Form 0920-0214 Redesigned Child Questionnaire

National Health Interview Survey

Att 3 ChildQuestionnaire Word 102219

Re-Designed Child Questionnaire

OMB: 0920-0214

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0214 can be found here:

2025-09-22 - No material or nonsubstantive change to a currently approved collection
2025-05-28 - No material or nonsubstantive change to a currently approved collection

Document [docx]

Download: docx | pdf

Attachment 3 Child Questionnaire

Assurance of confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

Notice – Public reporting burden of this collection of information is estimated to average 28 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. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333. ATTN: PRA

(0920-0214).

Form Approved

OMB No. 0920-0214

Exp. Date 12/31/2020

Shape1

Question Text:	How tall is ^SCNAME without shoes? If the child's height is given in inches, press 'ENTER' at feet and enter the measure in inches (36 inches maximum). Enter 'M' to record metric measurements.
Response:	DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	if HEIGHTFT_C ne <empty,0-7,RF,DK,M> [goto ERR1_HEIGHTFT_C] <empty,0-7> [goto HEIGHTIN_C] <RF,DK> [goto WEIGHTLB_C] <M> [goto HEIGHTM_C]

Shape2

Text:	{check ERR1_HEIGHTFT_C} Only empty, 0-7, Don't know/Refused, or M allowed in this field. Please Correct.
Hard / Soft Edit:	Hard
Universe:	HEIGHTFT_C not in (empty,0-7,R,D,M)

Shape3

Universe:

AGE GE '010' and AGE LE '017' and HEIGHTFT_C=empty or 0-7

Question Text:

How tall is ^SCNAME without shoes? Enter inches. Enter '0' if exactly

^HEIGHTFT_C feet tall.

Response:

DK: Don't Know

RF: Refused

Page 1 of 10

Fills:

^SCNAME Fill ALIAS of HHSTAT_C=1

^HEIGHTFT_C fill value from HEIGHTFT_C

Skip Instructions:

If (HEIGHTFT_C='0', 'empty') and (HEIGHTIN_C='0', 'empty') [goto ERR1_HEIGHTIN_C]

elseif HEIGHTFT_C='1-7' and HEIGHTIN_C ge '12' [goto ERR2_HEIGHTIN_C]

elseif (SEX='1' and

(AGE='10' and (CHTINCH_C lt '50' or CHTINCH_C gt '60')) or (AGE='11' and (CHTINCH_C lt '52' or CHTINCH_C gt '62')) or (AGE='12' and (CHTINCH_C lt '53' or CHTINCH_C gt '64')) or (AGE='13' and (CHTINCH_C lt '56' or CHTINCH_C gt '67')) or (AGE='14' and (CHTINCH_C lt '58' or CHTINCH_C gt '70')) or (AGE='15' and (CHTINCH_C lt '61' or CHTINCH_C gt '72')) or (AGE='16' and (CHTINCH_C lt '63' or CHTINCH_C gt '74')) or (AGE='17' and (CHTINCH_C lt '63' or CHTINCH_C gt '74'))) or (SEX='2' and

(AGE = '10' and (CHTINCH_C lt '50' or CHTINCH_C gt '60')) or (AGE = '11' and (CHTINCH_C lt '51' or CHTINCH_C gt '62')) or (AGE = '12' and (CHTINCH_C lt '54' or CHTINCH_C gt '65')) or (AGE = '13' and (CHTINCH_C lt '57' or CHTINCH_C gt '67')) or (AGE = '14' and (CHTINCH_C lt '58' or CHTINCH_C gt '68')) or (AGE = '15' and (CHTINCH_C lt '59' or CHTINCH_C gt '69')) or (AGE = '16' and (CHTINCH_C lt '59' or CHTINCH_C gt '69')) or

(AGE = '17' and (CHTINCH_C lt '59' or CHTINCH_C gt '69'))) [goto ERR3_HEIGHTIN_C]

else <0-36,RF,DK> [goto WEIGHTLB_C]

Shape5

Text:	{check ERR1_HEIGHTIN_C} Must enter an answer in at least the inches item. Please correct.
Hard / Soft Edit:	Hard
Universe:	(HEIGHTFT_C in (0,empty)) and (HEIGHTIN_C in (0,empty))

Shape6

Text:	{check ERR2_HEIGHTIN_C} Number of inches exceeds maximum allowed. Please correct.
Hard / Soft Edit:	Hard
Universe:	HEIGHTFT_C in (0-7) and HEIGHTIN_C gt 36

Shape7

Text:

{signal ERR3_HEIGHTIN_C} Please verify that the height was entered correctly. Probe only if necessary.

