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pdfAttachment 4c - Main Questionnaire Child Section
OMB Number 0920-0214 Expires: xx/xx/20xx
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. In addition, NCHS complies with the Federal Cybersecurity Enhancement Act of
2015 (6 U.S.C. §§ 151 & 151 note). This law requires the federal government to protect federal computer networks
by using computer security programs to identify cybersecurity risks like hacking, internet attacks, and other security
weaknesses. If information sent through government networks triggers a cyber threat indicator, the information may
be intercepted and reviewed for cyber threats by computer network experts working for, or on behalf of, the
government.
Notice – Public reporting burden of this collection of information is estimated to average 10 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).
2018 Q1 NHIS Instrument Spec Report
Section name: Child Identification and Verification
Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.001
Variable Name
CURRES
Universe
HHSTAT4 = 'C' and (CSTAT = empty or CSTAT = '2')
Universe-text
Sample child section not started or not completed
Question Text
* Enter the line number of the person to whom you are speaking.
Answer Codes
01-25
Question Type
Integer
Field Pane Description
Line Number of Current Respondent
Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Allowable entries are all non-deleted persons in the family with AGE ge '18' or with
HHSTAT4 = 'E'. Allow only the line numbers of these persons to be acceptable
entries.
Skip Instructions
if CSTAT ne empty and CSTAT ne '2' THEN
if ASTAT = empty or ASTAT = '2' THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG ne '1' THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif
goto back.OUTCOMEB1 procedure
endif
<01-25> if this is NOT an allowable line number
goto ERR_CURRES
elseif CURRES = a line number entered in KNOWSC2
store CURRES in CSPAVAIL and CSRESP
goto CSRELTIV
elseif KNOWSC2 = 'Don't know' or 'Refused' or empty (no line numbers in
KNOWSC2)
goto KNOAVAIL
else
goto CSPAVAIL
endif
Hard Edits
ERR_CURRES
* You have selected a non-selectable person.
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* Please correct.
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Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.009
Variable Name
CSRESP
Universe
Universe-text
Question Text
Answer Codes
01-25, 96
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions Storage variable for the line number of the Sample Child section respondent.
Skip Instructions
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Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.010
Variable Name
CSPAVAIL
Universe
KNOWSC2 ne empty and KNOWSC2 ne 'Don't know' and KNOWSC2 ne 'Refused'
and CURRES ne empty and CURRES ne any line number in KNOWSC2
Universe-text
Someone identified as knowledgeable about child's health and knowledgeable
person(s) not entered in CURRES
Question Text
The next questions are about [fill1: ALIAS of Sample Child].
Is [fill2:KNOWSC2 names] available to answer some questions about [fill3: HISHER]
health?
* Enter line number of available respondent from list or enter '96' if no one is available.
* If refused enter CTRL_R.
Answer Codes
display roster of line numbers and names for all persons listed on KNOWSC2
96. No one available
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Line Number of Available Respondent
fill2 = [all names for line numbers entered in KNOWSC2]
display up to three names with the word "or" between each name in the question text
Special Instructions Do not allow "Don't Know" as an answer.
Skip Instructions
<01-25> if line number not equal one of the line numbers in KNOWSC2
goto child.cid.ERR_CSPAVAIL
else
store child.cid.CSPAVAIL in child.cid.CSRESP
goto child.cid.CSRELTIV
endif
<96> store child.cid.CSPAVAIL in child.cid.CSRESP
goto cbk.CCALLBK1
store '4' in CSTAT(FAMINT)
if ASTAT = empty or ASTAT = '2' THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG ne '1' THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif
Hard Edits
ERR_CSPAVAIL
* You have selected a non-selectable person.
* Please correct.
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Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.015
Variable Name
KNOAVAIL
Universe
(KNOWSC2 = empty or KNOWSC2 = 'Don't know' or KNOWSC2 = 'Refused') and
CURRES ne empty
Universe-text
No line numbers entered in KNOWSC2 and some person's line number entered in
CURRES
Question Text
The next questions are about [fill1: ALIAS of Sample Child]. Is there any family
member available who can answer questions about [fill2: HISHER] health?
* Enter line number of available respondent from list or enter "96" if no one is
available.
* If refused enter CTRL_R.
Answer Codes
display roster of line numbers and names of all non-deleted adults (AGE ge '18') and
emancipated minors (HHSTAT4 = 'E') in the family
96. No one available
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Line Number of Any Respondent Available
Fill Instructions
Special Instructions Do not allow "Don't Know" as an answer.
Skip Instructions
<01-25> if line number is not an adult or emancipated minor
goto child.cid.ERR_KNOAVAIL
else
store child.cid.KNOAVAIL in child.cid.CSRESP
goto child.cid.CSRELTIV
endif
<96> store child.cid.KNOAVAIL in child.cid.CSRESP
goto cbk.CCALLBK1
store '4' in CSTAT(FAMINT)
if ASTAT = empty or ASTAT = '2' THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG ne '1' THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif
Hard Edits
ERR_KNOAVAIL
* You have selected a non-selectable person.
* Please correct.
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Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.030
Variable Name
CSRELTIV
Universe
(CURRES ne empty and CURRES = line number entered in KNOWSC2) or
(CSPAVAIL ne empty and CSPAVAIL ne '96' and CSPAVAIL ne 'Refused') or
(KNOAVAIL ne empty and KNOAVAIL ne '96' and KNOAVAIL ne 'Refused')
Universe-text
Someone identified as knowledgeable about child's health
Question Text
(book) C1
[fill1: The next questions are about [fill2: ALIAS of Sample Child].]
What is your relationship to [fill2: ALIAS of Sample Child]?
Answer Codes
1. Parent (Biological, adoptive, or step)
2. Grandparent
3. Aunt/Uncle
4. Brother/Sister
5. Other relative
6. Legal guardian
7. Foster parent
8. Other non-relative
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Child Respondent's Relationship to Child
[fill1: The next questions are about [fill2: ALIAS of Sample Child].] is a fill of the lead-in
statement for situations where CSRELTIV is the next question asked after CURRES
{i.e., CURRES = a line number entered in KNOWSC2).
Special Instructions if CURRES = a line number entered in KNOWSC2 then
display [fill1:] before the question text on this screen
else
display only the question text
endif
Skip Instructions
<1-8,R,D> If CSRESP = demographics.hhc.RELRESP_A
goto child.chs.BWGT_LB
elseif CSRESP = demographics.hhc.HHRESP
goto child.chs.BWGT_LB
else]
goto CSPVERF_S
endif]
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Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.035
Variable Name
SCDATE
Universe
CSRELTIV = response
Universe-text
Sample Child section has been started and child respondent's relationship given.
Question Text
Answer Codes
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions Set only if SCDATE = empty
If CSRELTIV ne empty
set SCDATE = CDATE (current date) (now called ComputationDate)
endif
This is an output variable that should be in the format 'MMDDYYYY'
Skip Instructions
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Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.036
Variable Name
SCTIME
Universe
CSRELTIV = response
Universe-text
Sample Child section has been started and child respondent's relationship given.
Question Text
Answer Codes
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions Set only if SCTIME = empty
If CSRELTIV ne empty
set SCTIME = current time
endif
This is an output variable that should be in the format "HH:MM [fill: a.m./p.m.]
Skip Instructions
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Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.040
Variable Name
CSPVERF_S
Universe
RELRESP_A ne CSRESP and HHRESP ne CSRESP
Universe-text
Respondent is not the person entered in HHRESP or RELRESP_A.
Question Text
* Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]'s sex as [fill2: Sex of Sample Child]. Is
this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".
Answer Codes
1. Yes
2. No
Question Type
Yes/No
Field Pane Description
Verified Child's Sex
Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Skip Instructions
<1> goto CSPVERF_A
<2> goto NEWSEX
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Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.041
Variable Name
NEWSEX
Universe
CSPVERF_S = '2' (No)
Universe-text
Respondent said child's sex is not correct.
Question Text
Is [fill: ALIAS of Sample Child] Male or Female?
*If don't know or refused enter your best guess.
Answer Codes
1. Male
2. Female
Question Type
Pick One - answer list pane
Field Pane Description
Child's Revised Sex
Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Skip Instructions
<1,2> store NEWSEX in SEX
goto ERR_NEWSEX
reset CSPVERF_S
goto CSPVERF_S
Hard Edits
ERR_NEWSEX
* The gender will now be changed to [fill: NEWSEX].
goto CSPVERF_S (as the default goto)
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Tuesday, June 13, 2017
Page 10 of 23
Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.042
Variable Name
CSPVERF_A
Universe
CSPVERF_S ne empty
Universe-text
Respondent verified child's sex
Question Text
* Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]'s age as [fill2: Age of Sample Child]
old. Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".
Answer Codes
1. Yes
2. No
Question Type
Yes/No
Field Pane Description
Fill Instructions
Verified Child's Age
If Sample Child's age in AGE is > "0"
[fill2: years]
else
[fill2: less than a year]
endif
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Display the most recently updated age in years to the right of the answer box in the
field pane, e.g., if the age is '15' display '15 years old'. For the case where the age is
'0' years, display 'less than a year old'.
Skip Instructions
<1> goto CSPVERF_D
<2> goto NEWAGE
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Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.043
Variable Name
NEWAGE
Universe
CSPVERF_A = ''2' (No)
Universe-text
Respondent said child's age is not correct
Question Text
How old is [fill1: ALIAS of Sample Child]?
* If age given in months, weeks, or days, convert age to appropriate year. If less than
one year old, enter "0".
Answer Codes
Question Type
Integer
Field Pane Description
Child's Revised Age
Fill Instructions
Special Instructions
Skip Instructions
<0-120, Refused, Don't know>
if NEWAGE = 'Refused' or NEWAGE = 'Don't know' or NEWAGE = AGE
reset CSPVERF_A
goto ERR_NEWAGE
else
store NEWAGE in AGE
goto NEWDOB_M
Hard Edits
ERR_NEWAGE
*Age of [fill1: ALIAS of Sample Child] remains [fill2: Age of Sample Child] years old.
goto CSPVERF_A (whether suppressed or not)
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Tuesday, June 13, 2017
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Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.044
Variable Name
CSPVERF_D
Universe
CSPVERF_S ne empty
Universe-text
Respondent verified child's sex
Question Text
* Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]'s birthday as [fill2: Birthday of Sample
Child]. Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".
Answer Codes
1. Yes
2. No
Question Type
Yes/No
Field Pane Description
Fill Instructions
Verified Child's Date of Birth
[fill2: , ] = date of birth, where should be filled
with the name of the month, not the number. For any part of the birth date that is
"refused", "don't know", or otherwise "blank", put a "?" for that field.
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Skip Instructions
<1> if AGE of Sample Child ge '18'
goto CNO_MORE
else
goto child.chs.BWGT_LB
endif
<2> goto NEWDOB_M
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Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.046_1
Variable Name
NEWDOB_M
Universe
CSPVERF_D = '2' (No) or CSPVERF_A = '2' (No)
Universe-text
Respondent said child's date of birth is not correct or child's age is not correct
Question Text
1 of 3
What is [fill: ALIAS of Sample Child]'s birthday?
*Enter month of birth.
Answer Codes
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Child's Revised Month of Birth
Fill Instructions
Special Instructions Display the name of the month for the answer entered in this question to the right of
the answer box in the field pane, e.g., if '10' is entered, display 'October'. If 'Refused'
or 'Don't know' is entered, do not display anything to the right of the answer box.
Skip Instructions
<01-12, Refused, Don't know> goto NEWDOB_D
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Page 14 of 23
Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.046_2
Variable Name
NEWDOB_D
Universe
CSPVERF_D = '2' (No) or CSPVERF_A = '2' (No)
Universe-text
Respondent said child's date of birth is not correct or child's age is not correct
Question Text
2 of 3
* Enter day of birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Child's Revised Day of Birth
[fill3: NEWDOB_M] = month of birth, where should be filled with the
name of the month, not the number.
Special Instructions Only allow valid days for month entered.
Skip Instructions
<01-31,Refused,Don't know> goto NEWDOB_Y
If days not valid, goto ERR_NEWDOB_D
Hard Edits
ERR_NEWDOB_D
* [fill2: NEWDOB_D] is not a valid day for [fill3: NEWDOB_M].
* Please correct.
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Page 15 of 23
Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.046_3
Variable Name
NEWDOB_Y
Universe
CSPVERF_D = '2' (No) or CSPVERF_A = '2' (No)
Universe-text
Respondent said child's date of birth is not correct or child's age is not correct
Question Text
3 of 3
* Enter year of birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Child's Revised Year of Birth
[fill2: , ] = date of birth, where
should be filled with the name of the month, not the number. For any
part of the birth date that is "refused", "don't know", or otherwise "blank", put a "?" for
that field.
[fill3: , ] = date of birth, where should be filled
with the name of the month, not the number. For any part of the birth date that is
"refused", "don't know", or otherwise "blank", put a "?" for that field.
