NSCH-T3 NSCH Topical 3 (12-17) - English

National Survey of Children's Health

NSCH_T3_FINAL

National Survey of Children's Health

OMB: 0607-0990

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26036202
OMB No. 0607-0990: Approval Expires 04/30/2019

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 conducting the National Survey of Children’s Health on behalf of the U.S. 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. The data collected under this agreement are confidential under 13 U.S.C.
Section 9. All access to Title 13 data from this survey is restricted to Census Bureau employees and those holding Census Bureau
Special Sworn Status pursuant to 13 U.S.C. Section 23(c).
Any information you provide will be shared among a limited number of Census Bureau and HHS staff only for work-related purposes
identified above and as permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a).
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 well do each of the following phrases describe
this child?
Definitely Somewhat
Not
true

Recently, you completed a survey that asked about the
children usually living or staying at this address.
Thank you for taking the time to complete that survey.
We now have some follow-up questions to ask about:

true

c. This child stays calm and
in control when faced with
a challenge
d. This child cares about
doing well in school

These questions will collect more detailed information
on various aspects of this child’s health including his
or her health status, visits to health care providers,
health care costs, and health insurance coverage.

e. This child does all
required homework

We have selected only one child per household in an
effort to minimize the amount of time necessary to
complete the follow-up questions.

f. This child is bullied,
picked on, or excluded by
other children

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

g. This child bullies others,
picks on them, or
excludes them

Your participation is important. Thank you.

h. This child argues too
much

A. This Child’s Health

true

a. This child shows interest
and curiosity in learning
new things
b. This child works to finish
tasks he or she starts

A4

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

DURING THE PAST 12 MONTHS, has this child had
FREQUENT or CHRONIC difficulty with any of the
following?
Yes

No

Yes

No

a. Breathing or other respiratory
problems (such as wheezing or
shortness of breath)
b. Eating or swallowing because of
a health condition

(the one named above)?
Excellent
Very good

c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea

Good
Fair

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

Poor

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

f. Bleeding gums

teeth?
Excellent
Very good

g. Decayed teeth or cavities
A5

Good

Does this child have any of the following?
a. Serious difficulty concentrating,
remembering, or making decisions
because of a physical, mental, or
emotional condition

Fair
Poor

b. Serious difficulty walking or climbing
stairs
c. Difficulty dressing or bathing
d. Difficulty doing errands alone, such
as visiting a doctor’s office or shopping,
because of a physical, mental, or
emotional condition
e. Deafness or problems with hearing
f. Blindness or problems with seeing,
even when wearing glasses

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A6 Has a doctor or other health care provider EVER told

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

you that this child has...
Allergies (including food, drug, insect, or other)?
Yes

A11 Cerebral Palsy?

No

Yes

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

No

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:

No

If yes, is it:

Mild

Moderate

Severe

Mild

Moderate

Severe

A12 Cystic Fibrosis?

A7 Arthritis?

Yes

No

Yes

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

No

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:

No

If yes, is it:

Mild

Moderate

Severe

Mild

Moderate

Severe

A13 Diabetes?

A8 Asthma?

Yes

Yes

No

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:

No

If yes, is it:

Mild

Moderate

Severe

Mild

Thalassemia, or Hemophilia)?

Yes

No

Severe

No

If yes, does this child CURRENTLY have the condition?

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

Moderate

A14 Down Syndrome?

A9 Blood Disorders (such as Sickle Cell Disease,

Yes

No

Yes

No

No

If yes, is it:

If yes, is it:

Mild

Mild

Moderate

Moderate

Severe

Severe
A15 Epilepsy or Seizure Disorder?

A10 Brain Injury, Concussion or Head Injury?

Yes

Yes

No

If yes, does this child CURRENTLY have the condition?

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

Yes

No

No

If yes, is it:

If yes, is it:
Mild

No

Mild
Moderate

Moderate

Severe

Severe

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

A22 Has a doctor, other health care provider, or educator

EVER told you that this child has...
Examples of educators are teachers and school nurses.

A16 Heart Condition?

Yes

Behavioral or Conduct Problems?

No

Yes

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

No

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:
Mild

Moderate

No

If yes, is it:

Severe

Mild

Moderate

Severe

A17 Frequent or Severe Headaches, including Migraine?

Yes

A23 Substance Abuse Disorder?

No

Yes

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

No

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:
Mild

Moderate

No

If yes, is it:

Severe

Mild

Moderate

Severe

A18 Tourette Syndrome?