Hard / Soft Edit:

Soft

Universe:

(SEX='1' and

Shape8

Universe:	HEIGHTFT_C='M'
Question Text:	How tall is ^SCNAME without shoes? Enter height in metric. If the child's height is given in centimeters, press 'ENTER' at meters and enter the measure in centimeters (241 centimeters maximum).
Response:	DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<0-2,empty> [goto HEIGHTCM_C] <RF,DK> [goto WEIGHTLB_C]

Shape9

Universe: HEIGHTM_C in (empty,0,1,2)

Question Text: How tall is ^SCNAME without shoes? Enter height in centimeters.

Response: DK: Don't Know

RF: Refused

Fills: ^SCNAME Fill ALIAS of HHSTAT_C=1

Skip Instructions: If (HEIGHTM_C in ('0' 'empty')) and (HEIGHTCM_C in ('0', 'empty')) [goto ERR1_HEIGHTCM_C]

elseif (HEIGHTM_C='2' and HEIGHTCM_C gt '41') or (HEIGHTM_C='1' and HEIGHTCM_C gt '141') [goto ERR2_HEIGHTCM_C]

elseif (SEX='1' and

(AGE='10' and (CHTCM_C lt '127' or CHTCM_C gt '152')) or (AGE='11' and (CHTCM_C lt '131' or CHTCM_C gt '157')) or (AGE='12' and (CHTCM_C lt '136' or CHTCM_C gt '164')) or (AGE='13' and (CHTCM_C lt '142' or CHTCM_C gt '171')) or (AGE='14' and (CHTCM_C lt '149' or CHTCM_C gt '179')) or (AGE='15' and (CHTCM_C lt '155' or CHTCM_C gt '184')) or (AGE='16' and (CHTCM_C lt '159' or CHTCM_C gt '187')) or (AGE='17' and (CHTCM_C lt '161' or CHTCM_C gt '189'))) or (SEX='2' and

(AGE='10' and (CHTCM_C lt '126' or CHTCM_C gt '151')) or (AGE='11' and (CHTCM_C lt '131' or CHTCM_C gt '158')) or (AGE='12' and (CHTCM_C lt '137' or CHTCM_C gt '165')) or

Shape14

(AGE='13' and (CHTCM_C lt '144' or CHTCM_C gt '170')) or (AGE='14' and (CHTCM_C lt '148' or CHTCM_C gt '173')) or (AGE='15' and (CHTCM_C lt '150' or CHTCM_C gt '174')) or (AGE='16' and (CHTCM_C lt '150' or CHTCM_C gt '175')) or

(AGE='17' and (CHTCM_C lt '151' or CHTCM_C gt '175'))) [goto ERR3_HEIGHTCM_C]

<0-241,RK,DK> [goto WEIGHTLB_C]

Shape15

Text:	{check ERR1_HEIGHTCM_C} Must enter an answerat least in centimeters item. Please correct
Hard / Soft Edit:	Hard
Universe:	(HEIGHTM_C in (0,empty)) and (HEIGHTCM_C in (0,empty))

Shape16

Text:	{check ERR2_HEIGHTCM_C} Total height exceeds maximum allowed. Please correct.
Hard / Soft Edit:	Hard
Universe:	(HEIGHTM_C=2 and HEIGHTCM_C gt 41) or (HEIGHTM_C=1 and HEIGHTCM_C gt 141)

Shape17

Text:

{signal ERR3_HEIGHTCM_C} Please verify that the height was entered correctly. Probe only if necessary.

Hard / Soft Edit:

Soft

Universe:

(SEX='1' and

(AGE='10' and (CHTCM_C lt '126' or CHTCM_C gt '151')) or (AGE='11' and (CHTCM_C lt '131' or CHTCM_C gt '158')) or (AGE='12' and (CHTCM_C lt '137' or CHTCM_C gt '165')) or (AGE='13' and (CHTCM_C lt '144' or CHTCM_C gt '170')) or (AGE='14' and (CHTCM_C lt '148' or CHTCM_C gt '173')) or (AGE='15' and (CHTCM_C lt '150' or CHTCM_C gt '174')) or (AGE='16' and (CHTCM_C lt '150' or CHTCM_C gt '175')) or (AGE='17' and (CHTCM_C lt '151' or CHTCM_C gt '175')))

Shape18

Question Text:

How much does ^SCNAME weigh now? Enter 'M' to record metric measurements. Enter '500' if 500 pounds or more.

