Form 1 Screener Survey

26009084

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
Respond online today at: https://respond.census.gov/nsch
OR complete this form and mail it back as soon as possible.
Thank you for helping us learn about the health and well-being of America’s children.
If your household has children 0 - 17 years old, the questions on this form should be answered by an adult who is familiar with
their health and health care. If your household does not have any children, please answer question 1 below AND return the
questionnaire.
For help or questions about completing this form, please call 1-800-845-8241. The telephone call is free.
For Telephone Device for the Deaf (TDD) assistance, please call: 1-800-582-8330. The telephone call is free.
Si necesita ayuda o tiene preguntas sobre cómo completar este formulario, llame al 1-800-845-8241. La llamada es gratuita.
Para recibir ayuda relacionada con el Dispositivo Telefónico para Personas Sordas (TDD), llame al 1-800-582-8330. La llamada
es gratuita.

In Your Home
1

Are there any children 0-17 years old who usually live or stay at this address?
Yes
No – STOP HERE after marking “No” and return this survey to us in the enclosed envelope. It is important that we
receive a response from every household selected for this study.

2

How many children 0-17 years old usually live or stay at this address?

Number of children living or staying at this address
3

What is the primary language spoken in the household?
English
Spanish
Other Language, specify:

4

C

Is this house, apartment, or mobile home –
Mark (X) ONE box.
Owned by you or someone in this household with a mortgage or loan? Include home equity loans.
Owned by you or someone in this household free and clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?

➜

Answer the remaining questions for each of the children 0-17 years old who usually live or stay at this address.
Start with the YOUNGEST CHILD, who we will call “Child 1” and continue with the next youngest until you have
answered the questions for all children who usually live or stay at this address.

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CHILD 1

7

(Youngest)
1

First name, initials, or nickname of the youngest child

2

How old is this child? If the child is less than one month
old, round age in months to 1.

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?
Yes

No

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?
Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

Years OR
3

Months

8

What is this child’s sex?
Male

No

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

➜ NOTE: Answer BOTH question

4 about Hispanic
origin and question 5 about race.
For this survey, Hispanic origins are not races.

4

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Female

Yes

No, not of Hispanic, Latino, or Spanish origin

Yes
9

Yes, Puerto Rican

5

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Is this child of Hispanic, Latino, or Spanish origin?

Yes, Mexican, Mexican American, Chicano

No

No

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?

Yes, Cuban

Yes

Yes, another Hispanic, Latino, or Spanish origin

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

What is this child’s race? Mark (X) one or more boxes.
White

Korean

Black or
African American

Vietnamese

American Indian or
Alaska Native

Other Asian

No

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

No

10 Does this child need or get special therapy, such as
physical, occupational, or speech therapy?

Native Hawaiian

Yes

Chinese

Guamanian or
Chamorro

If yes, is this because of ANY medical, behavioral,
or other health condition?

Filipino

Samoan

Japanese

Other Pacific Islander

Asian Indian

No

Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

6

Answer the following question only if this child is at
least 4 years old. Otherwise, SKIP to question 7 .
How well does this child speak English?

No

11 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?

Very well

Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

No

Not well
Yes

No

Not at all
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CHILD 2

7

(Next youngest)
1

First name, initials, or nickname of the next youngest
child

2

How old is this child? If the child is less than one month
old, round age in months to 1.

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?
Yes

No

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?
Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

Years OR
3

Months

8

What is this child’s sex?
Male

No

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

➜ NOTE: Answer BOTH question

4 about Hispanic
origin and question 5 about race.
For this survey, Hispanic origins are not races.

4

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Female

Yes

No, not of Hispanic, Latino, or Spanish origin

Yes
9

Yes, Puerto Rican

5

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Is this child of Hispanic, Latino, or Spanish origin?

Yes, Mexican, Mexican American, Chicano

No

No

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?

Yes, Cuban

Yes

Yes, another Hispanic, Latino, or Spanish origin

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

What is this child’s race? Mark (X) one or more boxes.
White

Korean

Black or
African American

Vietnamese

American Indian or
Alaska Native

Other Asian

No

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

No

10 Does this child need or get special therapy, such as
physical, occupational, or speech therapy?

Native Hawaiian

Yes

Chinese

Guamanian or
Chamorro

If yes, is this because of ANY medical, behavioral,
or other health condition?