Special Instructions
Skip Instructions
<1880-2020, Refused, Don't know> if CSPVERF_A = '2' (No) then reset CSPVERF_A
to empty
goto CSPVERF_A
elseif CSPVERF_D = '2' (No) then reset
CSPVERF_D to empty
goto CSPVERF_D
endif
(if year GT current year) or (if year = current year and month GT current month) or (if
year = current year and month = current month and day GT current day)
goto ERR1_NEWDOB_Y
endif
(if birth month = '02' and birth day = '29' and this is not a leap year)
goto ERR2_NEWDOB_Y
endif
(if NEWDOB_M = 'Ref' or 'DK') or (if NEWDOB_D = 'Ref' or 'DK') or (if NEWDOB_Y =
'Ref' or 'DK')
goto ERR3_NEWDOB_Y
else
store NEWDOB_M in DOBM
store NEWDOB_D in DOBD
store NEWDOB_Y in DOBY
if CSPVERF_A = '2' (No) then reset CSPVERF_A to empty
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goto CSPVERF_A
elseif CSPVERF_D = '2' (No) then reset CSPVERF_D to empty
goto CSPVERF_D
endif
endif
Calculate age from NEWDOB_M, NEWDOB_D, and NEWDOB_Y.
if age from NEWDOB items is ne AGE and age from NEWDOB items is valid
reset CSPVERF_A or CSPVERF_D
goto ERR4_NEWDOB_Y
endif
Hard Edits
ERR1_NEWDOB_Y
*Future date invalid: [fill2: , ]
*Please correct.
goto NEWDOB_M (whether suppressed or not)
ERR2_NEWDOB_Y
*Not a valid day: [fill2: , ]
*Please correct.
goto NEWDOB_M (whether suppressed or not)
ERR3_NEWDOB_Y
*DOB of [fill1: ALIAS of Sample Child] remains [fill3: , ]
goto CSPVERF_A
ERR4_NEWDOB_Y
*Data mismatched. Please fix Age or Birthday.
goto CSPVERF_A (whether suppressed or not)
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Tuesday, June 13, 2017
Page 17 of 23
Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.048
Variable Name
CNO_MORE
Universe
[(CSTAT = empty or CSTAT = '2') and HHSTAT4 = 'C' and AGE ge '18']
Universe-text
Sample child whose age is now 18+
Question Text
* [fill: ALIAS of Sample Child] is no longer the sample child for this family.
* You may need to ask additional questions before continuing with the rest of the
interview.
Answer Codes
1. Enter 1 to Continue
Question Type
Enter 1 to Continue
Field Pane Description
This Person No Longer Sample Child
Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Skip Instructions
<1> store '0' in CSTAT
store empty in HHSTAT4
if there is a sample adult (HHSTAT4 = 'S') and (if ASTAT = empty or ASTAT = '2')
goto adult.aid.SADULT
elseif rec.RCIFLAG ne '1'
goto rec.RCI_BEGIN
else
goto bck.OUTCOMEB1
endif
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Page 18 of 23
Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.050
Variable Name
CAGECHG
Universe
HHSTAT4 = 'C' and NEWAGE ne empty and NEWAGE ne original age
Universe-text
Question Text
* Because you changed the Sample child's age, you may need to ask additional
questions before continuing with the rest of the interview.
Answer Codes
1. Enter 1 to Continue
Question Type
Enter 1 to Continue
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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Page 19 of 23
Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.052
Variable Name
SCSSN4
Universe
HHSTAT4 = 'C' and AGE <18
Universe-text
All sample children less than 18 years old
Question Text
?[F1]
Finally, we would like the last four digits of [fill 1: ALIAS]’s Social Security Number.
This information will help us link [fill 1: ALIAS]’s survey data with other health-related
records, and allow us to conduct additional research without taking up your time with
more questions. The National Center for Health Statistics (NCHS) uses this
information for research purposes only. Providing this information is voluntary. There
will be no effect on [fill 1: ALIAS]’s benefits if you do not provide this information.
Federal laws authorize us to ask for this information. Like all other information you
have provided, your answer to this question will not be disclosed by NCHS or its
agents, which includes the U.S. Census Bureau.
* Read if necessary: The specific federal laws protecting your privacy and the
confidentiality of your data are the Public Health Service Act (Title 42, U.S.C., Section
242m(d)), the Confidential Information Protection and Statistical Efficiency Act (Title 5
of Public Law 107-347), and the Privacy Act of 1974 (5 U.S.C. § 552a). In addition,
NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C.
§§ 151 & 151 note), which requires the federal government to protect federal
computer networks by using computer security programs to identify cybersecurity risks
like hacking, internet attacks, and other security weaknesses.
What are the last four digits of [fill 1: ALIAS]’s Social Security Number?
* Enter 'N' if no Social Security Number.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
SSN
[fill 1: Alias] is the sample child's name
Special Instructions Allow 4 digits. QUESTION SHOULD APPEAR AT THE END OF SAMPLE CHILD
QUESTIONNAIRE.
Skip Instructions
<0001-9999> goto SCSSNRP4
<0-999> goto ERR1_SCSSN4
<0000> goto ERR2_SCSSN4
[goto SCRLINK]
Hard Edits
ERR1_SCSSN4
* You must enter all four of the last four digits of the Social Security Number.
* Please correct.
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Page 20 of 23
ERR2_SCSSN4
* The last 4 digits of a SSN may be between 0001-9999.
* Please correct.
* For a respondent who does not want to provide the SSN, enter 'Ctrl D' or 'Ctrl R' for
'Don't Know' or 'Refused.'
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AssocHelp
H_LNKINTRO
Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.053
Variable Name
SCSSNRP4
Universe
SCSSN4 ne blank, 'N', 'Refused', or 'Don't know'
Universe-text
Last four digits of the SSN were given at SCSSN4
Question Text
* Enter how the last four digits of the Social Security Number were reported.
Answer Codes
1. From memory
2. From records
Question Type
Pick One - answer list pane
Field Pane Description
SSN memory or records
Fill Instructions
Special Instructions Do not allow 'Refused' or 'Don't know'. QUESTION SHOULD BE ASKED AT THE
END OF MODULE 37.
Skip Instructions
<1,2> goto SCSSNTL4
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Tuesday, June 13, 2017
Page 21 of 23
Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.054
Variable Name
SCSSNTL4
Universe
All from SCSSNRP4
Universe-text
Recorded how last four digits of the SSN were reported
Question Text
* Select one category below to indicate reporting of the last four digits of the Social
Security Number.
Answer Codes
1. In person
2. Telephone
Question Type
Pick One - answer list pane
Field Pane Description
SSN in person or phone
Fill Instructions
Special Instructions Do not allow 'Refused' or 'Don't know'. QUESTION SHOULD BE ASKED AT THE
END OF MODULE 37.
Skip Instructions
<1,2> goto beginning of Sample Adult, Recontact, or Back section
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Tuesday, June 13, 2017
Page 22 of 23
Module
10
Section Name
Child Identification and Verification
Part
Question ID
CID.055
Variable Name
SCRLINK
Universe
HHSTAT4 = 'C' and SCSSN4='N', refused, don't know
Universe-text
Sample child less than 18 where the response to SCSSN4 was no SSN, refused, or
don't know
Question Text
?[F1]
May we try to link [fill 1: ALIAS]’s survey data without a Social Security Number?
* Read if necessary: Any data obtained are protected by strict federal laws, including
the Public Health Service Act, which is Title 42, U.S.C., Section 242m(d); the
Confidential Information Protection and Statistical Efficiency Act, which is Title 5 of
Public Law 107-347; and the Privacy Act of 1974, which is 5 U.S.C. § 552a. In
addition, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6
U.S.C. §§ 151 & 151 note), which requires the federal government to protect federal
computer networks by using computer security programs to identify cybersecurity risks
like hacking, internet attacks, and other security weaknesses.
Answer Codes
1. Yes
2. No
Refused
Don’t know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Linkage
fill 1: fill the sample child's name
Special Instructions QUESTION SHOULD BE ASKED AT THE END OF MODULE 37.
Skip Instructions
<1,2,R,D> [goto beginning of Sample Adult, Recontact or Back section]
Hard Edits
Soft Edits
AssocHelp
H_LNKINTRO
Tuesday, June 13, 2017
Page 23 of 23
2018 Q1 NHIS Instrument Spec Report
Section name: Child Conditions, Limitations, Health
Behaviors
Module
11
Section Name
Child Conditions, Limitations, Health Behaviors
Part
A
Question ID
CHS.010_01.000
Variable Name
BWGT_LB
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')
Universe-text
Sample children <18
Question Text
?[F1]
What was [fill: S.C.name]'s birth weight?
* Enter 'M' to record metric measurements.
Answer Codes
Question Type
Integer
Field Pane Description
Pounds
Fill Instructions
Special Instructions Formpane = variable description "pounds" on right; label "Birth weight" on left;
column heading = "US Customary"
Skip Instructions
<1-12> [goto BWGT_OZ]
<13-15> [goto ERR1_BWGT_LB]
[goto CHGT_FT]
[goto BWGT_GR]
[If NE <1-15, M, D, R> goto ERR2_BWGT_LB]
Hard Edits
ERR2_BWGT_LB
* Only "1-15" or "M" or "Don't know/Refused" allowed in this field.
* Please correct.
Soft Edits
ERR1_BWGT_LB
* [fill: BWGT_LB] is an unusually high number.
* Please verify.
AssocHelp
H_BWGT
Tuesday, June 13, 2017
Page 1 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.010_02.000
Variable Name
BWGT_OZ
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and BWGT_LB = <1-15>
Universe-text
Sample children <18 who have a value entered for weight in pounds.
Question Text
* Enter ounces.
Answer Codes
Question Type
Integer
Field Pane Description
Ounces
Fill Instructions
Special Instructions Formpane = variable description "ounces" on right
Skip Instructions
<0-15,R,D> [goto CHGT_FT]
[if BWGT_LB = <0-15, D, R> and BWGT_OZ = go to CHGT_FT]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 2 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Behaviors
Part
A
Question ID
CHS.010_H
Variable Name
H_BWGT
Universe
Universe-text
Question Text
If respondent insists weight is more than 15 pounds and 15 ounces, enter "15" for
each category and continue with next question. Enter a "Control D" or "Control R" for
an answer of "Don't Know" or "Refused."
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
BWGT_LB
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 3 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.011_00.000
Variable Name
BWGT_GR
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and BWGT_LB = M
Universe-text
Sample children <18 whose birth weight will be entered in metric.
Question Text
* Enter weight in grams.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Grams
fill2 and fill3 = BWGT_GR converted to pounds and ounces, round ounces to nearest
whole number
Special Instructions Formpane = variable description "grams" on right; label "Birth weight" on left; column
heading "Metric"
Skip Instructions
<500-5485, R,D> [goto CHGT_FT]
<5486-6900> [goto ERR_BWGT_GR]
Hard Edits
Soft Edits
ERR_BWGT_GR
* [fill1: BWGT_GR] is an unusually high number (equal to [fill2] pounds, [fill3]
ounces).
* Please verify.
AssocHelp
Tuesday, June 13, 2017
Page 4 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.020_01.000
Variable Name
CHGT_FT
Universe
HHSTAT4='C' and (AGE GE '012' and AGE NE ' ')
Universe-text
Sample children GE 12
Question Text
?[F1]
How tall is [fill: S.C. name] now (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.
Answer Codes
Question Type
Integer
Field Pane Description
Feet
Fill Instructions
Special Instructions Formpane = variable description "feet" on right; label "Current height" on left
Don't allow a '.' (a period) after a number. This is a 2 character field and will be
picked up in output
Skip Instructions
[goto CHGT_IN]
<0-7> [goto CHGT_IN]
[goto CWGT_LB]
[goto CHGT_M]
[If NE <0-7, M, D, R> go to ERR_CHGT_FT]
Hard Edits
ERR_CHGT_FT
* Only "0-7" or "M" or "Don't know/Refused" allowed in this field.
* Please correct.
Soft Edits
AssocHelp
H_CHGT
Tuesday, June 13, 2017
Page 5 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.020_02.000
Variable Name
CHGT_IN
Universe
HHSTAT4='C' and (AGE GE '012' and AGE NE ' ') and CHGT_FT = <0-7, empty>
Universe-text
Sample children GE 12 whose height in feet is 0-7 or is left empty.
Question Text
* Enter inches.
Answer Codes
Question Type
Integer
Field Pane Description
Inches
Fill Instructions
Special Instructions Formpane = variable description "inches" on right
If CHGT_FT = M, Refused, or Don’t know, do not calculate a value for CHTINCH
If CHGT_FT = ‘0’ and CHGT_IN = Refused or Don’t know, do not calculate a value for
CHTINCH
Create variable CHTINCH as follows: (CHGT_FT * 12) + CHGT_IN = CHTINCH
If CHGT_FT = ‘1-7’ and CHGT_IN = Refused or Don’t know use ‘0’ for CHGT_IN when
calculating CHTINCH
If ERR3_CHGT_IN is displayed, set CHGT_FLG = ‘1’
If ERR3_CHGT_IN is closed or you goto another screen from it, leave CHGT_FLG =
‘1’
If ERR3_CHGT_IN is suppressed, reset CHGT_FLG = ‘2’
Skip Instructions
<0-36,R,D> If (CHGT_FT = ‘0’, ’empty’) and (CHGT_IN = ‘0’, ‘empty’)
goto ERR1_CHGT_IN
elseif CHGT_FT = ‘1-7’ and CHGT_IN ge ‘12’
goto ERR2_CHGT_IN
elseif (SEX = ‘1’ and
AGE = ‘12’ and (CHTINCH lt ‘53’ or CHTINCH gt ‘68’)) or
AGE = ‘13’ and (CHTINCH lt ‘55’ or CHTINCH gt ‘72’)) or
AGE = ‘14’ and (CHTINCH lt ‘58’ or CHTINCH gt ‘73’)) or
AGE = ‘15’ and (CHTINCH lt ‘60’ or CHTINCH gt ‘74’)) or
AGE = ‘16’ and (CHTINCH lt ‘61’ or CHTINCH gt ‘74’)) or
AGE = ‘17’ and (CHTINCH lt ‘62’ or CHTINCH gt ‘75’)) or
(SEX = ‘2’ and
AGE = ‘12’ and (CHTINCH lt ‘54’ or CHTINCH gt ‘68’)) or
AGE = ‘13’ and (CHTINCH lt ‘55’ or CHTINCH gt ‘69’)) or
AGE = ‘14’ and (CHTINCH lt ‘57’ or CHTINCH gt ‘69’)) or
AGE = ‘15’ and (CHTINCH lt ‘57’ or CHTINCH gt ‘69’)) or
AGE = ‘16’ and (CHTINCH lt ‘57’ or CHTINCH gt ‘70’)) or
AGE = ‘17’ and (CHTINCH lt ‘57’ or CHTINCH gt ‘69’))
goto ERR3_CHGT_IN
else
goto CWGT_LB
Tuesday, June 13, 2017
Page 6 of 115
Hard Edits
ERR1_CHGT_IN
* Must enter an answer in at least the inches item.