Response:

DK: Don't Know

RF: Refused

Fills:

^SCNAME Fill ALIAS of HHSTAT_C=1

Page 6 of 10

Skip Instructions:

if WEIGHTLB_C lt '1' or WEIGHTLB_C gt '500' [goto ERR1_WEIGHTLB_C]

elseif (SEX='1' and

(AGE='10' and (WEIGHTLB_C lt '53' or WEIGHTLB_C gt '109')) or (AGE='11' and (WEIGHTLB_C lt '59' or WEIGHTLB_C gt '124')) or (AGE='12' and (WEIGHTLB_C lt '65' or WEIGHTLB_C gt '140')) or (AGE='13' and (WEIGHTLB_C lt '73' or WEIGHTLB_C gt '155')) or (AGE='14' and (WEIGHTLB_C lt '82' or WEIGHTLB_C gt '170')) or (AGE='15' and (WEIGHTLB_C lt '92' or WEIGHTLB_C gt '184')) or (AGE='16' and (WEIGHTLB_C lt '101' or WEIGHTLB_C gt '196')) or (AGE='17' and (WEIGHTLB_C lt '109' or WEIGHTLB_C gt '207'))) or (SEX='2' and

(AGE='10' and (WEIGHTLB_C lt '53' or WEIGHTLB_C gt '113')) or (AGE='11' and (WEIGHTLB_C lt '59' or WEIGHTLB_C gt '129')) or (AGE='12' and (WEIGHTLB_C lt '66' or WEIGHTLB_C gt '145')) or (AGE='13' and (WEIGHTLB_C lt '74' or WEIGHTLB_C gt '160')) or (AGE='14' and (WEIGHTLB_C lt '81' or WEIGHTLB_C gt '171')) or (AGE='15' and (WEIGHTLB_C lt '87' or WEIGHTLB_C gt '180')) or (AGE='16' and (WEIGHTLB_C lt '92' or WEIGHTLB_C gt '186')) or

(AGE='17' and (WEIGHTLB_C lt '96' or WEIGHTLB_C gt '190'))) [goto ERR2_WEIGHTLB_C]

<1-500,RF,DK> [goto next section]

<M> [goto WEIGHTKG_C]

Shape20

Text:	{check ERR1_WEIGHTLB_C} Weight is out of range (1-500). Please correct.
Hard / Soft Edit:	Hard
Universe:	WEIGHTLB_C lt 1 or WEIGHTLB_C gt 500

Page 7 of 10

Shape21

Text:

{signal ERR2_WEIGHTLB_C} Please verify that the weight was entered correctly. Probe only if necessary.

Hard / Soft Edit:

Soft

Universe:

(SEX='1' and

Shape22

Universe:

WEIGHTLB_C='M'

Question Text:

How much does ^SCNAME weigh now? Enter weight in kilograms. Enter '226' if 226 kilograms or more.

Response:

DK: Don't Know

RF: Refused

Page 8 of 10

Fills:

^SCNAME Fill ALIAS of HHSTAT_C=1

Skip Instructions:

if WEIGHTKG_C lt '2' or WEIGHTKG_C gt '226' [goto ERR1_WEIGHTKG_C]

elseif (SEX='1' and

(AGE='10' and (WEIGHTKG_C = '24' or WEIGHTKG_C = '49')) or (AGE='11' and (WEIGHTKG_C = '27' or WEIGHTKG_C = '56')) or (AGE='12' and (WEIGHTKG_C = '29' or WEIGHTKG_C = '63')) or (AGE='13' and (WEIGHTKG_C = '33' or WEIGHTKG_C = '70')) or (AGE='14' and (WEIGHTKG_C = '37' or WEIGHTKG_C = '77')) or (AGE='15' and (WEIGHTKG_C = '42' or WEIGHTKG_C = '83')) or (AGE='16' and (WEIGHTKG_C = '46' or WEIGHTKG_C = '89')) or (AGE='17' and (WEIGHTKG_C = '49' or WEIGHTKG_C = '94'))) or (SEX='2' and

