2 Survey Content for Participants with a Child Age

Generic Clearance for Questionnaire Pretesting Research

OMB letter attachment 2_Survey Content for Participants with a Child Aged 6 to 17_Updated 06292020

NSCH Crowdsourcing Cognitive Interviews

OMB: 0607-0725

Document [docx]
Download: docx | pdf

Survey Content for Participants with a Child Aged 6-17



The US Census Bureau is testing questions for a survey on children’s health topics. We would like you to answer the questions and then answer some follow-up questions about how you came up with your answers and how you interpret some of the questions.  There are no right or wrong answers. Please do not go back and change your original answers. 

 

Thank you for participating in our research. 

 

The survey questions will appear in bold.
The follow-up questions will appear in italics.





The U.S. Census Bureau is required by law to protect your information. We are conducting this voluntary survey under 13 U.S.C 8(b) to study possible improvements to the questionnaire. Federal law protects your privacy and keeps your answers confidential (The Confidential Information Protection and Statistical Efficiency Act). Per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems that transmit your data.


Your privacy is also protected by the Privacy Act, Title 5 U.S. Code. Routine uses of these data are limited to those identified in the Privacy Act System of Record Notice titled, “SORN COMMERCE/Census-7, Demographic Survey Collection (non-Census Bureau Sampling Frame).” The Census Bureau can use your responses only to produce statistics, and is not permitted to publicly release your responses in a way that could identify you.


We estimate that completing this survey will take 15 minutes on average. Send comments regarding this estimate or any other aspect of this survey, including suggestions for reducing the time it takes to complete this survey to adrm.pra@census.gov. This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-0725, confirms this approval. We are required to display this number to conduct this survey. By proceeding, you give your consent to participate in this study.






Are there any children 0-17 years old who usually live or stay at your address?

Yes

No (survey terminates)





To begin, read the instructions below:

 

If you have one child age 0-17 years old, think of that child when answering the questions in this survey.

  

 

If you have two or more children 0-17 years old, think of whichever child uses more medical, behavioral, or mental health services when answering the questions in the survey.  If none of your children use medical, behavioral, or mental health services, think of the one whose birthday was most recent.


What is this child's name? Instead of this child's name, you may use an identifying phrase, such as "Child 1, Child 2, etc..." This identifying phrase will be used throughout the remainder of the survey.



How old is this child? 

If less than 1 year old, enter 0.








Where do you or another caregiver USUALLY take {Child’s Name} when they are sick or you need advice about their health?

Shape3 Doctor's Office

Shape4 Hospital Emergency Room

Shape5 Hospital Outpatient Department

Shape6 Urgent Care

Shape7 Clinic or Health Center

Shape8 Retail Store Clinic or "Minute Clinic"

Shape9 School (Nurse's Office, Athletic Trainer's Office)

Shape10 Some Other Place

Shape11 No Usual Place

Did you have any trouble choosing just one place when answering the question above?

Shape12 Yes

Shape13 No


(If Yes)

Tell us more about why you had trouble choosing just one place.

Shape14



In your own words, how would you describe each of the following:

 

Urgent care

Shape15











Clinic or health center

Shape16


Retail or minute clinic

Shape17






Where does {Child’s Name} USUALLY go when they need routine PREVENTIVE care, such as a physical examination or well-child check-up?

Shape18 Doctor's Office

Shape19 Hospital Emergency Room

Shape20 Hospital Outpatient Department

Shape21 Urgent Care

Shape22 Clinic or Health Center

Shape23 Retail Store Clinic or "Minute Clinic"

Shape24 School (Nurse's Office, Athletic Trainer's Office)

Shape25 Some Other Place

Shape26 No Usual Place





Did you have any trouble choosing just one place when answering the question above?

Shape27 Yes

Shape28 No



(If Yes)

Tell us more about why you had trouble choosing just one place.

Shape29




DURING THE PAST 12 MONTHS, did {Child’s Name} see a dentist or other health care provider for any kind of dental or oral health care?

Shape30 Yes, saw a dentist or other oral health care provider

Shape31 Yes, saw another kind of health care provider

Shape32 No



(If Yes)

Were you thinking of any other health care provider besides a dentist when you answered the previous question?

Shape33 Yes

Shape34 No



(If Yes)

What types of health care providers were you thinking of?

Shape35



DURING THE PAST 12 MONTHS, how many times did {Child’s Name} visit a hospital emergency room?

Shape36 None

Shape37 1 time

Shape38 2 or more times





Were you considering visits to urgent care when you answered the previous question?

Shape39 Yes

Shape40 No





DURING THE PAST 12 MONTHS, did {Child’s Name} need any decisions to be made regarding their health care, such as whether to get prescriptions, referrals, or procedures?

Shape41 Yes

Shape42 No







What do you think the question above is asking?

Shape43



What types of decisions were you thinking of when answering this question?

Shape44



DURING THE PAST 12 MONTHS, did anyone help you arrange or coordinate {Child’s Name}’s care among the different doctors or services that {Child’s Name} uses?

Shape45 Yes

Shape46 No

Shape47 Did not see more than one health care provider in the PAST 12 MONTHS



(If Yes)

Who helped you coordinate your child's care?

Shape48





(If Yes or No is selected in response to the “had help arranging care” survey question)

DURING THE PAST 12 MONTHS, have you felt that you could have used extra help arranging or coordinating {Child’s Name}’s care among the different health care providers or services? 