* Please correct.
ERR2_CHGT_IN
* Number of inches exceeds maximum allowed.
* Please correct.
Soft Edits
ERR3_CHGT_IN
* Please verify that the height was entered correctly. Probe only if necessary.
AssocHelp
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.020_03.000
Variable Name
CHTINCH
Universe
Universe-text
Question Text
**OUT VARIABLE**
Answer Codes
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions If CHGT_FT = M, Refused, or Don’t know, do not calculate a value for CHTINCH
If CHGT_FT = ‘0’ and CHGT_IN = Refused or Don’t know, do not calculate a value for
CHTINCH
Create variable CHTINCH as follows: (CHGT_FT * 12) + CHGT_IN = CHTINCH
If CHGT_FT = ‘1-7’ and CHGT_IN = Refused or Don’t know use ‘0’ for CHGT_IN when
calculating CHTINCH
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 7 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.020_H
Variable Name
H_CHGT
Universe
Universe-text
Question Text
If the child's height is reported in inches only, enter "0" in the feet field and then enter
the inches. Round the number of inches up to the next whole number.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHGT_FT
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 8 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.021_01.000
Variable Name
CHGT_M
Universe
HHSTAT4='C' and (AGE GE '012' and AGE NE ' ') and CHGT_FT = M
Universe-text
Sample children GE 12 whose current height will be entered in metric.
Question Text
* 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).
Answer Codes
Question Type
Integer
Field Pane Description
Meters
Fill Instructions
Special Instructions Formpane = variable description "meters" on right; label "Current height" on left
Skip Instructions
<0-2,empty> [goto CHGT_CM]
[goto CWGT_LB]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 9 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.021_02.000
Variable Name
CHGT_CM
Universe
HHSTAT4='C' and (AGE GE '012' and AGE NE ' ') and CHGT_FT = M and CHGT_M
=
Universe-text
Sample Children GE 12 whose height will be entered in metric, and who entered "0-2"
for height in meters or left it empty.
Question Text
* Enter centimeters.
Answer Codes
Question Type
Integer
Field Pane Description
Centimeters
Fill Instructions
Special Instructions Formpane = variable description "centimeters" on right
If CHGT_M = Refused or Don’t know, do not calculate a value for CHTCM
If CHGT_M = ‘0’ and CHGT_CM = Refused or Don’t know, do not calculate a value for
CHTCM
Create variable CHTCM as follows: (CHGT_M * 100) + CHGT_CM = CHTCM
If CHGT_CM = Refused or Don’t know use ‘0’ for CHGT_CM when checking if height
exceeds maximum allowed or when calculating CHTCM
If ERR3_CHGT_CM is displayed, set CHGT_FLG = ‘1’
If ERR3_CHGT_CM is closed or you goto another screen from it, leave CHGT_FLG =
‘1’
If ERR3_CHGT_CM is suppressed, reset CHGT_FLG = ‘2’
Skip Instructions
<0-241,R,D> If (CHGT_M = ‘0’, ’empty’) and (CHGT_CM = ‘0’, ‘empty’)
goto ERR1_CHGT_CM
elseif (CHGT_M eq ‘2’ and CHGT_CM gt ‘41’) or (CHGT_M eq ‘1’ and
CHGT_CM gt ‘141’)
goto ERR2_CHGT_CM
elseif (SEX = ‘1’ and
AGE = ‘12’ and (CHTCM lt ‘137’ or CHTCM gt ‘174’)) or
AGE = ‘13’ and (CHTCM lt ‘140’ or CHTCM gt ‘184’)) or
AGE = ‘14’ and (CHTCM lt ‘148’ or CHTCM gt ‘186’)) or
AGE = ‘15’ and (CHTCM lt ‘152’ or CHTCM gt ‘189’)) or
AGE = ‘16’ and (CHTCM lt ‘156’ or CHTCM gt ‘189’)) or
AGE = ‘17’ and (CHTCM lt ‘157’ or CHTCM gt ‘192’)) or
(SEX = ‘2’ and
AGE = ‘12’ and (CHTCM lt ‘138’ or CHTCM gt ‘173’)) or
AGE = ‘13’ and (CHTCM lt ‘141’ or CHTCM gt ‘176’)) or
AGE = ‘14’ and (CHTCM lt ‘145’ or CHTCM gt ‘176’)) or
AGE = ‘15’ and (CHTCM lt ‘145’ or CHTCM gt ‘177’)) or
AGE = ‘16’ and (CHTCM lt ‘145’ or CHTCM gt ‘177’)) or
AGE = ‘17’ and (CHTCM lt ‘145’ or CHTCM gt ‘176’))
goto ERR3_CHGT_CM
else
Tuesday, June 13, 2017
Page 10 of 115
goto CWGT_LB
Hard Edits
ERR1_CHGT_CM
* Must enter an answer at least in the centimeters item.
* Please correct.
ERR2_CHGT_CM
* Total height exceeds maximum allowed.
* Please correct.
Soft Edits
ERR3_CHGT_CM
* Please verify that the height was entered correctly. Probe only if necessary.
AssocHelp
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.021_03.000
Variable Name
CHTCM
Universe
Universe-text
Question Text
**OUT VARIABLE**
Answer Codes
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions If CHGT_M = Refused or Don’t know, do not calculate a value for CHTCM
If CHGT_M = ‘0’ and CHGT_CM = Refused or Don’t know, do not calculate a value for
CHTCM
Create variable CHTCM as follows: (CHGT_M * 100) + CHGT_CM = CHTCM
If CHGT_CM = Refused or Don’t know use ‘0’ for CHGT_CM when checking if height
exceeds maximum allowed or when calculating CHTCM
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 11 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.021_04.000
Variable Name
CHGT_FLG
Universe
Universe-text
Question Text
**OUT VARIABLE**
Answer Codes
blank,1,2
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions If ERR3_CHGT_IN or ERR3_CHGT_CM is displayed, set CHGT_FLG = ‘1’
If ERR3_CHGT_IN or ERR3_CHGT_CM is closed or you goto another screen from it,
leave CHGT_FLG = ‘1’
If ERR3_CHGT_IN or ERR3_CHGT_CM is suppressed, reset CHGT_FLG = ‘2’
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 12 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.021_05.000
Variable Name
CMETERS
Universe
Universe-text
Question Text
**OUT VARIABLE**
Answer Codes
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions Create variable CMETERS as follows:
if CHTINCH ne ‘empty’
set CMETERS = CHTINCH/39.37008
elseif CHTCM ne ‘empty’
set CMETERS = CHTCM/100
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 13 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.022_00.000
Variable Name
CWGT_LB
Universe
HHSTAT4='C' and (AGE GE '012' and AGE NE ' ')
Universe-text
Sample children GE 12
Question Text
How much does [fill: S.C. name] weigh now (without shoes)?
* Enter 'M' to record metric measurements.
* Enter '500' if 500 pounds or more.
Answer Codes
Question Type
Integer
Field Pane Description
Pounds
Fill Instructions
Special Instructions Formpane = variable description "pounds" on right; label "Current weight" on left
If ERR2_CWGT_LB is displayed, set CWGT_FLG = ‘1’
If ERR2_CWGT_LB is closed or you goto another screen from it, leave CWGT_FLG =
‘1’
If ERR2_CWGT_LB is suppressed, reset CWGT_FLG = ‘2’
Skip Instructions
<1-500> if CWGT_LB lt ‘1’ or CWGT_LB gt ‘500’
goto ERR1_CWGT_LB
elseif (SEX = ‘1’ and
AGE = ‘12’ and (CWGT_LB lt ‘62’ or CWGT_LB gt ‘209’)) or
AGE = ‘13’ and (CWGT_LB lt ‘70’ or CWGT_LB gt ‘247’)) or
AGE = ‘14’ and (CWGT_LB lt ‘83’ or CWGT_LB gt ‘266’)) or
AGE = ‘15’ and (CWGT_LB lt ‘94’ or CWGT_LB gt ‘267’)) or
AGE = ‘16’ and (CWGT_LB lt ‘98’ or CWGT_LB gt ‘306’)) or
AGE = ‘17’ and (CWGT_LB lt ‘106’ or CWGT_LB gt ‘317’)) or
(SEX = ‘2’ and
AGE = ‘12’ and (CWGT_LB lt ‘62’ or CWGT_LB gt ‘212’)) or
AGE = ‘13’ and (CWGT_LB lt ‘73’ or CWGT_LB gt ‘238’)) or
AGE = ‘14’ and (CWGT_LB lt ‘84’ or CWGT_LB gt ‘252’)) or
AGE = ‘15’ and (CWGT_LB lt ‘84’ or CWGT_LB gt ‘238’)) or
AGE = ‘16’ and (CWGT_LB lt ‘87’ or CWGT_LB gt ‘257’)) or
AGE = ‘17’ and (CWGT_LB lt ‘90’ or CWGT_LB gt ‘292’))
goto ERR2_CWGT_LB
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE ge ‘2’
goto ADD_1
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE lt ‘2’
goto ADD1_2
else
calculate the BMI (Body Mass Index) – See CBMI spec page
if AGE ge ‘2’
goto ADD_1
Tuesday, June 13, 2017
Page 14 of 115
else
goto ADD1_2
goto CWGT_KG
Hard Edits
ERR1_CWGT_LB
* Weight is out of range (1-500).
* Please correct.
Soft Edits
ERR2_CWGT_LB
* Please verify that the weight was entered correctly. Probe only if necessary.
AssocHelp
Tuesday, June 13, 2017
Page 15 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.023_00.000
Variable Name
CWGT_KG
Universe
HHSTAT4='C' and (AGE GE '012' and AGE NE ' ') and CWGT_LB = M
Universe-text
Sample children GE 12 whose weight will be entered in metric.
Question Text
* Enter weight in kilograms.
Answer Codes
Question Type
Integer
Field Pane Description
Kilograms
Fill Instructions
Special Instructions Formpane = variable description "kilograms" on right; label "Current weight" on left;
column heading "Metric"
If ERR2_CWGT_KG is displayed, set CWGT_FLG = ‘1’
If ERR2_CWGT_KG is closed or you goto another screen from it, leave CWGT_FLG
= ‘1’
If ERR2_CWGT_KG is suppressed, reset CWGT_FLG = ‘2’
Skip Instructions
<2-226> if CWGT_KG lt ‘2’ or CWGT_KG gt ‘226’
goto ERR1_CWGT_KG
elseif (SEX = ‘1’ and
AGE = ‘12’ and (CWGT_KG = ‘28’ or CWGT_KG = ‘95’)) or
AGE = ‘13’ and (CWGT_KG = ‘32’ or CWGT_KG = ‘112’)) or
AGE = ‘14’ and (CWGT_KG = ‘38’ or CWGT_KG = ‘121’)) or
AGE = ‘15’ and (CWGT_KG = ‘42’ or CWGT_KG = ‘121’)) or
AGE = ‘16’ and (CWGT_KG = ‘44’ or CWGT_KG = ‘139’)) or
AGE = ‘17’ and (CWGT_KG = ‘48’ or CWGT_KG = ‘144’)) or
(SEX = ‘2’ and
AGE = ‘12’ and (CWGT_KG = ‘28’ or CWGT_KG = ‘96’)) or
AGE = ‘13’ and (CWGT_KG = ‘33’ or CWGT_KG = ‘108’)) or
AGE = ‘14’ and (CWGT_KG = ‘38’ or CWGT_KG = ‘114’)) or
AGE = ‘15’ and (CWGT_KG = ‘38’ or CWGT_KG = ‘108’)) or
AGE = ‘16’ and (CWGT_KG = ‘39’ or CWGT_KG = ‘117’)) or
AGE = ‘17’ and (CWGT_KG = ‘41’ or CWGT_KG = ‘133’))
goto ERR2_CWGT_KG
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE ge ‘2’
goto ADD_1
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE lt ‘2’
goto ADD1_2
else
calculate the BMI (Body Mass Index) – See CBMI spec page
if AGE ge ‘2’
goto ADD_1
else
goto ADD1_2
Tuesday, June 13, 2017
Page 16 of 115
Hard Edits
ERR1_CWGT_KG
* Weight is out of range (2-226).
* Please correct.
Soft Edits
ERR2_CWGT_KG
* Please verify that the weight was entered correctly. Probe only if necessary.