(AGE='10' and (WEIGHTKG_C = '24' or WEIGHTKG_C = '51')) or (AGE='11' and (WEIGHTKG_C = '27' or WEIGHTKG_C = '59')) or (AGE='12' and (WEIGHTKG_C = '30' or WEIGHTKG_C = '66')) or (AGE='13' and (WEIGHTKG_C = '33' or WEIGHTKG_C = '72')) or (AGE='14' and (WEIGHTKG_C = '37' or WEIGHTKG_C = '78')) or (AGE='15' and (WEIGHTKG_C = '40' or WEIGHTKG_C = '82')) or (AGE='16' and (WEIGHTKG_C = '42' or WEIGHTKG_C = '84')) or

(AGE='17' and (WEIGHTKG_C = '43' or WEIGHTKG_C = '86'))) [goto ERR2_WEIGHTKG_C]

<2-226,RF,DK> [goto next section]

Shape24

Text:	{check ERR1_WEIGHTKG_C} Weight is out of range (2-226). Please correct.
Hard / Soft Edit:	Hard
Universe:	WEIGHTKG_C lt 2 or WEIGHTKG_C gt 226

Shape25

Text:

{signal ERR2_WEIGHTKG_C} Please verify that the weight was entered correctly. Probe only if necessary.

Hard / Soft Edit:

Soft

Universe:

(SEX='1' and

Shape26

Question Text:	In the past 12 months, did ^SCNAME play or participate on a sports team or club or take sports lessons either at school or in the community?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1,2,RF,DK> [goto PEGYM_C]

Shape27

Question Text:	In the past 12 months, did ^SCNAME take a Physical Education, PE, or gym class?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1,2,RF,DK> [goto PADAYS_C]

Shape28

Question Text:	In a typical week during the school year, how often does ^SCNAME exercise, play a sport, or participate in physical activity for at least 60 minutes a day? Would you say never, some days, most days, or every day? Read if necessary: Please include exercise in and out of school.
Response:	Never Some days Most days Every day DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1-4,RF,DK> [goto STRENGTH_C]

Shape29

Question Text:

In a typical week during the school year, how often does ^SCNAME do exercises to strengthen or tone ^hisher_C muscles, such as push-ups, sit-ups, or weight lifting? Would you say never, some days, most days, or every day? Read if necessary: Please include lifting or using weights in and out of school.

Response:

DK: Don't Know

RF: Refused

Fills:

^SCNAME Fill ALIAS of HHSTAT_C=1

^hisher_C if GEN.SEX_FINAL[PX_C]=1 fill "his";

else if GEN.SEX_FINAL[PX_C]=2 fill "her";

else if GEN.SEX_FINAL[PX_C] in (blank,DK,RF): fill "their"

Skip Instructions:

<1-4,RF,DK> [goto WALK_C]

Shape31

Question Text:	In a typical week during the school year, how often does ^SCNAME walk for at least 10 minutes at a time? Read if necessary: Would you say never, some days, most days, or every day?
Response:	Never Some days Most days Every day DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1-4,RF,DK> [goto BIKE_C]

Shape32

Question Text:

In a typical week during the school year, how often does ^SCNAME bike for at least 10 minutes at a time? Read if necessary: Would you say never, some days, most days, or every day?

Response:

Never
Some days
Most days
Every day

DK: Don't Know

RF: Refused

Fills:

^SCNAME Fill ALIAS of HHSTAT_C=1

Skip Instructions:

<1-4,RF,DK> [goto Next Section]

Shape34

Question Text:	These next questions are about where ^SCNAME lives. Are there roads, sidewalks, paths or trails near ^hisher_C home where ^SCNAME can walk or ride a bicycle?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1 ^hisher_C if GEN.SEX_FINAL[PX_C]=1 fill "his"; else if GEN.SEX_FINAL[PX_C]=2 fill "her"; else if GEN.SEX_FINAL[PX_C] in (blank,DK,RF): fill "their"
Skip Instructions:	<1,2,RF,DK> [goto PARKS_C]

Shape35

Question Text:	Read if necessary: Where ^SCNAME lives... Are there parks or playgrounds close enough for ^SCNAME to walk or bike to?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1,2,RF,DK> [goto TRAFFIC_C]

Shape36

Question Text:	Where ^SCNAME lives does traffic make it unsafe for ^SCNAME to walk or ride a bicycle, even with an adult?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1,2,RF,DK> [goto CRIME_C]

Shape37

Question Text:	Read if necessary: Where ^SCNAME lives... Does crime make it unsafe for ^SCNAME to walk or ride a bicycle, even with an adult?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1,2,RF,DK> [goto next section]