Filipino

Samoan

Japanese

Other Pacific Islander

Asian Indian

No

Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

6

Answer the following question only if this child is at
least 4 years old. Otherwise, SKIP to question 7 .
How well does this child speak English?

No

11 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?

Very well

Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

No

Not well
Yes

No

Not at all
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CHILD 3

7

(Next youngest)
1

First name, initials, or nickname of the next youngest
child

2

How old is this child? If the child is less than one month
old, round age in months to 1.

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?
Yes

No

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?
Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

Years OR
3

Months

8

What is this child’s sex?
Male

No

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

➜ NOTE: Answer BOTH question

4 about Hispanic
origin and question 5 about race.
For this survey, Hispanic origins are not races.

4

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Female

Yes

No, not of Hispanic, Latino, or Spanish origin

Yes
9

Yes, Puerto Rican

5

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Is this child of Hispanic, Latino, or Spanish origin?

Yes, Mexican, Mexican American, Chicano

No

No

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?

Yes, Cuban

Yes

Yes, another Hispanic, Latino, or Spanish origin

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

What is this child’s race? Mark (X) one or more boxes.
White

Korean

Black or
African American

Vietnamese

American Indian or
Alaska Native

Other Asian

Yes

Filipino

Samoan

Japanese

Other Pacific Islander

No

10 Does this child need or get special therapy, such as
physical, occupational, or speech therapy?
Yes

Native Hawaiian
Guamanian or
Chamorro

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Asian Indian
Chinese

No

No

If yes, is this because of ANY medical, behavioral,
or other health condition?
Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

6

Answer the following question only if this child is at
least 4 years old. Otherwise, SKIP to question 7 .
How well does this child speak English?

No

11 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?

Very well

Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

No

Not well
Yes

No

Not at all
NSCH-S1

5

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CHILD 4

7

(Next youngest)
1

First name, initials, or nickname of the next youngest
child

2

How old is this child? If the child is less than one month
old, round age in months to 1.

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?
Yes

No

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?
Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

Years OR
3

Months

8

What is this child’s sex?
Male

No

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

➜ NOTE: Answer BOTH question

4 about Hispanic
origin and question 5 about race.
For this survey, Hispanic origins are not races.

4

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Female

Yes

No, not of Hispanic, Latino, or Spanish origin

Yes
9

Yes, Puerto Rican

5

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Is this child of Hispanic, Latino, or Spanish origin?

Yes, Mexican, Mexican American, Chicano

No

No

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?

Yes, Cuban

Yes

Yes, another Hispanic, Latino, or Spanish origin

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

What is this child’s race? Mark (X) one or more boxes.
White

Korean

Black or
African American

Vietnamese

American Indian or
Alaska Native

Other Asian

No

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

No

10 Does this child need or get special therapy, such as
physical, occupational, or speech therapy?

Native Hawaiian

Yes

Chinese

Guamanian or
Chamorro

If yes, is this because of ANY medical, behavioral,
or other health condition?

Filipino

Samoan

Japanese

Other Pacific Islander

Asian Indian

No

Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

6

Answer the following question only if this child is at
least 4 years old. Otherwise, SKIP to question 7 .
How well does this child speak English?

No

11 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?

Very well

Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

No

Not well
Yes

No

Not at all
NSCH-S1

6

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➜

If there are more than four children 0-17 years old who usually live or stay at this address, list the first name, initials,
or nickname for each child as well as their age and sex.
Do not repeat information for children already included for Child 1 through Child 4.

First name, initials, or nickname

CHILD 5
▲

(Next youngest)

Age

Years OR

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

First name, initials, or nickname

CHILD 6
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

CHILD 7
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

CHILD 8
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

CHILD 9
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

CHILD 10
▲

(Next youngest)

Age

Years OR

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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 your household and the children of this household.
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.

➜ Make sure you have:
• Listed all first names, initials, or nicknames of children 0-17 years old in the household
• Answered all questions for each child reported

➜ Place the completed questionnaire in the postage-paid return envelope. If the envelope has been
misplaced, please 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.

We estimate that completing the National Survey of Children’s Health will take 5 minutes on average. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to U.S. Department of Commerce, 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. This collection has been
approved by the Office of Management and Budget (OMB). The eight-digit OMB approval number that appears
at the upper left of the form confirms this approval. If this number were not displayed, we could not conduct this
survey.

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