AssocHelp
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.024_01.000
Variable Name
CWGT_FLG
Universe
Universe-text
Question Text
**OUT VARIABLE**
Answer Codes
blank,1,2
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions If ERR2_CWGT_LB or ERR2_CWGT_KG is displayed, set CWGT_FLG = ‘1’
If ERR2_CWGT_LB or ERR2_CWGT_KG is closed or you goto another screen from
it, leave CWGT_FLG = ‘1’
If ERR2_CWGT_LB or ERR2_CWGT_KG is suppressed, reset CWGT_FLG = ‘2’
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 17 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.024_02.000
Variable Name
CKG
Universe
Universe-text
Question Text
**OUT VARIABLE**
Answer Codes
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions Create variable CKG as follows:
If CWGT_LB ne ‘M’, ‘Refused’, ‘Don’t know’, or ‘empty’
Set CKG = CWGT_LB/2.20462
elseif CWGT_KG ne ‘Refused’, ‘Don’t know’, or ‘empty’
Set CKG = CWGT_KG
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 18 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.024_03.000
Variable Name
CBMI
Universe
Universe-text
Question Text
**OUT VARIABLE**
Answer Codes
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions Create variable CBMI as follows: (CKG/(CMETERS * CMETERS)) = CBMI
If ERR_CBMI is displayed, set CBMI_FLG = ‘1’
If ERR_CBMI is closed or you goto another screen from it, leave CBMI_FLG = ‘1’
If ERR_CBMI is suppressed, reset CBMI_FLG = ‘2’
Skip Instructions
if (SEX = ‘1’ and
AGE = ‘12’ and (CBMI lt ‘14’ or CBMI gt ‘35’)) or
AGE = ‘13’ and (CBMI lt ‘14’ or CBMI gt ‘39’)) or
AGE = ‘14’ and (CBMI lt ‘15’ or CBMI gt ‘40’)) or
AGE = ‘15’ and (CBMI lt ‘15’ or CBMI gt ‘39’)) or
AGE = ‘16’ and (CBMI lt ‘17’ or CBMI gt ‘44’)) or
AGE = ‘17’ and (CBMI lt ‘17’ or CBMI gt ‘43’)) or
(SEX = ‘2’ and
AGE = ‘12’ and (CBMI lt ‘13’ or CBMI gt ‘39’)) or
AGE = ‘13’ and (CBMI lt ‘15’ or CBMI gt ‘41’)) or
AGE = ‘14’ and (CBMI lt ‘16’ or CBMI gt ‘41’)) or
AGE = ‘15’ and (CBMI lt ‘16’ or CBMI gt ‘39’)) or
AGE = ‘16’ and (CBMI lt ‘16’ or CBMI gt ‘45’)) or
AGE = ‘17’ and (CBMI lt ‘16’ or CBMI gt ‘48’))
goto ERR_CBMI
elseif AGE ge ‘2’
goto ADD_1
else
goto ADD1_2
Hard Edits
Soft Edits
ERR_CBMI
* Please verify that the entries for height and weight were entered correctly. Probe
only if necessary.
AssocHelp
Tuesday, June 13, 2017
Page 19 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.024_04.000
Variable Name
CBMI_FLG
Universe
Universe-text
Question Text
**OUT VARIABLE**
Answer Codes
blank,1,2
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions If ERR_CBMI is displayed, set CBMI_FLG = ‘1’
If ERR_CBMI is closed or you goto another screen from it, leave CBMI_FLG = ‘1’
If ERR_CBMI is suppressed, reset CBMI_FLG = ‘2’
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 20 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.031_02.000
Variable Name
ADD1_2
Universe
HHSTAT4='C' and (AGE LE '001' and AGE NE ' ')
Universe-text
Sample children <2
Question Text
?[F1]
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Intellectual disability, also known as mental retardation?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Intellectual disability
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto ADD1_3]
Hard Edits
Soft Edits
AssocHelp
H_MENTRD
Tuesday, June 13, 2017
Page 21 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.031_03.000
Variable Name
ADD1_3
Universe
HHSTAT4='C' and (AGE LE '001' and AGE NE ' ')
Universe-text
Sample children <2
Question Text
?[F1]
* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Other developmental delay
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> if ADD1_2=1 [goto ADD1_2N; else if ADD1_3=1 [goto ADD1_3N; else
[goto CONDL]
Hard Edits
Soft Edits
AssocHelp
H_DEVDLAY
Tuesday, June 13, 2017
Page 22 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.031_04.000
Variable Name
ADD1_2N
Universe
HHSTAT4='C' and (AGE LE '001' and AGE NE ' ') and ADD1_2(e)='1'
Universe-text
Sample children <2 who have been told by a doctor or other health professional that
they have an intellectual disability, also known as mental retardation
Question Text
?[F1]
Does [fill: S.C. name] currently have an intellectual disability, also known as mental
retardation?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Intellectual disability-now
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> if ADD1_3=1 [goto ADD1_3N]; else [goto CONDL]
Hard Edits
Soft Edits
AssocHelp
H_MENTRD
Tuesday, June 13, 2017
Page 23 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.031_05.010
Variable Name
ADD1_3N
Universe
HHSTAT4='C' and (AGE LE '001' and AGE NE ' ') and ADD1_3(e)='1'
Universe-text
Sample children <2 who have been told by a doctor or other health professional that
they have any other developmental delay
Question Text
?[F1]
Does [fill: S.C. name] currently have any other developmental delay?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Other developmental delay-now
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto CONDL]
Hard Edits
Soft Edits
AssocHelp
H_DEVDLAY
Tuesday, June 13, 2017
Page 24 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Behaviors
Part
A
Question ID
CHS.031_2_H
Variable Name
H_MENTRD
Universe
Universe-text
Question Text
Children with intellectual disability or mental retardation are significantly below
average in intellectual functioning and also have problems in adaptive behavior that
affect everyday, general living
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
ADD1_2, ADD1_2N
ADD_2, ADD_2N
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
ADD1_2, ADD1_2N
ADD_2, ADD_2N
Tuesday, June 13, 2017
Page 25 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Behaviors
Part
A
Question ID
CHS.031_3_H
Variable Name
H_DEVDLAY
Universe
Universe-text
Question Text
Children with developmental delays do not achieve developmental milestones on
time. Developmental delays can be in physical development, mental development,
social or emotional development, or adaptive development.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
ADD1_3, ADD1_3N
ADD_3, ADD_3N
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
ADD1_3, ADD1_3N
ADD_3, ADD_3N
Tuesday, June 13, 2017
Page 26 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.032_01.000
Variable Name
ADD_1
Universe
HHSTAT4='C' and ('002' <= AGE<= '017')
Universe-text
Sample children 2-17
Question Text
?[F1]
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
ADHD/ADD
Fill Instructions
Special Instructions Formpane = Column heading "Children 2-17 years of age"
Skip Instructions
<1,2,R,D> [go to ADD_2]
Hard Edits
Soft Edits
AssocHelp
H_ADD
Tuesday, June 13, 2017
Page 27 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.032_02.000
Variable Name
ADD_2
Universe
HHSTAT4='C' and ('002' <= AGE<= '017')
Universe-text
Sample children 2-17
Question Text
?[F1]
* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Intellectual disability, also known as mental retardation?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Intellectual disability
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to AUTISM]
Hard Edits
Soft Edits
AssocHelp
H_MENTRD
Tuesday, June 13, 2017
Page 28 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.032_02.010
Variable Name
AUTISM
Universe
HHSTAT4='C' and ('002' <= AGE<= '017')
Universe-text
Sample children 2-17
Question Text
?[F1]
* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Autism, Asperger’s disorder, pervasive developmental disorder, or autism spectrum
disorder?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Autism
Fill Instructions
Special Instructions Associated Screens:
H_AUTISM
Skip Instructions
<1,2,R,D> [go to ADD_3]
Hard Edits
Soft Edits
AssocHelp
H_AUTISM
Tuesday, June 13, 2017
Page 29 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.032_03.000
Variable Name
ADD_3
Universe
HHSTAT4='C' and ('002' <= AGE<= '017')
Universe-text
Sample children 2-17
Question Text
?[F1]
* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Other developmental delay
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> if ADD_1=1 [goto ADD_1N]; else if ADD_2=1 [go to ADD_2N]; else if
AUTISM=1 [goto AUTISMN] else if ADD_3=1 [goto ADD_3N]; else [goto CONDL]
Hard Edits
Soft Edits
AssocHelp
H_DEVDLAY
Tuesday, June 13, 2017
Page 30 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.032_04.000
Variable Name
ADD_1N
Universe
HHSTAT4='C' and ('002' <= AGE<= '017') and ADD_1(e)='1'
Universe-text
Sample children 2-17 who have ever been told by a doctor or other health
professional that they had Attention Deficit Hyperactivity Disorder (ADHD) or Attention
Deficit Disorder (ADD)
Question Text
?[F1]
Does {S.C. name] currently have Attention Deficit Hyperactivity Disorder (ADHD) or
Attention Deficit Disorder (ADD)?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
ADHD/ADD now
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> if ADD_2=1 [go to ADD_2N]; else if AUTISM=1 [goto AUTISMN] else if
ADD_3=1 [goto ADD_3N]; else [goto CONDL]
Hard Edits
Soft Edits
AssocHelp
H_ADD
Tuesday, June 13, 2017
Page 31 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.032_05.000
Variable Name
ADD_2N
Universe
HHSTAT4='C' and ('002' <= AGE<= '017') and ADD_2(e)='1'
Universe-text
Sample children 2-17 who have ever been told by a doctor or other health
professional that they had an intellectual disability, aka mental retardation
Question Text
?[F1]
Does [fill: S.C. name] currently have an Intellectual disability, also known as mental
retardation?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Intellectual disability now
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> if AUTISM=1 [goto AUTISMN] else if ADD_3=1 [goto ADD_3N]; else [goto
CONDL]
Hard Edits
Soft Edits
AssocHelp
H_MENTRD
Tuesday, June 13, 2017
Page 32 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.032_06.010
Variable Name
AUTISMN
Universe
HHSTAT4='C' and ('002' <= AGE<= '017') and AUTISM(e)='1'
Universe-text
Sample children 2-17 who have ever been told by a doctor or other health
professional that they had Autism, Asperger's Disorder, pervasive developmental
disorder, or autism spectrum disorder
Question Text
?[F1]
Does [fill: S.C. name] currently have Autism, Asperger’s disorder, pervasive
developmental disorder, or autism spectrum disorder?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Autism now
Fill Instructions
Special Instructions Associated Screens:
H_AUTISM
Skip Instructions
<1,2,R,D> if ADD_3=1 [goto ADD_3N]; else [goto CONDL]
Hard Edits
Soft Edits
AssocHelp
H_AUTISM
Tuesday, June 13, 2017
Page 33 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.032_07.000
Variable Name
ADD_3N
Universe
HHSTAT4='C' and ('002' <= AGE<= '017') and ADD_3(e)='1'
Universe-text
Sample children 2-17 who have ever been told by a doctor or other health
professional that they had any other developmental delay
Question Text
?[F1]
Does [fill: S.C. name] currently have any other developmental delay?
Answer Codes
1. Yes
2. No
Don't Know
Refused
Question Type
Yes/No
Field Pane Description
Otr dev. delay now
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CONDL]
Hard Edits
Soft Edits
AssocHelp
H_DEVDLAY
Tuesday, June 13, 2017
Page 34 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Behaviors
Part
A
Question ID
CHS.032_1_H
Variable Name
H_ADD
Universe
Universe-text
Question Text
Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder is diagnosed by a
health or school professional. Children with the condition are characterized by
problems with attention,
impulsiveness, hyperactivity, and sometimes aggression.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
ADD_1, ADD_1N
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
ADD_1, ADD_1N
Tuesday, June 13, 2017
Page 35 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Behaviors
Part
Question ID
CHS.032_2_H
Variable Name
H_AUTISM
Universe
Universe-text
Question Text
Children with autism have delays in language, communication, and social skills, as
well as routine repetitive behaviors or movements. They may have an intense interest
in a single subject or topic. Children with Asperger's disorder have impaired social
skills but may not have speech or language delays. Children with pervasive
developmental disorder have severe and persistent delays in language,
communication, and social skills.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
AUTISM, AUTISMN
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
AUTISM, AUTISMN
Tuesday, June 13, 2017
Page 36 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.060_00.000
Variable Name
CONDL
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')
Universe-text
Sample children <18
Question Text
(book) C2 ?[F1]
Looking at this list, has a doctor or health professional ever told you that [fill: S.C.
name] had any of these conditions?
*Read if necessary.
Down syndrome
Cerebral palsy
Muscular dystrophy
Cystic fibrosis
Sickle cell anemia
Diabetes
Arthritis
Congenital heart disease
Other heart condition
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Conditions-yes/no
Fill Instructions
Special Instructions Fill grayed out answer categories 1-9 under question text. They are only for reference
in case this question is being answered over the phone, so the FR does not have to
enter "yes" to get to the next question in order to see the condition list. This is similar
to HHC.170 (NATOR).
Skip Instructions
<1> [goto CONDL1] <2,R,D> [goto CPOX]
Hard Edits
Soft Edits
AssocHelp
H_CONDL
Tuesday, June 13, 2017
Page 37 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.060_H
Variable Name
H_CONDL
Universe
Universe-text
Question Text
[b] Cerebral palsy [b] is pronounced (ce-Re-bral Pawl-zee)
[b] Muscular dystrophy [b] is pronounced (Dis-tro-fee)
[b] Cystic fibrosis [b] is pronounced (Sis-tic fi-Bro-sis)
Include as heart disease or heart condition any of the following: heart failure, chronic
heart condition, rheumatic heart disease, heart murmurs, atrial or mitral valve
disease/damage, etc.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CONDL
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 38 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.061_00.000
Variable Name
CONDL1
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CONDL(e)='1'
Universe-text
Sample children <18 who have one of the CONDL conditions
Question Text
(book) C2 ?[F1]
Which ones?
* Enter all that apply, separate with commas.
Answer Codes
1. Down syndrome
2. Cerebral palsy
3. Muscular dystrophy
4. Cystic fibrosis
5. Sickle cell anemia
6. Diabetes
7. Arthritis
8. Congenital heart disease
9. Other heart condition
Refused
Don’t know
Question Type
Enter All That Apply
Field Pane Description
Conditions-which
Fill Instructions
Special Instructions
Skip Instructions
<1-9, R,D> [go to CPOX]
Hard Edits
Soft Edits
AssocHelp
H_CONDL
Tuesday, June 13, 2017
Page 39 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.070_00.000
Variable Name
CPOX
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')
Universe-text
Sample children <18
Question Text
Has [fill: S.C. name] EVER had chickenpox?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Chickenpox - ever
Fill Instructions
Special Instructions
Skip Instructions
<1> [go to CPOX12MO]
<2, D, R> [go to CASHMEV]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 40 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.072_00.000
Variable Name
CPOX12MO
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CPOX(e)='1'
Universe-text
Sample children <18 who have had chickenpox
Question Text
Has [fill: S.C. name] had chickenpox DURING THE PAST 12 MONTHS?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Chickenpox - past 12 months
Fill Instructions
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.