Shape38

Universe:	HHSTAT_C=1 & AGE_FINAL GE 002 and AGE_FINAL LE 017
Question Text:	In a typical ^SCHOOLWEEK, how often does ^SCNAME wake up well-rested? Would you say never, some days, most days, or everyday?
Response:	Never Some days Most days Every day Refused Not Ascertained Don't Know DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1 ^SCHOOLWEEK school week fill
Skip Instructions:	<1-4,RF,DK> [goto OUTOFBED_C]

Shape39

Universe:	HHSTAT_C='1' & (AGE_FINAL GE '002' and AGE_FINAL LE '017')
Question Text:	In a typical ^SCHOOLWEEK, how often does ^SCNAME have difficulty getting out of bed in the morning? Would you say never, some days, most days, or everyday?
Response:	Never Some days Most days

Page 1 of 4

4. Every day

Refused
Not Ascertained
Don't Know

DK: Don't Know

RF: Refused

Fills:

^SCHOOLWEEK school week fill

^SCNAME Fill ALIAS of HHSTAT_C=1

Skip Instructions:

<1-4,RF,DK> [goto TIRED_C]

Shape40

Universe:	HHSTAT_C="1" & (AGE_FINAL GE '002' AND AGE_FINAL LE '017')
Question Text:	Read if necessary: In a typical ^SCHOOLWEEK... How often does ^SCNAME complain about being tired during the day? Read if necessary: Would you say never, some days, most days, or everyday?
Response:	Never Some days Most days Every day DK: Don't Know RF: Refused
Fills:	^SCHOOLWEEK school week fill ^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1-4,RF,DK> [goto NAPS_C]

Page 2 of 4

Shape41

Universe:	HHSTAT_C='1' & (AGE_FINAL GE '002' and AGE_FINAL LE '017')
Question Text:	Read if necessary: In a typical ^SCHOOLWEEK... How often does ^SCNAME nap or fall asleep during the day, such as in school, watching TV, or riding in a car? Read if necessary: Would you say never, some days, most days, or everyday?
Response:	Never Some days Most days Every day DK: Don't Know RF: Refused
Fills:	^SCHOOLWEEK school week fill ^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1-4,RF,DK> [goto BEDTIME_C]

Shape42

Universe:

HHSTAT_C="1' AND (AGE_FINAL GE '002' and AGE_FINAL LE '017')

Question Text:

In a typical ^SCHOOLWEEKN, how often did ^heshe_C go to bed at the same time? Read if necessary: Would you say never, some days, most days, or everyday?

Response:

Never
Some days
Most days
Every day

DK: Don't Know

RF: Refused

Page 3 of 4

Fills:

^SCHOOLWEEKN school week - bedtime fill

^heshe_C If GEN.SEX_FINAL[PX_C]=1 fill "he"

else if GEN.SEX_FINAL[PX_C]=2 fill "she"

else if GEN.SEX_FINAL[PX_C] in (RF,DK): fill "they"

Skip Instructions:

<1-4,RF,DK> [goto WAKETIME_C]

Shape44

Universe:	HHSTAT_C="1' AND (AGE_FINAL GE '002' and AGE_FINAL LE '017')
Question Text:	In a typical ^SCHOOLWEEKD, how often did ^SCNAME wake up at the same time? Read if necessary: Would you say never, some days, most days, or everyday?
Response:	Never Some days Most days Every day DK: Don't Know RF: Refused
Fills:	^SCHOOLWEEKD school week - wake time fill ^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1-4,RF,DK> [goto next section]

Shape45

Universe:	HHSTAT_C=1
Question Text:	On most weekdays, does ^SCNAME spend more than 2 hours a day in front of a TV, computer, cellphone or other electronic device watching programs, playing games, accessing the internet, or using social media? Read if necessary: Do not include time spent doing school work.
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1,2,RF,DK> [goto next section]

Shape46

Question Text:	The next set of questions asks about all types of injuries. People can be injured accidentally, or on purpose. They may hurt themselves or others may cause them to be hurt. Enter '1' to continue.
Response:
Skip Instructions:	<1> [goto ANYINJURY_C]

Shape47

Question Text:	During the past 3 months, did ^SCNAME have an accident or an injury where any part of ^hisher_C body was hurt?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1 ^hisher_C if GEN.SEX_FINAL[PX_C]=1 fill "his"; else if GEN.SEX_FINAL[PX_C]=2 fill "her"; else if GEN.SEX_FINAL[PX_C] in (blank,DK,RF): fill "their"
Skip Instructions:	<1> [goto INJLIMIT_C] <2,RF,DK> [goto next section]