Shape49 Yes

Shape50 No







(If Yes is selected in response to “Needed help arranging care” )

What type of help were you thinking of?

Shape51








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

Shape52 This child does not need health care provided at home on a weekly basis

Shape53 Less than 1 hour per week

Shape54 1-4 hours per week

Shape55 5-10 hours per week

Shape56 11 or more hours per week



What types of care were you thinking about when you answered the above question?

Shape57



DURING THE PAST 12 MONTHS, how often was {Child’s Name} bullied, picked on, or excluded by other children? If the frequency changed throughout the year, report the highest frequency.

Shape58 Never (in the past 12 months)

Shape59 1-2 times (in the past 12 months)

Shape60 1-2 times per month

Shape61 1-2 times per week

Shape62 Almost every day



(If any response other than “Never” is selected above)

Who were you thinking of bullying {Child’s Name} when you answered the question above?

Shape63







DURING THE PAST 12 MONTHS, how often did {Child’s Name} bully others, pick on them, or exclude them? If the frequency changed throughout the year, report the highest frequency.

Shape64 Never (in the past 12 months)

Shape65 1-2 times (in the past 12 months)

Shape66 1-2 times per month

Shape67 1-2 times per week

Shape68 Almost every day


(If any response other than “Never” is selected above)

What were you thinking of when you answered the question above?

Shape69



Was it easy or hard for you to answer the questions above about bullying?

Shape70 Easy

Shape71 Hard



(If “Easy” is selected)

Please tell us about why it was easy to answer the questions about bullying.

Shape72

(If “Hard” is selected)

Please tell us about why it was hard to answer the questions about bullying.

Shape73




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

Shape74 Yes

Shape75 No



Did you think about vaping when answering the previous question?

Shape76 Yes

Shape77 No



Does anyone living in your household use vaping products or e-cigarettes?

Shape78 Yes

Shape79 No


To the best of your knowledge, has {Child’s Name} EVER experienced the following?

 

Treated or judged unfairly because of their sexual orientation or gender identity.

Shape80 Yes

Shape81 No


Treated or judged unfairly because of their race or ethnic group.

Shape82 Yes

Shape83 No



How did you feel about answering the question about sexual orientation and gender identity?

Shape84


In your own words, what does "sexual orientation" mean?

Shape85


In your own words, what does "gender identity" mean?

Shape86




How are you related to {Child’s Name}?

Shape87 Biological or Adoptive Parent

Shape88 Step-parent

Shape89 Grandparent

Shape90 Foster Parent

Shape91 Other: Relative

Shape92 Other: Non-Relative


What is your sex?

Shape93 Male

Shape94 Female


What is your age?

Shape95



What is the highest grade or level of school you have completed?

Shape96 8th grade or less

Shape97 9th-12th grade; No diploma

Shape98 High School Graduate or GED Completed

Shape99 Completed a vocational, trade, or business school program

Shape100 Some College Credit, but no Degree

Shape101 Associate Degree (AA, AS)

Shape102 Bachelor’s Degree (BA, BS, AB)

Shape103 Master’s Degree (MA, MS, MSW, MBA)

Shape104 Doctorate (PhD, EdD) or Professional Degree (MD, DDS, DVM, JD)





Does {Child’s Name} have another parent or adult caregiver who lives in this household?

Shape105 Yes

Shape106 No




What do you think is meant by "parent or adult caregiver"?

Shape107



How many people did you consider when thinking about your answer?

Shape108



Here's another way we might ask this question:

Does {Child’s Name} have another primary adult caregiver who lives in the household?

 

Which version of the question do you think is easier to understand?

Shape109 Does {Child’s Name} have another primary adult caregiver who lives in the household?

Shape110 Does {Child’s Name} have another parent or adult caregiver who lives in the household?





Tell us more about why you think this question is easier to understand when asked as "{Fills with respondent selection}".

Shape111





(If No is selected for “Does {Child’s Name} have another parent or adult caregiver who lives in this household?”)

Are there any other adults in the household besides you?

Shape112 Yes

Shape113 No



(If Yes)

Tell us why you chose not to count these other adults as parents or caregivers.

Shape114



(If Yes is selected for “Does {Child’s Name} have another parent or adult caregiver who lives in this household?”)

How did you decide who to list as this other caregiver?

Shape115



How is this other caregiver related to {Child’s Name}?

Shape116 Biological or Adoptive Parent

Shape117 Step-parent

Shape118 Grandparent

Shape119 Foster Parent

Shape120 Other: Relative

Shape121 Other: Non-Relative



What is this caregiver's sex?

Shape122 Male

Shape123 Female



What is this caregiver's age?

Shape124











What is the highest grade or level of school this caregiver has completed?

Shape125 8th grade or less

Shape126 9th-12th grade; No diploma

Shape127 High School Graduate or GED Completed

Shape128 Completed a vocational, trade, or business school program

Shape129 Some College Credit, but no Degree

Shape130 Associate Degree (AA, AS)

Shape131 Bachelor’s Degree (BA, BS, AB)

Shape132 Master’s Degree (MA, MS, MSW, MBA)

Shape133 Doctorate (PhD, EdD) or Professional Degree (MD, DDS, DVM, JD)






Overall, what would you say about the survey questions you looked at today?

Shape134


Is there anything else you would like to tell us that you haven't already mentioned?

Shape135





File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorSarah S Vetting (CENSUS/DSMD FED)
File Modified0000-00-00
File Created2021-01-14

© 2024 OMB.report | Privacy Policy