Yes

A24 Developmental Delay?

No

Yes

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

No

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:
Mild

Moderate

No

If yes, is it:

Severe

Mild
A19 Anxiety Problems?

Yes

Moderate

Severe

A25 Intellectual Disability (also known as Mental Retardation)?

No

Yes

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

No

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:

No

If yes, is it:

Mild

Moderate

Severe

A20 Depression?

Mild

Moderate

Severe

A26 Speech or Other Language Disorder?

Yes

No

Yes

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

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:
Moderate

Severe

A21 Other Genetic or Inherited Condition?

Mild

Yes

If yes, does this child CURRENTLY have the condition?

Severe

No

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:
Mild

Moderate

A27 Learning Disability?

No

Yes

No

If yes, is it:

Mild

Yes

No

No

If yes, is it:
Moderate

Severe

Mild

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Moderate

Severe

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A28 Has a doctor or other health care provider EVER told

A32

you that this child has...
Any Other Mental Health Condition?
Yes

Yes

No

A33

If yes, specify: C

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

No

At any time DURING THE PAST 12 MONTHS, did this
child receive behavioral treatment for Autism, ASD,
Asperger’s Disorder or PDD, such as training or an
intervention that you or this child received to help
with his or her behavior?
No

A34 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?

Moderate

Severe

No ➔ SKIP to question A37

Yes

A29 Has a doctor or other health care provider EVER told

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

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

Mild

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

No

Moderate

Yes

Severe

child receive behavioral treatment for ADD or ADHD,
such as training or an intervention that you or this
child received to help with his or her behavior?
Yes

Don’t know

A31 What type of doctor or other health care provider was

No

A36 At any time DURING THE PAST 12 MONTHS, did this

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

No

A37 DURING THE PAST 12 MONTHS, how often have this

child’s health conditions or problems affected his or her
ability to do things other children his or her age do?

the FIRST to tell you that this child had Autism, ASD,
Asperger’s Disorder or PDD? Mark ONE only.
Primary Care Provider

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

Specialist

Never

School Psychologist/Counselor

Sometimes

Other Psychologist (Non-School)

Usually

Psychiatrist

Always

Other, specify: C

Severe

ADHD?

A30 How old was this child when a doctor or other health

Age in years

Moderate

A35 Is this child CURRENTLY taking medication for ADD or

If yes, is it:
Mild

No

If yes, is it:

No ➔ SKIP to question A34

Yes

No

Yes

If yes, is it:
Mild

Is this child CURRENTLY taking medication for Autism,
ASD, Asperger’s Disorder or PDD?

A38 To what extent do this child’s health conditions or

problems affect his or her ability to do things?
Very little

Don’t know

Somewhat
A great deal

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B. This Child as an Infant
B1

C3

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

Less than 10 minutes

Yes

10-20 minutes

No
B2

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.

How much did he or she weigh when born?
Answer in pounds and ounces OR kilograms and grams.
Provide your best estimate.

pounds

AND

More than 20 minutes
C4

At his or her LAST preventive check-up, did this child
have a chance to speak with a doctor or other health
care provider privately, without you or another adult in
the room?

ounces
Yes

OR

No
kilograms
B3

AND

grams

C5

What is this child’s CURRENT height?

What was the age of the mother when this child was
born?

feet

AND

inches

OR
Age in years
meters

C. Health Care Services
C1

C6

DURING THE PAST 12 MONTHS, did this child see a
doctor, nurse, or other health care professional for
sick-child care, well-child check-ups, physical exams,
hospitalizations or any other kind of medical care?

AND

centimeters

How much does this child CURRENTLY weigh?

pounds
OR

Yes
kilograms

No ➔ SKIP to question C5
C2

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.

C7

Are you concerned about this child’s weight?
Yes, it’s too high
Yes, it’s too low
No, I am not concerned

0 visits ➔ SKIP to question C5
1 visit
2 or more visits

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C8 Is there a place that this child USUALLY goes when

C14 DURING THE PAST 12 MONTHS, did this child see a

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

he or she is sick or you or another caregiver needs
advice about his or her health?
Yes

Yes, saw a dentist

No ➔ SKIP to question C10

Yes, saw other oral health care provider
No ➔ SKIP to question C17

C9 If yes, where does this child USUALLY go?