Shape48

Universe:	ANYINJURY_C=1
Question Text:	Did any of these injuries limit ^SCNAME's usual activities for at least 24 hours after the injury occurred?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1> [goto NUMINJ_C] <2,RF,DK> [goto next section]

Shape49

Universe:	INJLIMIT_C=1
Question Text:	For the next questions, please think only about the significant injuries that occured during the past 3 months. By significant, I mean those injuries that limited ^SCNAME's usual activities for at least 24 hours after the injury occured. During the past 3 months, how many times did ^SCNAME have a significant injury? Enter 96 if number is 96 or greater
Response:	DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1-9,RF,DK> [goto INJHOME_C] <10-96> [goto ERR1_NUMINJ_C]

Shape50

Text:	{signal ERR1_NUMINJ_C} ^NUMINJ_C is an unusually large number. Please verify.
Hard / Soft Edit:	Soft
Fills:
Universe:	NUMINJ_C>=10 & NUMINJ_C<=96

Shape51

Universe:	INJLIMIT_C=1
Question Text:	During the past 3 months did ^siginj_C occur while ^SCNAME was at ^hisher_C home? Read if necessary: Include the yards, garage, basement, and other places on the home property.
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^siginj_C the significant injury/any significant injuries ^SCNAME Fill ALIAS of HHSTAT_C=1 ^hisher_C if GEN.SEX_FINAL[PX_C]=1 fill "his"; else if GEN.SEX_FINAL[PX_C]=2 fill "her"; else if GEN.SEX_FINAL[PX_C] in (blank,DK,RF): fill "their"
Skip Instructions:	<1> if NUMINJ_C=1 & AGE_FINAL LE 2 [goto INJFALL_C] elseif NUMINJ_C=1 & AGE_FINAL GE 3 [goto INJSPORTS_C] elseif (NUMINJ_C>1 OR NUMINJ_C in (RF,DK)) [goto INJSCHOOL_C] <2,RF,DK> [goto INJSCHOOL_C]

Shape52

Universe:	INJLIMIT_C=1 & ((NUMINJ_C>1 or NUMINJ_C in (DK,RF)) or (NUMINJ_C=1 & INJHOME_C IN (2,RF,DK))
Question Text:	During the past 3 months, did ^siginj_C occur while ^SCNAME was at ^DAYCARESCHOOL? Read if necessary: Include classrooms, playgrounds, sports fields, swimming pools, parking lots and other places on school or daycare property.
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^siginj_C the significant injury/any significant injuries ^SCNAME Fill ALIAS of HHSTAT_C=1 ^DAYCARESCHOOL If GEN.AGE_FINAL[PX_C] ge 0 and GEN.AGE_FINAL[PX_C] le 2, fill: "daycare" If GEN.AGE_FINAL[PX_C] ge 3 and GEN.AGE_FINAL[PX_C] le 5, fill: "school or daycare" ifGEN.AGE_FINAL[PX_C] ge 6 and GEN.AGE_FINAL[PX_C] le 17, fill: "school"
Skip Instructions:	<1,2,RF,DK> if AGE_FINAL<3 [goto INJFALL_C] elseif AGE_FINAL>=3 [goto INJSPORTS_C]

Shape53

Universe:	INJLIMIT_C=1 & AGE_FINAL GE 3 & AGE_FINAL LE 17
Question Text:	During the past 3 months, did ^siginj_C occur while ^SCNAME was playing sports or exercising, including walking, biking, or running, playing baseball, basketball, football or doing any other physical activity? Read if necessary: Include recreational sports such as skating, skiing, tennis, golf, bowling, or fishing.
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^siginj_C the significant injury/any significant injuries ^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1,2,RF,DK> [goto INJFALL_C]

Shape54

Universe:	INJLIMIT_C=1
Question Text:	During the past 3 months, did ^siginj_C occur as a result of a fall or falling?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^siginj_C the significant injury/any significant injuries

Page 5 of 13

Skip Instructions:

<1> if NUMINJ_C=1 [goto INJMOTOR_C]

elseif NUMINJ_C>1 or NUMINJ>C IN ('RF','DK') & INJHOME_C=1 [goto INJFALLHOM_C]

elseif NUMINJ_C>1 or NUMINJ>C IN ('RF','DK') & INJSCHOOL_C=1 [goto INJFALLSCH_C]

else [goto INJMOTOR_C]

<2,RF,DK> [goto INJMOTOR_C]