Skip Instructions
<1,2,R,D> [goto CASHMEV]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 41 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.080_00.000
Variable Name
CASHMEV
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')
Universe-text
Sample children <18
Question Text
? [F1]
Has a doctor or other health professional EVER told you that [fill: S.C. name] had
asthma?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Asthma - ever
Fill Instructions
Special Instructions
Skip Instructions
<1> [go to CASSTILL]
<2,R,D> if AGE LE 2 [go to CCONDT1_1];
else [go to CCONDT_1]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 42 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.080_H
Variable Name
H_CASHMEV
Universe
Universe-text
Question Text
Accept asthma of any kind such as smoker's asthma, bronchial asthma, allergic
asthma, and the like. Do not accept self-diagnosed lung problems or conditions
reported by a person who is not a doctor and not working with or for a doctor.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CASHMEV
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 43 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.085_00.000
Variable Name
CASSTILL
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CASHMEV(e)='1'
Universe-text
Sample child <18 and doctor has informed that child had asthma
Question Text
Does [fill: S.C. name] still have asthma?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Asthma - still
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CASHYR]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 44 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.090_00.000
Variable Name
CASHYR
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CASHMEV(e) ='1'
Universe-text
Sample child <18 and doctor has informed that child had asthma
Question Text
The following questions are about [fill: S.C. name]'s asthma DURING THE PAST 12
MONTHS.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had an episode of asthma or
an asthma attack?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Asthma - past 12 months
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto CASMERYR]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 45 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.000
Variable Name
CASMERYR
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CASHMEV(e) ='1'
Universe-text
Sample child <18 and doctor has informed that child had asthma
Question Text
DURING THE PAST 12 MONTHS, did [fill1: S.C. name] have to visit an emergency
room or urgent care center because of [fill2: his/her] asthma?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Asthma - ER past 12 months
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> if CASSTILL =1 or CASHYR=1 [goto CASMHSP]; else if AGE LE 2 [go to
CCONDT1_1];
else [go to CCONDT_1]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 46 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.010
Variable Name
CASMHSP
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (CASSTILL(e)='1' or
CASHYR(e)='1')
Universe-text
Sample child <18 who still have asthma or who had asthma episode/attack in past 12
months
Question Text
DURING THE PAST 12 MONTHS, has [fill: S.C. name] stayed overnight in a hospital
because of asthma?
*If in hospital for asthma AND other reasons, enter '1'.
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CWZMSWK]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 47 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.030
Variable Name
CWZMSWK
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (CASSTILL(e)='1' or
CASHYR(e)='1')
Universe-text
Sample child <18 who still have asthma or who had asthma episode/attack in past 12
months
Question Text
DURING THE PAST 12 MONTHS, HOW MANY DAYS of [fill1: daycare or
preschool/fill2: school/fill3: school or work] did [fill: S.C. name] miss because of [fill:
his/her] asthma?
*Enter '0' for none.
*Enter 995 if child home schooled.
*Enter 996 if child did not go to [fill1: daycare or preschool/fill2: school/fill3: school or
work].
Answer Codes
Allow 0-365, 995,996,R,D
Question Type
Integer
Field Pane Description
Fill Instructions
Days missed school
Fill1: Children ages 0-4 fill1 "daycare or preschool"
Fill2: Children ages 5-13 fill2 "school"
Fill3: Children ages 14-17 fill3 "school or work"
Special Instructions
Skip Instructions
<0-100,995,996,R,D> [go to CASMPMED]
<101-365> [go to ERR1_CWZMSWK]
<366-994> [go to ERR2_CWZMSWK]
Hard Edits
if CWZMSWK = 366-994 then display ERR2_CWZMSWK:
"366-994 days not allowed in this field.
* Please correct."
Soft Edits
if CWZMSWK >100 and ne 996 then display ERR1_CWZMSWK:
"CWZMSWK is an unusually large number; Did [fill: S.C. name] miss CWZMSWK
days of [fill1/fill2/fill3] due to asthma?"
1 correct proceed to CASMPMED;
2 incorrect, change answer
AssocHelp
Tuesday, June 13, 2017
Page 48 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.060
Variable Name
CASMPMED
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (CASSTILL(e)='1' or
CASHYR(e)='1')
Universe-text
Sample child <18 who still have asthma or who had asthma episode/attack in past 12
months
Question Text
Now I'm going to ask you about two different kinds of ASTHMA medicine. One
prevents symptoms over the long term. The other is for quick relief of symptoms
during an attack or episode. This quick relief medicine is breathed in through your
mouth using a canister inhaler or a disk inhaler.
DURING THE PAST 3 MONTHS, has [fill: S.C. name] used the kind of
PRESCRIPTION asthma inhaler that gives QUICK relief from asthma symptoms
during an attack? Include only medications prescribed by a health care professional.
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Quick relief inhaler
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto CASMTYP]
<2,R,D> [go to CASMDTP2]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 49 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.065
Variable Name
CASMTYP
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CASMPMED(e)='1'
Universe-text
Sample child <18 who have used a quick relief prescription asthma inhaler in the past
three months
Question Text
When [fill: S.C. name] takes [his/her]rescue prescription asthma medication, would
you say that [he/she] most often uses an inhaler and/or disk, or does [he/she] most
often use a nebulizer?
*Read if necessary: Both an inhaler or a disk inhaler are very portable canisters or
devices used to inhale medication in one or two breaths. A nebulizer is a machine
that turns liquid medication into a mist that you inhale into the lungs over a few
minutes.
Answer Codes
1. Inhaler or disk
2. Nebulizer
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1> [go to CASMCAN]
<2,R,D> [go to CASMDTP2]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 50 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.070
Variable Name
CASMCAN
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CASMTYP(e)='1'
Universe-text
Sample child <18 who have used a prescription asthma inhaler/disk most often in the
past three months
Question Text
DURING THE PAST 3 MONTHS, did [fill: S.C. name] use more than three canisters or
disks of this type of quick relief inhaler?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
More than 3 canisters
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CASMDTP2]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 51 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.090
Variable Name
CASMDTP2
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (CASSTILL(e)='1' or
CASHYR(e)='1')
Universe-text
Sample child <18 who still have asthma or who had asthma episode/attack in past 12
months
Question Text
The second kind of asthma medication is different from inhalers used for quick relief.
It is the preventive kind that is used to protect your lungs and keep you from having
attacks. It can be either a pill or an inhaler.
Is [fill: S.C. name] NOW taking a preventive asthma medication every day or almost
every day, less often, or never?
Answer Codes
1. Every day or almost every day
2. Less often
3. Never
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1-3,R,D> [go to CASWMP]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 52 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.100
Variable Name
CASWMP
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (CASSTILL(e)='1' or
CASHYR(e)='1')
Universe-text
Sample child <18 who still have asthma or who had asthma episode/attack in past 12
months
Question Text
An asthma action plan is a printed form with specific instructions based on [fill: S.C.
name]'s asthma that tells when to change the amount or type of medicine, when to call
the doctor for advice, and when to go to the emergency room.
Has a doctor or other health professional EVER given [fill: S.C. name] an asthma
action plan?
*Read if necessary: Include nurses and asthma educators.
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Action plan
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CASCLASS]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 53 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.110
Variable Name
CASCLASS
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (CASSTILL(e)='1' or
CASHYR(e)='1')
Universe-text
Sample child <18 who still have asthma or who had asthma episode/attack in past 12
months
Question Text
Has [fill: S.C. name] ever taken a course or class on how to manage [fill: his/her]
asthma?
*Include adult(s) who took a course for the child's asthma.
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Course or class
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CAS_REC]
Hard Edits
Soft Edits
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Tuesday, June 13, 2017
Page 54 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.116
Variable Name
CAS_REC
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (CASSTILL(e)='1' or
CASHYR(e)='1')
Universe-text
Sample child <18 who still have asthma or who had asthma episode/attack in past 12
months
Question Text
Has a doctor or other health professional EVER taught [fill: S.C. name] or [fill: his/her]
parent or guardian
...how to recognize early signs or symptoms of an asthma episode?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Recognize early signs
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CAS_RES]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 55 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.117
Variable Name
CAS_RES
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (CASSTILL(e)='1' or
CASHYR(e)='1')
Universe-text
Sample child <18 who still have asthma or who had asthma episode/attack in past 12
months
Question Text
*Read if necessary: Has a doctor or other health professional EVER taught [fill: S.C.
name] or [fill: his/her] parent or guardian
...how to respond to episodes of asthma?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Respond to episodes
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CAS_MON]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 56 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.118
Variable Name
CAS_MON
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (CASSTILL(e)='1' or
CASHYR(e)='1')
Universe-text
Sample child <18 who still have asthma or who had asthma episode/attack in past 12
months
Question Text
*Read if necessary: Has a doctor or other health professional EVER taught [fill: S.C.
name] or [fill: his/her] parent or guardian
...how to monitor peak flow for daily therapy?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Monitor peak flow
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CAPENVLN]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 57 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.130
Variable Name
CAPENVLN
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (CASSTILL(e)='1' or
CASHYR(e)='1')
Universe-text
Sample child <18 who still have asthma or who had asthma episode/attack in past 12
months
Question Text
Has a doctor or other health professional EVER advised you to change things in [fill:
S.C. name]'s home, school, or work environment to improve [fill: his/her] asthma?
Answer Codes
1. Yes
2. No
3. Was told no changes needed
Don't know
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Advised you
Fill Instructions
Special Instructions
Skip Instructions
<1-3,R,D> [go to CAROUTIN]
Hard Edits
Soft Edits
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Tuesday, June 13, 2017
Page 58 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.135
Variable Name
CAROUTIN
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (CASSTILL(e)='1' or
CASHYR(e)='1')
Universe-text
Sample child <18 who still have asthma or who had asthma episode/attack in past 12
months
Question Text
DURING THE PAST 12 MONTHS, how many times did [fill: S.C. name] see a doctor
or other health professional for a routine checkup for [fill: his/her] asthma? Please do
not include emergency room visits, visits to urgent care centers, or other visits for
acute care for an asthma episode or attack.
*Enter '0' for none.
Answer Codes
Allow 0-365,R,D
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<0-50,R,D> [go to CASYMPT]
<51-365> [goto ERR_CAROUTIN]
Hard Edits
Soft Edits
ERR_CAROUTIN
[fill4: CAROUTIN] is an unusually large number.
* Please verify.
AssocHelp
Tuesday, June 13, 2017
Page 59 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.140
Variable Name
CASYMPT
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (CASSTILL(e)='1' or
CASHYR(e)='1')
Universe-text
Sample child <18 who still have asthma or who had asthma episode/attack in past 12
months and saw a doctor/health professional about S.C.'s asthma in the past year
Question Text
The next three questions are about the last time [S.C. name] saw a doctor or other
health care professional for routine care or for any reason.
At his/her last visit, did [fill: S.C. name]'s doctor or other health professional ask HOW
OFTEN
….[fill: he/she] had asthma symptoms?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CARESCUE]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 60 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.145
Variable Name
CARESCUE
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (CASSTILL(e)='1' or
CASHYR(e)='1')
Universe-text
Sample child <18 who still have asthma or who had asthma episode/attack in past 12
months and use a quick relief inhaler and saw a doctor/health professional about
S.C.'s asthma in the past year
Question Text
At his/her last visit, did [fill: S.C. name]’s doctor or other health professional ask HOW
OFTEN
...[fill: he/she] used a quick relief inhaler
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CAACTLIM]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 61 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.100_00.150
Variable Name
CAACTLIM
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (CASSTILL(e)='1' or
CASHYR(e)='1')
Universe-text
Sample child <18 who still have asthma or who had asthma episode/attack in past 12
months and saw a doctor/health professional about S.C.'s asthma in the past year
Question Text
At his/her last visit, did [fill: S.C. name]’s doctor or other health professional ask HOW
OFTEN
…asthma symptoms limited [fill: his/her] daily activities?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [if AGE LE 2 go to CCONDT1_1; else go to CCONDT_1]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 62 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.111_01.000
Variable Name
CCONDT1_1
Universe
HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')
Universe-text
Sample children LE 2
Question Text
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Hay fever?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Hay fever
Fill Instructions
Special Instructions Formpane = column heading "Children under 3 years of age"
Skip Instructions
<1,2,R,D> [go to CCONDT1_2]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 63 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.111_02.000
Variable Name
CCONDT1_2
Universe
HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')
Universe-text
Sample children LE 2
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Any kind of respiratory allergy?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Respiratory allergy
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CCONDT1_3]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 64 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.111_03.000
Variable Name
CCONDT1_3
Universe
HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')
Universe-text
Sample children LE 2
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Any kind of food or digestive allergy?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Food/digestive allergy
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CCONDT1_4]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 65 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.111_03.005
Variable Name
QARNDM41
Universe
QAASK4 = '1'
Universe-text
All families selected for QA question
Question Text
Random number generator
Answer Codes
(Allow 00-09)
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 66 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.111_04.000
Variable Name
CCONDT1_4
Universe
HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')
Universe-text
Sample children LE 2
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Eczema or any kind of skin allergy?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Eczema/skin allergy
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CCONDT1_5]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 67 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.111_04.001
Variable Name
QACHK41
Universe
HHSTAT4 = 'C' and (AGE LE '002' and AGE NE ' ') and QAASK4 = '1'
Universe-text
Sample children 2 years or less where QA question was selected
Question Text
*Please enter [Fill1: QARNDM41 ] for quality assurance.
Answer Codes
(Allow 0-9)
Question Type
Procedure
Field Pane Description
Fill Instructions
QA Check
Fill1: QARNDM41 is the number that was randomly selected is filled in here
Special Instructions
Skip Instructions
[goto CCONDT1_5]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 68 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.111_04.002
Variable Name
QACHNG41
Universe
QACHK41=0-9
Universe-text
All families selected for QA question
Question Text
Flag field to indicate whether or not the value entered by the FR matched or not.