Mark ONE only.
C15 If yes, DURING THE PAST 12 MONTHS, did this child

Doctor’s Office

see a dentist or other oral health care provider for
preventive dental care, such as check-ups, dental
cleanings, dental sealants, or fluoride treatments?

Hospital Emergency Room

No preventive visits in
the past 12 months ➔ SKIP to question C17

Hospital Outpatient Department
Clinic or Health Center

Yes, 1 visit

Retail Store Clinic or “Minute Clinic”
School (Nurse’s Office, Athletic Trainer’s Office)

Yes, 2 or more visits
C16 If yes, DURING THE PAST 12 MONTHS, what

preventive dental services did this child receive?
Mark ALL that apply.

Some other place
C10 Is there a place that this child USUALLY goes when

Check-up

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

Cleaning

Yes

Instruction on tooth brushing and oral health care

No ➔ SKIP to question C12

X-Rays

C11 If yes, is this the same place this child goes when he

Fluoride treatment

or she is sick?
Yes

Sealant (plastic coatings on back teeth)

No

Don’t know

C12 DURING THE PAST 2 YEARS, has this child had his or

her vision tested with pictures, shapes, or letters?

C17 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.

Yes
No ➔ SKIP to question C14

Yes

C13 If yes, what kind of place or places did this child have

his or her vision tested? Mark ALL that apply.

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

Eye doctor or eye specialist (ophthalmologist,
optometrist) office

No, this child did not need to see a
mental health professional ➔ SKIP to question C19

Pediatrician or other general doctor’s office
Clinic or health center

C18 How much of a problem was it to get the mental health

treatment or counseling that this child needed?

School
Other, specify:

Not a problem
C

Small problem
Big problem

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C19 DURING THE PAST 12 MONTHS, has this child taken

C25 Which of the following contributed to this child not

receiving needed health services:

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

Yes

Yes

a. This child was not eligible for the
services?

No

b. The services this child needed were
not available in your area?
c. There were problems getting an
appointment when this child needed
one?

C20 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.

d. There were problems with getting
transportation or child care?

Yes

e. The (clinic/doctor’s) office wasn’t
open when this child needed care?

No, but this child needed to see a specialist

f. There were issues related to cost?

No, this child did not need to
see a specialist ➔ SKIP to question C22

C26 DURING THE PAST 12 MONTHS, how often were you

frustrated in your efforts to get services for this child?

C21 How much of a problem was it to get the specialist

Never

care that this child needed?
Not a problem

Sometimes

Small problem

Usually

Big problem

Always

C22 DURING THE PAST 12 MONTHS, did this child use any

No

C27 DURING THE PAST 12 MONTHS, how many times did

type of alternative health care or treatment? Alternative
health care can include acupuncture, chiropractic care,
relaxation therapies, herbal supplements, and others.
Some therapies involve seeing a health care provider,
while others can be done on your own.

this child visit a hospital emergency room?
No visits
1 visit

Yes

2 or more visits

No

C28 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).

C23 DURING THE PAST 12 MONTHS, was there any time

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

Yes
No ➔ SKIP to question C31

Yes
No ➔ SKIP to question C26

C29 If yes, how old was this child at the time of the FIRST

plan?

C24 If yes, which types of care were not received?

Mark ALL that apply.
Medical Care

Years

AND

Months

Dental Care
C30 Is this child CURRENTLY receiving services under one

of these plans?

Vision Care
Hearing Care

Yes

Mental Health Services

No

Other, specify:

C

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C31 Has this child EVER received special services to meet

D4

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

Answer the following questions only if this child had a
health care visit IN THE PAST 12 MONTHS. Otherwise,
SKIP to question D13 .
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers:

No ➔ SKIP to question D1

Always

Usually Sometimes

Never

a. Spend enough time
with this child?

C32 If yes, how old was this child when he or she began

receiving these special services?

b. Listen carefully to
you?
Years

AND

c. Show sensitivity to
your family’s values
and customs?

Months

C33 Is this child CURRENTLY receiving these special

d. Provide the specific
information you
needed concerning
this child?

services?
Yes

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

No

D. Experience with This
Child’s Health Care
Providers
D1

Do you have one or more persons you think of as this
child’s personal doctor or nurse? A personal doctor or
nurse is a health professional who knows this child well
and is familiar with this child’s health history. This can be
a general doctor, a pediatrician, a specialist doctor, a
nurse practitioner, or a physician’s assistant.

