4 Questionnaire V4

Generic Clearance for Questionnaire Pretesting Research

Enclosure 6T3 nscht3_18_020818

2018 NSCH Usability Evaluation

OMB: 0607-0725

Document [pdf]
Download: pdf | pdf
26038208
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-T3
(02/08/2018) Draft 6

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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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Moderate

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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No

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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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C

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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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C

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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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No

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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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12

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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

NSCH-T3

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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
NSCH-T3

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§;$ql¤

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

NSCH-T3

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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)
NSCH-T3

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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)
NSCH-T3

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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

NSCH-T3

19

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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.

NSCH-T3

20

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