' ' (empty) - if the check was not asked or answered
0 - if the check was asked and the value entered matches the random value
1 - if the check was asked and the value entered does NOT match the random
value (cannot be undone)
Answer Codes
' ', 0,1
Question Type
Flag
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 69 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.111_05.000
Variable Name
CCONDT1_5
Universe
HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')
Universe-text
Sample children LE 2
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Frequent or repeated diarrhea or colitis?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Frequent diarrhea/colitis
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CCONDT1_6]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 70 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.111_06.000
Variable Name
CCONDT1_6
Universe
HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')
Universe-text
Sample children LE 2
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Anemia?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Anemia
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CCONDT1_8]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 71 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.111_08.000
Variable Name
CCONDT1_8
Universe
HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')
Universe-text
Sample children LE 2
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Three or more ear infections?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Ear infections
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CCONDT1_9]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 72 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.111_09.000
Variable Name
CCONDT1_9
Universe
HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')
Universe-text
Sample children LE 2
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Seizures?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Seizures
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CHSTATYR]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 73 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.115_01.000
Variable Name
CCONDT_1
Universe
HHSTAT4='C' and ('003' <= AGE <= '017')
Universe-text
Sample children = 3-17
Question Text
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Hay fever?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Hay fever
Fill Instructions
Special Instructions Formpane = column heading "Children 3-17 years of age"
Skip Instructions
<1,2,R,D> [go to CCONDT_2]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 74 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.115_02.000
Variable Name
CCONDT_2
Universe
HHSTAT4='C' and ('003' <= AGE <= '017')
Universe-text
Sample children = 3-17
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Any kind of respiratory allergy?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Respiratory allergy
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CCONDT_3]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 75 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.115_03.000
Variable Name
CCONDT_3
Universe
HHSTAT4='C' and ('003' <= AGE <= '017')
Universe-text
Sample children = 3-17
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Any kind of food or digestive allergy?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Food/digestive allergy
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CCONDT_4]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 76 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.115_03.005
Variable Name
QARNDM4
Universe
QAASK4 = 1
Universe-text
All families selected for QA question
Question Text
Random number generator
Answer Codes
(Allow 00-09)
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 77 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.115_04.000
Variable Name
CCONDT_4
Universe
HHSTAT4='C' and ('003' <= AGE <= '017')
Universe-text
Sample children = 3-17
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Eczema or any kind of skin allergy?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Eczema/skin allergy
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CCONDT_5]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 78 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.115_04.001
Variable Name
QACHK4
Universe
HHSTAT4='C' and ('003' <= AGE <= '017') and QAASK4 = '1'
Universe-text
Sample children 3-17 where QA question was selected
Question Text
*Please enter [Fill1: QARNDM4 ] for quality assurance.
Answer Codes
(Allow 0-9)
Question Type
Procedure
Field Pane Description
Fill Instructions
QA Check
Fill1: QARNDM4 is the number that was randomly selected is filled in here
Special Instructions
Skip Instructions
[goto CCONDT_5]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 79 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.115_04.002
Variable Name
QACHNG4
Universe
QACHK4=0-9
Universe-text
All families selected for QA question
Question Text
Flag field to indicate whether or not the value entered by the FR matched or not.
' ' (empty) - if the check was not asked or answered
0 - if the check was asked and the value entered matches the random value
1 - if the check was asked and the value entered does NOT match the random
value (cannot be undone)
Answer Codes
' ', 0,1
Question Type
Flag
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 80 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.115_05.000
Variable Name
CCONDT_5
Universe
HHSTAT4='C' and ('003' <= AGE <= '017')
Universe-text
Sample children = 3-17
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Frequent or repeated diarrhea or colitis?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Frequent diarrhea/colitis
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CCONDT_6]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 81 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.115_06.000
Variable Name
CCONDT_6
Universe
HHSTAT4='C' and ('003' <= AGE <= '017')
Universe-text
Sample children = 3-17
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Anemia?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Anemia
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CCONDT_7]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 82 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.115_07.000
Variable Name
CCONDT_7
Universe
HHSTAT4='C' and ('003' <= AGE <= '017')
Universe-text
Sample children = 3-17
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Frequent or severe headaches, including migraines?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Frequent headaches/migraines
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CCONDT_8]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 83 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.115_08.000
Variable Name
CCONDT_8
Universe
HHSTAT4='C' and ('003' <= AGE <= '017')
Universe-text
Sample children = 3-17
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Three or more ear infections?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Ear infections
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CCONDT_9]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 84 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.115_09.000
Variable Name
CCONDT_9
Universe
HHSTAT4='C' and ('003' <= AGE <= '017')
Universe-text
Sample children = 3-17
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Seizures?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Seizures
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [go to CCONDT_10]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 85 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.115_10.000
Variable Name
CCONDT_10
Universe
HHSTAT4='C' and ('003' <= AGE <= '017')
Universe-text
Sample children = 3-17
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Stuttering or stammering?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Stuttering/Stammering
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto CHSTATYR]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 86 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.210_00.000
Variable Name
CHSTATYR
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')
Universe-text
Sample children <18
Question Text
Compared with 12 months ago, would you say [fill: S.C. name]'s health is now better,
worse, or about the same?
Answer Codes
1. Better
2. Worse
3. About the same
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Health now vs. 12 months ago
Fill Instructions
Special Instructions
Skip Instructions
<1-3,R,D> [if AGE le <4> goto CCOLD2W; else goto SCHDAYR]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 87 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.220_00.000
Variable Name
SCHDAYR
Universe
HHSTAT4='C' and ('005' <= AGE <= '017')
Universe-text
Sample children 5-17
Question Text
DURING THE PAST 12 MONTHS about how many days did [fill2: S.C. name] miss
school because of illness or injury?
* Enter '996' if child did not go to school in the past 12 months.
Answer Codes
Question Type
Integer
Field Pane Description
Missed days
Fill Instructions
Special Instructions Note that first part of soft edit is to be spoken, and written in the same font as question
text.
Skip Instructions
<0-99,996,R,D> [goto CCOLD2W]
<100-240> [go to ERR1_SCHDAYR]
<241-995> [goto ERR2_SCHDAYR]
Hard Edits
ERR2_SCHDAYR
* "241-995" days not allowed in this field.
* Please correct.
Soft Edits
ERR1_SCHDAYR
[fill4: SCHDAYR] is an unusually large number. Did [fill2: SC name] miss [fill:
SCHDAYR] days of school because of illness or injury?
* Please verify.
AssocHelp
Tuesday, June 13, 2017
Page 88 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.230_00.000
Variable Name
CCOLD2W
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')
Universe-text
Sample children <18
Question Text
These next questions are about [fill: S.C. name]'s recent health DURING THE LAST 2
WEEKS.
Did [fill: S.C. name] have a head cold or chest cold that started DURING THE LAST 2
WEEKS?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Cold - past 2 weeks
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto CINTIL2W]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 89 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.240_00.000
Variable Name
CINTIL2W
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')
Universe-text
Sample children <18
Question Text
Did [fill: S.C. name] have a stomach or intestinal illness with vomiting or diarrhea that
started DURING THE LAST 2 WEEKS?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Stomach illness - past 2 weeks
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto CHEARST1]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 90 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.250_00.000
Variable Name
CHEARST1
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')
Universe-text
Sample children <18
Question Text
Which statement best describes [fill: S.C. name]'s hearing without a hearing aid:
Excellent, good, a little trouble hearing, moderate trouble, a lot of trouble, or is [fill:
SC's name] deaf?
Answer Codes
1. Excellent
2. Good
3. A little trouble hearing
4. Moderate trouble
5. A lot of trouble
6. Deaf
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Hearing
Fill Instructions
Special Instructions
Skip Instructions
<1-6,R,D> [go to CVISION]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 91 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.260_00.000
Variable Name
CVISION
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')
Universe-text
Sample children <18
Question Text
Does [fill1: SC name] have any trouble seeing [fill2: , even when wearing glasses or
contact lenses]?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Trouble seeing
fill2 = [if AGE ge <2> = "even when wearing glasses or contact lenses?"]
Special Instructions
Skip Instructions
<1> [goto CBLIND]
<2,R,D> [goto IHSPEQ]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 92 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.270_00.000
Variable Name
CBLIND
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CVISION(e)='1'
Universe-text
Sample children <18 who have trouble seeing
Question Text
Is [fill: SC name] blind or unable to see at all?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Blind
Fill Instructions
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.
Skip Instructions
<1,2,R,D> [goto IHSPEQ]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 93 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.290_00.000
Variable Name
IHSPEQ
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')
Universe-text
Sample children <18
Question Text
Does [fill1: S.C. name] have any impairment or health problem that requires [fill2:
him/her] to use special equipment, such as a brace, a wheelchair, or a hearing aid
(excluding ordinary eyeglasses or corrective shoes)?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Special equipment
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [goto IHMOB]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 94 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.300_00.000
Variable Name
IHMOB
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')
Universe-text
Sample children <18
Question Text
Does [fill1: S.C. name] have an impairment or health problem that limits [fill2: his/her]
ability to (crawl), walk, run, or play?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Limited ability to walk/play
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto IHMOBYR]
<2,R,D> [goto PROBRX]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 95 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.310_00.000
Variable Name
IHMOBYR
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and IHMOB(e)='1'
Universe-text
Sample children <18 that have limited ability to crawl, walk, run, or play
Question Text
Is this an impairment or health problem that has lasted, or is expected to last, 12
months or longer?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Lasted or will last 12 months
Fill Instructions
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.
Skip Instructions
<1,2,R,D> [goto PROBRX]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 96 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.311_00.000
Variable Name
PROBRX
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')
Universe-text
Sample children <18
Question Text
?[F1]
Does [fill1: S.C. name] NOW have a problem for which [fill2: he/she] has regularly
taken prescription medication for at least three months?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Prescription meds for 3 months
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [if AGE LE <1> go to CAU.CUSUALPL;
else if AGE GE 3 go to LEARND;
else if AGE = 2 and SEX = 1 go to CMHAGM11_1;
if AGE = 2 and SEX = 2 go to CMHAGF11_1]
Hard Edits
Soft Edits
AssocHelp
H_PROBRX
Tuesday, June 13, 2017
Page 97 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Behaviors
Part
A
Question ID
CHS.311_H
Variable Name
H_PROBRX
Universe
Universe-text
Question Text
Prescription medication is:
[blt] any medicine obtained on a licensed health care professional's written
prescription,
[blt] any medicine prepared on the basis of a doctor's telephone call to a
pharmacist,
[blt] any medicine including injections given by the doctor (or nurse) to the person
to take at home
or administered in the office, hospital or clinic.
Do not include medicine only recommended by a doctor if no prescription is necessary.
[b] Regularly taken [b] - Do not count medicine that the sample child is taking for a
short term illness, such as taking antibiotics for 10 days for an infection.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
PROBRX
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 98 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
A
Question ID
CHS.312_00.000
Variable Name
LEARND
Universe
HHSTAT4='C' and ('003' <= AGE <= '017')
Universe-text
Sample children 3-17
Question Text
?[F1]
Has a representative from a school or a health professional ever told you that [fill:
S.C. name] had a learning disability?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Learning disability
Fill Instructions
Special Instructions
Skip Instructions
<1,2,R,D> [if AGE > 3 go to CUSUALPL;
if AGE = 3 and SEX = 1 go to CMHAGM11_1;
if AGE = 3 and SEX = 2 go to CMHAGF11_1]
Hard Edits
Soft Edits
AssocHelp
H_LEARND
Tuesday, June 13, 2017
Page 99 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Behaviors
Part
A
Question ID
CHS.312_H
Variable Name
H_LEARND
Universe
Universe-text
Question Text
A learning disability is a disorder in one or more of the basic psychological processes
involved in understanding or in using language, spoken or written. It may be evident
by an inability to listen, think, speak, read, write, spell or do mathematical
calculations. It includes conditions such as brain injury, minimal brain dysfunction,
dyslexia or aphasia. It does not apply to children who have difficulty learning as a
result of visual, hearing, motor, mental retardation, or emotional disturbance.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
LEARND
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 100 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
B
Question ID
CHS.321_01.000
Variable Name
CMHAGM11_1
Universe
HHSTAT4='C' and AGE IN('002','003') and SEX='1'
Universe-text
Male sample children 2-3
Question Text
(book) C3 ?[F1]
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
He:
Has been uncooperative?
Answer Codes
0. Not true
1. Sometimes true
2. Often true
Don't know
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Uncooperative
Fill Instructions
Special Instructions
Skip Instructions
<0-2,R,D> [go to CMHAGM11_2]
Hard Edits
Soft Edits
AssocHelp
H_CMHAG
Tuesday, June 13, 2017
Page 101 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.321_01.005
Variable Name
QARNDM3M
Universe
QAASK3 = 1
Universe-text
All families selected for QA question
Question Text
Random number generator
Answer Codes
(Allow 00-09)
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 102 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
B
Question ID
CHS.321_02.000
Variable Name
CMHAGM11_2
Universe
HHSTAT4='C' and AGE IN('002','003') and SEX='1'
Universe-text
Male sample children 2-3
Question Text
(book) C3 ?[F1]
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
He:
Has trouble getting to sleep?
Answer Codes
0. Not true
1. Sometimes true
2. Often true
Don't know
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Trouble getting sleep
Fill Instructions
Special Instructions
Skip Instructions
<0-2,R,D> [go to CMHAGM11_3]
Hard Edits
*****Author, please make sure that the reference period is the same in Spanish as it is
in English. There was a slight discrepancy that I think is now fixed. Please double
check. Thanks. AG
Soft Edits
AssocHelp
H_CMHAG
Tuesday, June 13, 2017
Page 103 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.321_02.001
Variable Name
QACHK3M
Universe
HHSTAT4='C' and AGE IN('002','003') and SEX='1' and QAASK3 = 1
Universe-text
Male sample children 2-3 years where QA question was selected
Question Text
*Please enter [Fill1: QARNDM3M ] for quality assurance.