D5

DURING THE PAST 12 MONTHS, were any decisions
needed about this child’s health care services or
treatment, such as whether to start or stop a
prescription or therapy services, get a referral to a
specialist, or have a medical procedure?
Yes
No ➔ SKIP to question D7

D6

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

Yes, one person

Always

Yes, more than one person

No
D2

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

DURING THE PAST 12 MONTHS, did this child need a
referral to see any doctors or receive any services?
Yes
No ➔ SKIP to question D4

D3

Usually Sometimes Never

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

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

If yes, how much of a problem was it to get referrals?
Not a problem
Small problem
Big problem

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D7 Does anyone help you arrange or coordinate this

D13 Do any of this child’s doctors or other health care

providers treat only children?

child’s care among the different doctors or services
that this child uses?

Yes

Yes

No ➔ SKIP to question D15

No
Did not see more than one
health care provider in
PAST 12 MONTHS ➔ SKIP to question D11

D14 If yes, have they talked with you about having this child

eventually see doctors or other health care providers
who treat adults?
Yes

D8 DURING THE PAST 12 MONTHS, have you felt that you

could have used extra help arranging or coordinating
this child’s care among the different health care
providers or services?

No
D15 Has this child’s doctor or other health care provider

actively worked with this child to:

Yes

Yes

No ➔ SKIP to question D10

No

Don’t
know

a. Think about and plan for his
or her future. For example, by
taking time to discuss future
plans about education, work,
relationships, and development
of independent living skills?

D9 If yes, DURING THE PAST 12 MONTHS, how often

did you get as much help as you wanted with
arranging or coordinating this child’s health care?
Usually

b. 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?

Sometimes
Never
D10 Overall, how satisfied are you with the communication

c. 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?

among this child’s doctors and other health care
providers?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied

d. 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?

Very dissatisfied
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?

D16 Have this child’s doctors or other health care providers

worked with you and this child to create a written plan
to meet his or her health goals and needs?

Yes
No ➔ SKIP to question D13

Yes

Did not need health care
provider to communicate
with these providers ➔ SKIP to question D13

No ➔ SKIP to question D20

D12 If yes, overall, how satisfied are you with the health

care provider’s communication with the school, child
care provider, or special education program?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

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E. This Child’s Health
Insurance Coverage

D17 If yes, does this plan identify specific health goals for

this child and any health needs or problems this child
may have and how to get these needs met?
Yes

E1

No

DURING THE PAST 12 MONTHS, was this child EVER
covered by ANY kind of health insurance or health
coverage plan?
Yes, this child was covered
all 12 months ➔ SKIP to question E4

D18 Did you and this child receive a written copy of this

plan of care?
Yes, but this child had a gap in coverage

Yes

No

No
E2
D19 Is this plan CURRENTLY up-to-date for this child?

Indicate whether any of the following is a reason this
child was not covered by health insurance DURING
THE PAST 12 MONTHS:
Yes

Yes

No

a. Change in employer or employment
status

No

b. Cancellation due to overdue
premiums

D20 Eligibility for health insurance often changes in young

adulthood. Do you know how this child will be insured
as he or she becomes an adult?

c. Dropped coverage because it was
unaffordable

Yes ➔ SKIP to question E1

d. Dropped coverage because benefits
were inadequate

No

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

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?

f. Problems with application or
renewal process

Yes

g. Other, specify: C

No
E3

Is this child CURRENTLY covered by ANY kind of
health insurance or health coverage plan?
Yes
No ➔ SKIP to question F1

E4

Is this child covered by any of the following types of
health insurance or health coverage plans?
Yes

a. Insurance through a current or
former employer or union
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
d. TRICARE or other military
health care
e. Indian Health Service
f. Other, specify: C

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E5

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

F2

How often are these costs reasonable?
Always

Always
Usually
Usually
Sometimes
Sometimes
Never
Never
F3
E6

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

Yes

Usually

No

Sometimes

F4

Never
E7

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

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

No

a. Stopped working because of this
child’s health or health conditions?

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?

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

This child does not use mental or behavioral
health services

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

Always
F5

Usually
Sometimes

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

Never

No at home care was provided by me or other family
members

F. Providing for This
Child’s Health
F1

IN AN AVERAGE WEEK, how many hours do you or
other family members spend providing health care at
home for this child? Care might include changing
bandages, or giving medication and therapies when needed.