Shape56

Universe:	INJLIMIT_C=1 & (NUMINJ_C>1 OR NUMINJ_C in (RF,DK)) & INJFALL_C=1 & INJHOME_C=1
Question Text:	Did any fall occur while ^SCNAME was at ^hisher_C home?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1 ^hisher_C if GEN.SEX_FINAL[PX_C]=1 fill "his"; else if GEN.SEX_FINAL[PX_C]=2 fill "her"; else if GEN.SEX_FINAL[PX_C] in (blank,DK,RF): fill "their"
Skip Instructions:	<1,2,RF,DK> if INJSCHOOL_C=1 [goto INJFALLSCH_C] else [goto INJMOTOR_C]

Shape57

Universe:	INJLIMIT_C=1 & (NUMINJ_C>1 OR NUMINJ_C in (RF,DK)) & INJFALL_C=1 & INJSCHOOL_C=1
Question Text:	Did any fall occur while ^SCNAME was at ^DAYCARESCHOOL?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1 ^DAYCARESCHOOL If GEN.AGE_FINAL[PX_C] ge 0 and GEN.AGE_FINAL[PX_C] le 2, fill: "daycare" If GEN.AGE_FINAL[PX_C] ge 3 and GEN.AGE_FINAL[PX_C] le 5, fill: "school or daycare" ifGEN.AGE_FINAL[PX_C] ge 6 and GEN.AGE_FINAL[PX_C] le 17, fill: "school"
Skip Instructions:	<1,2,RF,DK> [goto INJMOTOR_C]

Shape58

Universe:	INJLIMIT_C=1
Question Text:	During the past 3 months, did ^siginj_C occur as a result of being in a motor vehicle crash or being hit by a motor vehicle while walking or biking? Read if necessary: Motor vehicles include cars, trucks, vans, buses, motorcyles, motorized scooters, motorized carts, tractors, ATVs, snowmobiles, dune buggies, and other motorized vehicles.

Response:

DK: Don't Know

RF: Refused

Fills:

^siginj_C the significant injury/any significant injuries

Skip Instructions:

<1> [goto INJMVTYPE_C]

<2,RF,DK> [goto INJSAWDOC_C]

Shape59

Universe:	INJLIMIT_C=1 & INJMOTOR_C=1
Question Text:	Was ^SCNAME a ^DRIVER passenger, bicyclist, pedestrian, or doing something else when this occurred?
Response:	Driver Passenger Bicyclist Pedestrian Something else DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1 ^DRIVER whether child was driver
Skip Instructions:	<1-5,RF,DK> [goto INJSAWDOC_C]

Shape60

Universe:	INJLIMIT_C=1
Question Text:	During the past 3 months, did ^SCNAME see a doctor or other health professional about ^siginj_C?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1 ^siginj_C the significant injury/any significant injuries
Skip Instructions:	<1> if EMERGE12M_C IN (1-96,RF,DK) [goto INJER_C] elseif EMERGE12M_C=0 & HOSPONGT_C IN (1,RF,DK) [goto INJHOSP_C] else [goto INJBONES_C] <2,RF,DK> [goto INJSCHDAYS_C]

Shape61

Universe:

INJLIMIT_C=1 & INJSAWDOC_C=1 & EMERGE12M_C in (1-96,RF,DK)

Question Text:

During the past 3 months, did ^SCNAME go to an emergency room because of

^siginj_C?

Response:

DK: Don't Know

RF: Refused

Fills:

^SCNAME Fill ALIAS of HHSTAT_C=1

^siginj_C the significant injury/any significant injuries

Skip Instructions:

<1,2,RF,DK> if HOSPONGT_C IN (1,RF,DK) [goto INJHOSP_C]

else [goto INJBONES_C]

Shape63

Universe:	INJLIMIT_C=1 & INJSAWDOC_C=1 & HOSPONGT_C IN (1,RF,DK)
Question Text:	During the past 3 months, was ^SCNAME hospitalized overnight for ^siginj_C?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1 ^siginj_C the significant injury/any significant injuries
Skip Instructions:	<1,2,RF,DK> [goto INJBONES_C]

Shape64

Universe:

INJLIMIT_C=1 & INJSAWDOC_C=1

Question Text:

During the past 3 months, did ^SCNAME have any broken bones as a result of

^siginj_C?

