or
lessons, such as music, dance,
language, or other arts?
G. This Child’s Schooling
and Activities
d. Any type of community service or
volunteer work at school, place of
worship, or in the community?
G1 DURING THE PAST 12 MONTHS, about how many days
e. Any paid work, including regular
jobs as well as babysitting, cutting
grass, or other occasional work?
did this child miss school because of illness or injury?
Include days missed from any formal home schooling.
No missed school days
G6
1-3 days
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?
4-6 days
0 days
7-10 days
1-3 days
11 or more days
4-6 days
This child was not enrolled in school
Every day
G2 DURING THE PAST 12 MONTHS, how many times has
No
a. A sports team or did he or she
take sports lessons after school
or on weekends?
G7
this child’s school contacted you or another adult in
your household about any problems he or she is
having with school?
Compared to other children his or her age, how much
difficulty does this child have making or keeping
friends?
No difficulty
None
A little difficulty
1 time
A lot of difficulty
2 or more times
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26038075
H. About You and This
Child
H1
H7
How well can you and this child share ideas or talk
about things that really matter?
Very well
Was this child born in the United States?
Somewhat well
Yes ➔ SKIP to question H3
Not very well
No
Not well at all
H2
If no, how long has this child been living in the
United States?
Years AND
H3
H8
Months
How well do you think you are handling the day-to-day
demands of raising children?
Very well
How many times has this child moved to a new address
since he or she was born?
Somewhat well
Not very well
Number of times
Not at all
H4
How often does this child go to bed at about the same
time on weeknights?
H9
Never
Always
Sometimes
b. That this
child does
things that
really bother
you a lot?
Rarely
Never
DURING THE PAST WEEK, how many hours of sleep
did this child get on most weeknights?
Less than 6 hours
c. Angry with
this child?
H10 DURING THE PAST 12 MONTHS, was there someone
that you could turn to for day-to-day emotional support
with parenting or raising children?
6 hours
7 hours
Yes
8 hours
No ➔ SKIP to question I1 on page 15
9 hours
H6
Rarely Sometimes Usually Always
a. That this
child is much
harder to care
for than most
children his
or her age?
Usually
H5
DURING THE PAST MONTH, how often have you felt...
H11 If yes, did you receive emotional support from...
Yes
10 hours
a. Spouse or domestic partner?
11 or more hours
b. Other family member or close friend?
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.
c. Health care provider?
d. Place of worship or religious leader?
e. Support or advocacy group related
to specific health condition?
Less than 1 hour
f. Peer support group?
1 hour
2 hours
g. Counselor or other mental health
professional?
3 hours
h. Other person, specify:
C
4 or more hours
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No
26038067
I. About Your Family and
Household
I1
I6
When your family faces problems, how often are you
likely to do each of the following?
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?
Most of
the time
Some of
the time
None of
the time
a. Talk together
about what to do
0 days
b. Work together to
solve our problems
1-3 days
c. Know we have
strengths to draw on
d. Stay hopeful
even in difficult
times
4-6 days
Every day
I7
I2
I3
Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?
Yes
Never
No ➔ SKIP to question I4
Rarely
If yes, does anyone smoke inside your home?
Somewhat often
Yes
No
I4
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?
Very often
I8
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.
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.
More than once a week
We could always afford enough to eat but not always
the kinds of food we should eat.
Once a week
Sometimes we could not afford enough to eat.
Once a month
Often we could not afford enough to eat.
Once every 2-5 months
I9
At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive...
Once every 6 months
I5
Yes
Once during the past 12 months
a. Cash assistance from a government
welfare program?
Never
b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?
Don’t know
c. 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?
d. Benefits from the Woman, Infants,
and Children (WIC) Program?
Yes
No
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No
26038059
I10 In your neighborhood, is/are there:
I13 The next questions are about events that may have
Yes
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. 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?
f. Lived with anyone who was mentally
ill, suicidal, or severely depressed
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree
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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26038042
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
Widowed
Grandparent
Foster Parent
J8
Very Good
Other: Non-Relative
Good
What is your sex?
Fair
Male
Poor
Female
J3
In general, how is your physical health?
Excellent
Other: Relative
J2
What is your marital status?
What is your age?
J9
In general, how is your mental or emotional health?
Excellent
Age in years
J4
Very Good
Where were you born?
Good
In the United States ➔ SKIP to question J6
Fair
Outside of the United States
J5
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 page18
High School Graduate or GED Completed
Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question J13 on page 18
Completed a vocational, trade, or business school
program
Now on active duty
Some College Credit, but no Degree
On active duty in the past, but not now
Associate Degree (AA, AS)
J12
Were you deployed at any time during this child’s life?
Bachelor’s Degree (BA, BS, AB)
Yes
Master’s Degree (MA, MS, MSW, MBA)
No
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
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26038034
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 in the
household for this child ➔ SKIP to question K1 on
page 19
Never Married
Divorced
Biological or Adoptive Parent
Separated
Step-parent
Widowed
Grandparent
J20 In general, how is this primary caregiver’s physical
health?
Foster Parent
Excellent
Other: Relative
Very Good
Other: Non-Relative
Good
J14 What is this primary caregiver’s sex?
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?
Excellent
Age in years
Very Good
J16 Where was this primary caregiver born?
In the United States ➔ SKIP to question J18
Good
Outside of the United States
Fair
Poor
J17 When did this primary caregiver come to live in the
United States?
Year
J22 Was this primary caregiver employed at least 50 out of
the past 52 weeks?
Yes
No
J18 What is the highest grade or level of school this primary
caregiver has completed? Mark (X) ONE box.
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.
8th grade or less
9th-12th grade; No diploma
Never served in the
military ➔ SKIP to question K1 on page 19
High School Graduate or GED Completed
Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question K1 on page 19
Completed a vocational, trade, or business school
program
Now on active duty
Some College Credit, but no Degree
Associate Degree (AA, AS)
On active duty in the past, but not now
J24 Was this primary caregiver deployed at any time during
this child’s life?
Bachelor’s Degree (BA, BS, AB)
Yes
Master’s Degree (MA, MS, MSW, MBA)
No
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
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26038026
K. Household Information
K1
e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office.
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
f. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support, or alimony.
Number of people
K2
$
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
K3
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.
K4
a. Wages, salary, commissions, bonuses, or tips for
all jobs.
Yes ➔
$
,
,
.00
$
TOTAL AMOUNT
in the last calendar year
No
b. Self-employment income from own nonfarm
businesses or farm business, including
proprietorships and partnerships.
Yes ➔
$
,
,
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
,
.00
,
TOTAL AMOUNT
in the last calendar year
Loss
TOTAL AMOUNT
in the last calendar year
No
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Yes ➔
$
,
,
.00
Loss
TOTAL AMOUNT
in the last calendar year
No
d. Social security or railroad retirement; retirement,
survivor, or disability pensions.
Yes ➔
No
$
,
,
.00
TOTAL AMOUNT
in the last calendar year
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26038018
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 | 2018-02-08 |
| File Created | 2018-02-08 |