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

Including co-pays and amounts from Health Savings
Accounts (HSA) and Flexible Spending Accounts
(FSA), how much money did you pay for this child’s
medical, health, dental, and vision care DURING THE
PAST 12 MONTHS? Do not include health insurance
premiums or costs that were or will be reimbursed by
insurance or another source.

5-10 hours per week
11 or more hours per week

$0 (No medical or health-related
expenses) ➔ SKIP to question F4
$1-$249
$250-$499
$500-$999
$1,000-$5,000
More than $5,000

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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?

G4 DURING THE PAST 12 MONTHS, did this child

participate in:
Yes

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

b. Any clubs or organizations after
school or on weekends?

No health or medical care was arranged or coordinated
by me or other family members

c. Any other organized activities or
lessons, such as music, dance,
language, or other arts?

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

d. Any type of community service or
volunteer work at school, church, or
in the community?

5-10 hours per week

e. Any paid work, including regular
jobs as well as babysitting, cutting
grass, or other occasional work?

11 or more hours per week

G. This Child’s Schooling
and Activities

G5 DURING THE PAST 12 MONTHS, how often did you

attend events or activities that this child participated in?
Always

G1 DURING THE PAST 12 MONTHS, about how many days

did this child miss school because of illness or injury?

Usually

No missed school days

Sometimes

1-3 days

Rarely

4-6 days

Never

7-10 days

G6

11 or more days
G2 DURING THE PAST 12 MONTHS, how many times has

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?
0 days

this child’s school contacted you or another adult in
your household about any problems he or she is
having with school?

1-3 days
4-6 days

No times

Every day

1 time
2 or more times

No

a. A sports team or did he or she
take sports lessons after school
or on weekends?

G7

Compared to other children his or her age, how much
difficulty does this child have making or keeping
friends?

G3 SINCE STARTING KINDERGARTEN, has this child

repeated any grades?

No difficulty

Yes

A little difficulty

No

A lot of difficulty

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H. About You and This
Child
H1

H2

H6 ON AN AVERAGE WEEKDAY, about how much time

does this child usually spend in front of a TV watching
TV programs, videos, or playing video games?
None

Was this child born in the United States?
Yes ➔ SKIP to question H3

Less than 1 hour

No

1 hour

If no, how long has this child been living in the
United States?

2 hours
3 hours

Years
H3

AND

4 or more hours

Months

How many times has this child moved to a new address
since he or she was born?

H7 ON AN AVERAGE WEEKDAY, about how much time

does this child usually spend with computers, cell
phones, handheld video games, and other electronic
devices, doing things other than schoolwork?
None

Number of times
H4

Less than 1 hour

How often does this child go to bed at about the same
time on weeknights?

1 hour

Always

2 hours

Usually

3 hours

Sometimes

4 or more hours

Rarely
H8

Never
H5

How well can you and this child share ideas or talk
about things that really matter?
Very well

DURING THE PAST WEEK, how many hours of sleep
did this child get on an average weeknight?

Somewhat well

Less than 6 hours

Not very well

6 hours

Not at all

7 hours
H9

8 hours

How well do you think you are handling the day-to-day
demands of raising children?

9 hours

Very well

10 hours

Somewhat well

11 or more hours

Not very well
Not at all

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26036061

I. About Your Family and
Household

H10 DURING THE PAST MONTH, how often have you felt:
Never

Rarely Sometimes Usually Always

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

I1

b. That this
child does
things that
really bother
you a lot?

DURING THE PAST WEEK, on how many days did all the
family members who live in the household eat a meal
together?
0 days
1-3 days
4-6 days

c. Angry with
this child?

Every day

H11 DURING THE PAST 12 MONTHS, was there someone

I2

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

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

Yes
No ➔ SKIP to question

No ➔ SKIP to question I4

I1
I3

H12 If yes, did you receive emotional support from:
Yes

If yes, does anyone smoke inside your home?
Yes

No

No

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

I4

When your family faces problems, how often are you
likely to do each of the following?

c. Health care provider?

All of
the time

d. Place of worship or religious leader?

a. Talk together
about what to do

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

b. Work together to
solve our problems

f. Peer support group?

c. Know we have
strengths to draw on

g. Counselor or other mental health
professional?
h. Other person, specify:

Most of
the time

Some of None of
the time the time

d. Stay hopeful
even in difficult
times

C

I5

SINCE THIS CHILD WAS BORN, how often has it been
very hard to get by on your family’s income – hard to
cover the basics like food or housing?
Never
Rarely
Somewhat often
Very often

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I6

The next question is about whether you were able to
afford the food you need. Which of these statements
best describes the food situation in your household
IN THE PAST 12 MONTHS?