Answer Codes
(Allow 0-9)
Question Type
Procedure
Field Pane Description
Fill Instructions
QA Check
Fill1: QARNDM3M is the number that was randomly selected is filled in here
Special Instructions
Skip Instructions
[goto CMHAGM11_3]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 104 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.321_02.002
Variable Name
QACHNG3M
Universe
QACHK3M=0-9
Universe-text
All families selected for QA question
Question Text
Flag field to indicate whether or not the value entered by the FR matched or not.
' ' (empty) - if the check was not asked or answered
0 - if the check was asked and the value entered matches the random value
1 - if the check was asked and the value entered does NOT match the random
value (cannot be undone)
Answer Codes
' ', 0,1
Question Type
Flag
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 105 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
B
Question ID
CHS.321_03.000
Variable Name
CMHAGM11_3
Universe
HHSTAT4='C' and AGE IN('002','003') and SEX='1'
Universe-text
Male sample children 2-3
Question Text
(book) C3 ?[F1]
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
He:
Has speech problems?
Answer Codes
0. Not true
1. Sometimes true
2. Often true
Don't know
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Speech problems
Fill Instructions
Special Instructions
Skip Instructions
<0-2,R,D> [go to CMHAGM11_4]
Hard Edits
Soft Edits
AssocHelp
H_CMHAG
Tuesday, June 13, 2017
Page 106 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
B
Question ID
CHS.321_04.000
Variable Name
CMHAGM11_4
Universe
HHSTAT4='C' and AGE IN('002','003') and SEX='1'
Universe-text
Male sample children 2-3
Question Text
(book) C3 ?[F1]
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
He:
Has been unhappy, sad, or depressed?
Answer Codes
0. Not true
1. Sometimes true
2. Often true
Don't know
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Unhappy/depressed
Fill Instructions
Special Instructions
Skip Instructions
<0-2,R,D> [go to CAU.CUSUALPL]
Hard Edits
Soft Edits
AssocHelp
H_CMHAG
Tuesday, June 13, 2017
Page 107 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Behaviors
Part
B
Question ID
CHS.321_H
Variable Name
H_CMHAG
Universe
Universe-text
Question Text
If respondent gives an answer which does not match the categories read in the
question, reread the question emphasizing the wording of the answer categories.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CMHAGM11_1
CMHAGM11_2
CMHAGM11_3
CMHAGM11_4
CMHAGF11_1
CMHAGF11_2
CMHAGF11_3
CMHAGF11_4
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 108 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
B
Question ID
CHS.361_01.000
Variable Name
CMHAGF11_1
Universe
HHSTAT4='C' and AGE IN('002','003') and SEX = '2'
Universe-text
Female sample children 2-3
Question Text
(book) C3 ?[F1]
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
She:
Has temper tantrums or a hot temper?
Answer Codes
0. Not true
1. Sometimes true
2. Often true
Don't know
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Temper tantrums
Fill Instructions
Special Instructions
Skip Instructions
<0-2,R,D> [go to CMHAGF11_2]
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H_CMHAG
Tuesday, June 13, 2017
Page 109 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.361_01.005
Variable Name
QARNDM3F
Universe
QAASK3 = 1
Universe-text
All families selected for QA question
Question Text
Random number generator
Answer Codes
(Allow 00-09)
Question Type
Integer
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 110 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
B
Question ID
CHS.361_02.000
Variable Name
CMHAGF11_2
Universe
HHSTAT4='C' and AGE IN('002','003') and SEX = '2'
Universe-text
Female sample children 2-3
Question Text
(book) C3 ?[F1]
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
She:
Has speech problems?
Answer Codes
0. Not true
1. Sometimes true
2. Often true
Don't know
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Speech problems
Fill Instructions
Special Instructions
Skip Instructions
<0-2,R,D> [go to CMHAGF11_3]
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H_CMHAG
Tuesday, June 13, 2017
Page 111 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.361_02.001
Variable Name
QACHK3F
Universe
HHSTAT4='C' and AGE IN('002','003') and SEX='2' and QAASK3 = 1
Universe-text
Female sample children 2-3 years where QA question was selected
Question Text
*Please enter [Fill1: QARNDM3F ] for quality assurance.
Answer Codes
(Allow 0-9)
Question Type
Procedure
Field Pane Description
Fill Instructions
QA Check
Fill1: QARNDM3F is the number that was randomly selected is filled in here
Special Instructions
Skip Instructions
[goto CMHAGF11_3]
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Tuesday, June 13, 2017
Page 112 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
Question ID
CHS.361_02.002
Variable Name
QACHNG3F
Universe
QACHK3F=0-9
Universe-text
All families selected for QA question
Question Text
Flag field to indicate whether or not the value entered by the FR matched or not.
' ' (empty) - if the check was not asked or answered
0 - if the check was asked and the value entered matches the random value
1 - if the check was asked and the value entered does NOT match the random
value (cannot be undone)
Answer Codes
' ', 0,1
Question Type
Flag
Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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AssocHelp
Tuesday, June 13, 2017
Page 113 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
B
Question ID
CHS.361_03.000
Variable Name
CMHAGF11_3
Universe
HHSTAT4='C' and AGE IN('002','003') and SEX = '2'
Universe-text
Female sample children 2-3
Question Text
(book) C3 ?[F1]
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
She:
Has been nervous or high-strung?
Answer Codes
0. Not true
1. Sometimes true
2. Often true
Don't know
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Nervous/high-strung
Fill Instructions
Special Instructions
Skip Instructions
<0-2,R,D> [go to CMHAGF11_4]
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H_CMHAG
Tuesday, June 13, 2017
Page 114 of 115
Module
11
Section Name
Child Conditions, Limitations, Health Status
Part
B
Question ID
CHS.361_04.000
Variable Name
CMHAGF11_4
Universe
HHSTAT4='C' and AGE IN('002','003') and SEX = '2'
Universe-text
Female sample children 2-3
Question Text
(book) C3 ?[F1]
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
She:
Has been unhappy, sad, or depressed?
Answer Codes
0. Not true
1. Sometimes true
2. Often true
Don't know
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Unhappy/depressed
Fill Instructions
Special Instructions
Skip Instructions
<0-2,R,D> [go to CAU.CUSUALPL]
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H_CMHAG
Tuesday, June 13, 2017
Page 115 of 115
2018 Q1 NHIS Instrument Spec Report
Section name: Child Health Care Access and Utilization
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.020
Variable Name
CUSUALPL
Universe
HHSTAT4 = 'C' and AGE <18
Universe-text
Sample Children <18
Question Text
?[F1]
The next questions are about health care.
Is there a place that [fill1: alias] USUALLY goes when [fill2: he/she] is sick or you
need advice
about [fill3: his/her] health?
Answer Codes
1. Yes
2. There is NO place
3. There is MORE THAN ONE place
Don't know
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Usually go when sick
Fill Instructions
Special Instructions
Skip Instructions
<1,3> [go to CPLKIND]
<2,D,R> [go to CHCPLKND]
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H_CUSUALPL
Tuesday, June 13, 2017
Page 1 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.020_H
Variable Name
H_CUSUALPL
Universe
Universe-text
Question Text
A place to USUALLY go when a child is sick or in need of advice about his/her health
includes:
[blt]Walk-in clinic
[blt]Doctor's office
[blt]Clinic
[blt]Health Center
[blt]Health Maintenance Organization
[blt]Hospital - Emergency Room or Outpatient Clinic
[blt]Military or VA Health Care Facility
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CUSUALPL
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 2 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.030
Variable Name
CPLKIND
Universe
HHSTAT4 = 'C' and AGE <18 and CUSUALPL = 1,3
Universe-text
Sample children <18 with one or more usual places to go when sick or need health
advice
Question Text
?[F1]
[fill1: What kind of place is it / What kind of place does [fill2: alias] go to most often] a clinic, doctor's office, emergency room, or some other place?
Answer Codes
1. Clinic or health center
2. Doctor's office or HMO
3. Hospital emergency room
4. Hospital outpatient department
5. Some other place
6. Doesn't go to one place most often
Don't know
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Go to most often
fill1: [if CUSUALPL/CAU.020 = 1 then "What kind of place is it...";
if CUSUALPL/CAU.020 = 3 then "What kind of place does [fill2: alias] go to most
often..."
Special Instructions
Skip Instructions
<1-5> [go to CHCPLROU]
<6,D,R> [go to CHCPLKND]
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H_CPLKIND
Tuesday, June 13, 2017
Page 3 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.030_H
Variable Name
H_CPLKIND
Universe
Universe-text
Question Text
[b]Doctor[b] includes medical doctors, as well as other health care professionals, such
as: general practitioners, psychologists, chiropractors, etc.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CPLKIND
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 4 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.035
Variable Name
CHCPLROU
Universe
HHSTAT4 = 'C' and AGE <18 and CPLKIND =1-5
Universe-text
Sample children <18 with one or more usual places to go when sick or need health
advice who reported that place as a clinic or health center, doctor's office or HMO,
hospital emergency room, hospital outpatient department, or some other place
Question Text
?[F1]
Is that [fill1: CPLKIND/CAU.030] the same place [fill2: alias] USUALLY goes when
[fill3: he/she] needs routine or preventive care, such as a physical examination or
(well baby/child) check-up?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Routine / prev. care place
fill1 = CPLKIND answer text
Special Instructions
Skip Instructions
<1> [go to CHCCHGYR]
<2,D,R> [go to CHCPLKND]
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H_CHCPLROU
Tuesday, June 13, 2017
Page 5 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.035_H
Variable Name
H_CHCPLROU
Universe
Universe-text
Question Text
[b]Routine or preventive care[b] is a health procedure or series of health procedures
done to help a person avoid illness or to detect problems early.
A [b]general physical exam or check-up [b] is an examination not for a specific
condition or problem. This may include the following: a periodic health examination,
a complete medical examination, an annual health check-up, or a comprehensive
physical examination. It does NOT include dental exams and vision tests.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCPLROU
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 6 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.037
Variable Name
CHCPLKND
Universe
HHSTAT4 = 'C' and AGE <18 and [CUSUALPL=2,D,R or CPLKIND =6,D,R, or
CHCPLROU =2,D,R]
Universe-text
Sample Children <18 who do not have a usual source of sick care; who Ref/NA/DK if
have a usual source of sick care; who have a usual source of sick care but does not
go to one place most often; who have a usual source of sick care but Ref/NA/DK what
kind of place; who have a usual source of sick care, but it is not same place as usual
source of routine/preventive care; who have a usual source of sick care but
Ref/NA/DK if it is same place as usual source of routine/preventive care.
Question Text
?[F1]
What kind of place does [fill1: alias] USUALLY go to when [fill2: he/she] needs routine
or preventive care, such as a physical examination or (well baby/child) check-up?
Answer Codes
0. Doesn't get preventive care anywhere
1. Clinic or health center
2. Doctor's office or HMO
3. Hospital emergency room
4. Hospital outpatient department
5. Some other place
6. Doesn't go to one place most often
Don't know
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Usually go for routine / prev. care
Fill Instructions
Special Instructions
Skip Instructions
<0-6,R,D>
if CUSUALPL=2,R,D [goto CHCDLYR1_1];
ELSE [goto CHCCHGYR]
Hard Edits
Soft Edits
AssocHelp
H_CHCPLKND
Tuesday, June 13, 2017
Page 7 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
Question ID
CAU.037_H
Variable Name
H_CHCPLKND
Universe
Universe-text
Question Text
Accept whatever the respondent reports.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCPLKND
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 8 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.040
Variable Name
CHCCHGYR
Universe
HHSTAT4 = 'C' and AGE <18 and [CUSUALPL=1,3 or CHCPLROU = 1]
Universe-text
Sample children <18 with one or more place to go when sick/need advice [or who
reported same place as usual source of routine/preventive care]
Question Text
?[F1]
At any time IN THE PAST 12 MONTHS did you CHANGE the place(s) to which [fill:
alias] USUALLY goes for health care?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Change health care place
Fill Instructions
Special Instructions
Skip Instructions
<1> [go to CHCCHGHI]
<2,D,R> to CHCDLYR1_1]
Hard Edits
Soft Edits
AssocHelp
H_CHCCHGYR
Tuesday, June 13, 2017
Page 9 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.040_H
Variable Name
H_CHCCHGYR
Universe
Universe-text
Question Text
[b]Change the place[b] refers to a change in health care providers, not a change of
address for a current provider.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCCHGYR
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 10 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.050
Variable Name
CHCCHGHI
Universe
HHSTAT4 = 'C' and AGE <18 and CHCCHGYR=1
Universe-text
All sample children <18 that have changed their usual place of health care in the past
12 months
Question Text
Was this change for a reason related to health insurance?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Change due to health ins.
Fill Instructions
Special Instructions
Skip Instructions
<1,2,D,R> [goto CHCDLYR1_1]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 11 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
Question ID
CAU.080_1
Variable Name
CHCDLYR1_1
Universe
HHSTAT4 = 'C' and AGE <18
Universe-text
All sample children <18
Question Text
?[F1]
There are many reasons people delay getting medical care. Have you delayed
getting care for [fill: alias] for any of the following reasons IN THE PAST 12
MONTHS...
You couldn't get through on the telephone.
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Couldn't get through on phone
Fill Instructions
Special Instructions Formpane: column heading = "Past 12 months"
Skip Instructions
<1,2,D,R> [goto CHCDLYR1_2]
Hard Edits
Soft Edits
AssocHelp
H_CHCDLYR1_1
Tuesday, June 13, 2017
Page 12 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.080_1_H
Variable Name
H_CHCDLYR1_1
Universe
Universe-text
Question Text
Delayed assumes that medical care has been or will eventually be received.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCDLYR1_1
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 13 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.080_2
Variable Name
CHCDLYR1_2
Universe
HHSTAT4 = 'C' and AGE <18
Universe-text
All sample children <18
Question Text
?[F1]
* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed
getting care for [fill: alias] for any of the following reasons IN THE PAST 12
MONTHS...