Response:

1. Yes

2. No

DK: Don't Know

RF: Refused

Fills:

^SCNAME Fill ALIAS of HHSTAT_C=1

^siginj_C the significant injury/any significant injuries

Skip Instructions:

<1,2,RF,DK> [goto INJSTITCH_C]

Shape65

Universe:	INJLIMIT_C=1 & INJSAWDOC_C=1
Question Text:	During the past 3 months, did ^SCNAME get any stitches or staples because of ^siginj_C?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1 ^siginj_C the significant injury/any significant injuries
Skip Instructions:	<1,2,RF,DK> [goto INJSCHDAYS_C]

Page 11 of 13

Shape66

Universe:	INJLIMIT_C=1
Question Text:	During the past 3 months, how many days of ^DAYCARESCHOOL did ^SCNAME miss because of ^siginj_C? Enter 90 if ^SCNAME missed every day of daycare or school in the past 3 months
Response:	DK: Don't Know RF: Refused
Fills:	^DAYCARESCHOOL If GEN.AGE_FINAL[PX_C] ge 0 and GEN.AGE_FINAL[PX_C] le 2, fill: "daycare" If GEN.AGE_FINAL[PX_C] ge 3 and GEN.AGE_FINAL[PX_C] le 5, fill: "school or daycare" ifGEN.AGE_FINAL[PX_C] ge 6 and GEN.AGE_FINAL[PX_C] le 17, fill: "school" ^SCNAME Fill ALIAS of HHSTAT_C=1 ^siginj_C the significant injury/any significant injuries
Skip Instructions:	<0,DK> [goto next section] <1-90,RF> [goto INJFUTSCH_C]

Shape67

Universe:

INJSCHDAYS_C>=1 & INJSCHDAYS_C<=90 or INJSCHDAYS_C=DK

Question Text:

Do you expect ^SCNAME to miss any more days of ^DAYCARESCH because of

^siginj_C that occurred during the past 3 months?

Response:

1. Yes

Page 12 of 13

2. No

DK: Don't Know

RF: Refused

Fills:

^siginj_C the significant injury/any significant injuries

^SCNAME Fill ALIAS of HHSTAT_C=1

^DAYCARESCH DAYCARESCH

Skip Instructions:

<1,2,RF,DK> [goto next section]

Shape68

Question Text:	The next questions are about head injuries that may have occured anytime in ^SCNAME's life. Please think about all head injuries, for example, from playing sports, car accidents, falls, or being hit by something or someone.
Response:	1. Enter 1 to Continue
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1> [goto TBILOSTCON_C]

Shape69

Question Text:	As a result of a blow or jolt to the head, has ^SCNAME ever been knocked out or lost consciousness? Read if necessary: Please think about all head injuries, for example, from playing sports, car accidents, falls, or being hit by something or someone.
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1> [goto TBICHKCONC_C] <2,RF,DK> [goto TBIDAZED_C]

Shape70

Universe:	TBILOSTCON_C IN (2,RF,DK)
Question Text:	As a result of a blow or jolt to the head, has ^SCNAME ever been dazed or had a gap in ^hisher_C memory? Read if necessary: Please think about all head injuries, for example, from playing sports, car accidents, falls, or being hit by something or someone.
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1 ^hisher_C if GEN.SEX_FINAL[PX_C]=1 fill "his"; else if GEN.SEX_FINAL[PX_C]=2 fill "her"; else if GEN.SEX_FINAL[PX_C] in (blank,DK,RF): fill "their"
Skip Instructions:	<1,2,RF,DK> [goto TBIHEADSYM_C]

Shape71

Universe:

TBILOSTCON_C IN (2,RF,DK)

Question Text:

As a result of a blow or jolt to the head, has ^SCNAME had headaches, vomiting, blurred vision, or changes in mood or behavior? Read if necessary: Please think about all head injuries, for example, from playing sports, car accidents, falls, or being hit by something or someone.

Response:

DK: Don't Know

RF: Refused

Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1,2,RF,DK> [goto TBICHKCONC_C]

Shape73

Question Text:	Has ^SCNAME ever been checked for a concussion or brain injury by a doctor, nurse, athletic trainer, or other health care professional?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1
Skip Instructions:	<1,DK> [goto TBIDRCONC_C] <2,RF> [goto next section]

Shape74

Universe:	TBICHKCONC_C IN (1,DK)
Question Text:	Did a doctor, nurse, athletic trainer, or other health care professional ever say that ^SCNAME had a concussion or brain injury?
Response:	Yes No DK: Don't Know RF: Refused
Fills:	^SCNAME Fill ALIAS of HHSTAT_C=1

Skip Instructions:

<1,2,RF,DK> [goto next section]

Page 4 of 4

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Modified	0000-00-00
File Created	2021-01-14