I9

Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

a. People in this
neighborhood
help each other
out

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

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

Sometimes we could not afford enough to eat.
Often we could not afford enough to eat.
I7

c. This child is
safe in our
neighborhood

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

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

No

a. Cash assistance from a government
welfare program?
b. Food Stamps or Supplemental Nutrition
Assistance Program benefits (SNAP)?

e. This child is safe
at school

c. Free or reduced-cost breakfasts or
lunches at school?
I10

d. Benefits from the Woman, Infants,
and Children (WIC) Program?
I8

To what extent do you agree with these statements
about your neighborhood or community?

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?

In your neighborhood, is/are there:
Yes

Yes

No

a. Sidewalks or walking paths?
b. A park or playground?

No
I11

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

The next questions are about events that may have
happened during this child’s life. These things can
happen in any family, but some people may feel
uncomfortable with these questions. You may skip any
questions you do not want to answer.
To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated

e. Litter or garbage on the street
or sidewalk?
f. Poorly kept or rundown housing?
g. Vandalism such as broken
windows or graffiti?

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

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26036046

J. About You

J6

➜ Complete the questions for each of the two adults

8th grade or less

in the household who are this child’s primary
caregivers. If there is just one adult, provide
answers for that adult.

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

ADULT 1 (Respondent)
J1

Completed a vocational, trade, or business school
program

How are you related to this child?
Biological or Adoptive Parent

Some College Credit, but no Degree

Step-parent

Associate Degree (AA, AS)

Grandparent

Bachelor’s Degree (BA, BS, AB)

Foster Parent

Master’s Degree (MA, MS, MSW, MBA)

Aunt or Uncle

Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)

Other: Relative

J7

J3

What is your marital status?
Married

Other: Non-Relative
J2

What is the highest grade or year of school you have
completed? Mark ONE only.

Not married, but living with a partner

What is your sex?
Male

Never Married

Female

Divorced
Separated

What is your age?

Widowed
Age in years
J4

J5

J8

In general, how is your physical health?
Excellent

Where were you born?
In the United States ➔ SKIP to question J6

Very Good

Outside of the United States

Good

When did you come to live in the United States?

Fair

Year

Poor
J9

In general, how is your mental or emotional health?
Excellent
Very Good
Good
Fair
Poor

J10

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

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ADULT 2

J17 What is Adult 2’s marital status?

Married

J11 How is Adult 2 related to this child?

Biological or Adoptive Parent

Not married, but living with a partner

Step-parent

Never Married

Grandparent

Divorced

Foster Parent

Separated

Aunt or Uncle

Widowed

Other: Relative

J18 In general, how is Adult 2’s physical health?

Other: Non-Relative

Excellent

There is only one primary adult
caregiver for this child ➔ SKIP to question K1

Very Good
Good

J12 What is Adult 2’s sex?

Male

Fair

Female

Poor

J13 What is Adult 2’s age?

J19 In general, how is Adult 2’s mental or emotional health?

Excellent
Age in years

Very Good

J14 Where was Adult 2 born?

Good

In the United States ➔ SKIP to question J16

Fair

Outside of the United States

Poor

J15 When did Adult 2 come to live in the United States?

J20 Was Adult 2 employed at least 50 out of the past 52

weeks?

Year

Yes
No
J16 What is the highest grade or year of school Adult 2 has

completed? Mark ONE only.

K. Household Information

8th grade or less
K1

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

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.

Completed a vocational, trade, or business school
program
Number of people

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

K2

Bachelor’s Degree (BA, BS, AB)

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.

Master’s Degree (MA, MS, MSW, MBA)
Number of people
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
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26036020

K3

Income IN THE LAST CALENDAR YEAR
(January 1 - December 31, 2015)
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 from all
jobs?
Yes

C

No

$

The following question is about your income and is very
important. 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 business, farm, or rent, and any other money
income received.

$

Total Amount

Total Amount

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

C

No

$

Total Amount

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

C

No

$

Total Amount

d. Social security or railroad retirement; retirement,
survivor, or disability pensions?
Yes

C

No

$

Total Amount

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

C

No

$

Total Amount

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

$

C

No

Total Amount

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26036012

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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