You couldn't get an appointment for [fill: alias] soon enough.
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
No appt. soon enough
Fill Instructions
Special Instructions
Skip Instructions
<1,2,D,R> [goto CHCDLYR1_3]
Hard Edits
Soft Edits
AssocHelp
H_CHCDLYR1_2
Tuesday, June 13, 2017
Page 14 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.080_2_H
Variable Name
H_CHCDLYR1_2
Universe
Universe-text
Question Text
[b]Delayed[b] assumes that medical care has been or will eventually be received.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCDLYR1_2
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 15 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.080_3
Variable Name
CHCDLYR1_3
Universe
HHSTAT4 = 'C' and AGE <18
Universe-text
All sample children <18
Question Text
?[F1]
* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed
getting care for [fill: alias] for any of the following reasons IN THE PAST 12
MONTHS...
Once you get there, [fill: alias] has to wait too long to see the doctor.
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Wait too long to see Dr.
Fill Instructions
Special Instructions
Skip Instructions
<1,2,D,R> [goto CHCDLYR1_4]
Hard Edits
Soft Edits
AssocHelp
H_CHCDLYR1_3
Tuesday, June 13, 2017
Page 16 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.080_3_H
Variable Name
H_CHCDLYR1_3
Universe
Universe-text
Question Text
[b]Delayed[b] assumes that medical care has been or will eventually be received.
[b]Waiting time to see the doctor[b] includes only time from arrival until the health care
provider is seen.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCDLYR1_3
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 17 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.080_4
Variable Name
CHCDLYR1_4
Universe
HHSTAT4 = 'C' and AGE <18
Universe-text
All sample children <18
Question Text
?[F1]
* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed
getting care for [fill: alias] for any of the following reasons IN THE PAST 12
MONTHS...
The (clinic/doctor's office) wasn't open when you could get there.
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Clinic / office not open
Fill Instructions
Special Instructions
Skip Instructions
<1,2,D,R> [goto CHCDLYR1_5]
Hard Edits
Soft Edits
AssocHelp
H_CHCDLYR1_4
Tuesday, June 13, 2017
Page 18 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.080_4_H
Variable Name
H_CHCDLYR1_4
Universe
Universe-text
Question Text
[b]Delayed[b] assumes that medical care has been or will eventually be received.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCDLYR1_4
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 19 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.080_5
Variable Name
CHCDLYR1_5
Universe
HHSTAT4 = 'C' and AGE <18
Universe-text
All sample children <18
Question Text
?[F1]
* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed
getting care for [fill: alias] for any of the following reasons IN THE PAST 12
MONTHS...
You didn’t have transportation.
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
No transportation
Fill Instructions
Special Instructions
Skip Instructions
<1,2,D,R> [if AGE GE <2> goto CHCAFYR1_1; else goto CHCAFYR]
Hard Edits
Soft Edits
AssocHelp
H_CHCDLYR1_5
Tuesday, June 13, 2017
Page 20 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.080_5_H
Variable Name
H_CHCDLYR1_5
Universe
Universe-text
Question Text
[b]Delayed[b] assumes that medical care has been or will eventually be received.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCDLYR1_5
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 21 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.130
Variable Name
CHCAFYR
Universe
HHSTAT4 = 'C' and AGE <2
Universe-text
Sample children <2
Question Text
?[F1]
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any
of the following, but didn't get it because you couldn't afford it...
Prescription medicines?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Prescription medicines
Fill Instructions
Special Instructions Formpane: column heading: "Children under 2 years old - past 12 months"
Skip Instructions
<1, 2, D, R> [if AGE <1 goto CHCSYR1_2; else goto CDENLONG]
Hard Edits
Soft Edits
AssocHelp
H_CHCAFYR
Tuesday, June 13, 2017
Page 22 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.130_H
Variable Name
H_CHCAFYR
Universe
Universe-text
Question Text
[b]Prescription Medicines[b] are medication which can only be obtained with the
approval of a licensed health care professional. The medication is usually obtained
through a pharmacy using a written note or telephoned instructions from the health
care professional to the pharmacy.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCAFYR
CHCAFYR1_1
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 23 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.135_1
Variable Name
CHCAFYR1_1
Universe
HHSTAT4 = 'C' and AGE GE 2
Universe-text
Sample children GE 2
Question Text
?[F1]
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any
of the following, but didn't get it because you couldn't afford it...
Prescription medicines?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Prescription medicines
Fill Instructions
Special Instructions Formpane: column heading: "Children 2-17 years old - past 12 months"
Skip Instructions
<1, 2, D, R> [goto CHCAFYR1_2]
Hard Edits
Soft Edits
AssocHelp
H_CHCAFYR
Tuesday, June 13, 2017
Page 24 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.135_2
Variable Name
CHCAFYR1_2
Universe
HHSTAT4 = 'C' and AGE GE 2
Universe-text
Sample children GE 2
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any
of the following, but didn't get it because you couldn't afford it...
Mental health care or counseling?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Mental health care / counseling
Fill Instructions
Special Instructions
Skip Instructions
<1, 2, D, R> [goto CHCAFYR1_3]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 25 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.135_3
Variable Name
CHCAFYR1_3
Universe
HHSTAT4 = 'C' and AGE GE 2
Universe-text
Sample children GE 2
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any
of the following, but didn't get it because you couldn't afford it...
Dental care (including check-ups)?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Dental care
Fill Instructions
Special Instructions
Skip Instructions
<1, 2, D, R> [goto CHCAFYR1_4]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 26 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.135_4
Variable Name
CHCAFYR1_4
Universe
HHSTAT4 = 'C' and AGE GE 2
Universe-text
Sample children GE 2
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any
of the following, but didn't get it because you couldn't afford it...
Eyeglasses?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Eyeglasses
Fill Instructions
Special Instructions
Skip Instructions
<1, 2, D, R> [goto CDENLONG]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 27 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
B
Question ID
CAU.160
Variable Name
CDENLONG
Universe
HHSTAT4 = 'C' and AGE GE 1
Universe-text
Sample children GE 1
Question Text
(book) C4 ?[F1]
About how long has it been since [fill: alias] last saw a dentist? Include all types of
dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well
as dental hygienists.
Answer Codes
0. Never
1. 6 months or less
2. More than 6 months, but not more than 1 year ago
3. More than 1 year, but not more than 2 years ago
4. More than 2 years, but not more than 5 years ago
5. More than 5 years ago
Don't know
Refused
Question Type
Pick One - answer list pane
Field Pane Description
Last saw dentist
Fill Instructions
Special Instructions
Skip Instructions
<0-5, D,R> [if AGE GE <2> goto CHCSYR_1; else go to CHCSYR1_2]
Hard Edits
Soft Edits
AssocHelp
H_CDENLONG
Tuesday, June 13, 2017
Page 28 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.160_H
Variable Name
H_CDENLONG
Universe
Universe-text
Question Text
Always probe for an exact number.
If the respondent reports a range or interval, assist the respondent in making an
estimate by probing. For example, you might ask "Could you give me a more exact
number?"
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CDENLONG
CHCHNOYR
CSRGNOYR
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 29 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.170_1
Variable Name
CHCSYR1_2
Universe
HHSTAT4 = 'C' and AGE <2
Universe-text
Sample children <2
Question Text
DURING THE PAST 12 MONTHS, has anyone in the family seen or talked to any of
the following health care providers about [fill2: alias]'s health?
An optometrist, ophthamologist, or eye doctor (someone who prescribes eyeglasses)?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Eye doctor
Fill Instructions
Special Instructions Formpane: column heading = "Children under 2 years old - past 12 months"
Skip Instructions
<1, 2, D, R> [goto CHCSYR1_3]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 30 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.170_2
Variable Name
CHCSYR1_3
Universe
HHSTAT4 = 'C' and AGE <2
Universe-text
Sample children <2
Question Text
?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS, has anyone in the family seen or talked to any of
the following health care providers about [fill2: alias]'s health?
A foot doctor?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Foot doctor
Fill Instructions
Special Instructions
Skip Instructions
<1,2, D, R> [goto CHCSYR1_5]
Hard Edits
Soft Edits
AssocHelp
H_CHCSYR1_3
Tuesday, June 13, 2017
Page 31 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.170_2_H
Variable Name
H_CHCSYR1_3
Universe
Universe-text
Question Text
A foot doctor is someone who treats diseases of the foot and is commonly known as a
podiatrist.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCSYR1_3
CHCSYR_3
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 32 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.170_3
Variable Name
CHCSYR1_5
Universe
HHSTAT4 = 'C' and AGE <2
Universe-text
Sample children <2
Question Text
?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS, has anyone in the family seen or talked to any of
the following health care providers about [fill2: alias]'s health?
A physical therapist, speech therapist, respiratory therapist, audiologist, or
occupational therapist?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Physical / speech / resp. therapist
Fill Instructions
Special Instructions
Skip Instructions
<1,2, D, R> [goto CHCSYR1_6]
Hard Edits
Soft Edits
AssocHelp
H_CHCSYR1_5
Tuesday, June 13, 2017
Page 33 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.170_3_H
Variable Name
H_CHCSYR1_5
Universe
Universe-text
Question Text
A [b] physical therapist [b] is a health care professional skilled in working with persons
with health problems resulting from injury, disease, or developmental problems. A
physical therapist diagnoses muscle and joint problems and provides exercises and
treatments.
A [b] speech therapist [b] is a health care professional skilled in working with
communication and language disorders. Speech pathologists diagnose speech and
language problems and provide therapy including treatment for stuttering, impaired
articulation, or language or voice impairment.
A [b] respiratory therapist [b] is a health care professional skilled in working with
persons with respiratory difficulties. Respiratory therapists treat and manage the care
of persons with respiratory diseases. This may include administration of breathing
treatments, oxygen, and education of patients in regards to respiratory treatment
procedures.
An [b] audiologist [b] is a health care professional skilled in working with hearing
problems. An audiologist diagnoses hearing problems and their nature, and
determines if a person can benefit from using hearing aids.
An [b] occupational therapist [b] is a health care professional skilled in working with
health problems resulting from injury, disease, or developmental problems.
Occupational therapy involves working on functional activities such as dressing,
feeding, and writing.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCSYR1_5
CHCSYR_5
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 34 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.170_4
Variable Name
CHCSYR1_6
Universe
HHSTAT4 = 'C' and AGE <2
Universe-text
Sample children <2
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, has anyone in the family seen or talked to any of
the following health care providers about [fill2: alias]'s health?
A nurse practitioner, physician assistant or midwife?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Nurse prac. / physician asst.
Fill Instructions
Special Instructions
Skip Instructions
<1, 2, D, R> [goto CHCSYR8_1]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 35 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.175_1
Variable Name
CHCSYR_1
Universe
HHSTAT4 = 'C' and AGE GE 2
Universe-text
Sample children GE 2
Question Text
DURING THE PAST 12 MONTHS, have you seen or talked to any of the following
health care providers about [fill2: alias]'s health...
A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or
clinical social worker?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Mental health professional
Fill Instructions
Special Instructions Formpane: column heading: "Children 2-17 years old - past 12 months"
Skip Instructions
<1, 2, D, R> [goto CHCSYR_2]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 36 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.175_2
Variable Name
CHCSYR_2
Universe
HHSTAT4 = 'C' and AGE GE 2
Universe-text
Sample children GE 2
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to any of the following
health care providers about [fill2: alias]'s health...
An optometrist, ophthalmologist (AHF-thal-MOL-oh-jist), or eye doctor (someone who
prescribes eyeglasses)?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Eye doctor
Fill Instructions
Special Instructions
Skip Instructions
<1, 2, D, R> [goto CHCSYR_3]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 37 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.175_3
Variable Name
CHCSYR_3
Universe
HHSTAT4 = 'C' and AGE GE 2
Universe-text
Sample children GE 2
Question Text
?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to any of the following
health care providers about [fill2: alias]'s health...
A foot doctor?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Foot doctor
Fill Instructions
Special Instructions
Skip Instructions
<1, 2, D, R> [goto CHCSYR_4]
Hard Edits
Soft Edits
AssocHelp
H_CHCSYR1_3
Tuesday, June 13, 2017
Page 38 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.175_4
Variable Name
CHCSYR_4
Universe
HHSTAT4 = 'C' and AGE GE 2
Universe-text
Sample children GE 2
Question Text
?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to any of the following
health care providers about [fill2: alias]'s health...
A chiropractor?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Chiropractor
Fill Instructions
Special Instructions
Skip Instructions
<1, 2, D, R> [goto CHCSYR_5]
Hard Edits
Soft Edits
AssocHelp
H_CHCSYR_4
Tuesday, June 13, 2017
Page 39 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.175_4_H
Variable Name
H_CHCSYR_4
Universe
Universe-text
Question Text
A chiropractor is a licensed professional, but not a medical doctor, who uses
manipulation of the body joints, especially the spine, to restore normal nerve function.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCSYR_4
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 40 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.175_5
Variable Name
CHCSYR_5
Universe
HHSTAT4 = 'C' and AGE GE 2
Universe-text
Sample children GE 2
Question Text
?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to any of the following
health care providers about [fill2: alias]'s health...
A physical therapist, speech therapist, respiratory therapist, audiologist, or
occupational therapist?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Physical / speech / resp. therapist
Fill Instructions
Special Instructions
Skip Instructions
<1, 2, D, R> [goto CHCSYR_6]
Hard Edits
Soft Edits
AssocHelp
H_CHCSYR1_5
Tuesday, June 13, 2017
Page 41 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.175_6
Variable Name
CHCSYR_6
Universe
HHSTAT4 = 'C' and AGE GE 2
Universe-text
Sample children GE 2
Question Text
?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to any of the following
health care providers about [fill2: alias]'s health...
A nurse practitioner, physician assistant or midwife?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Nurse prac. / phys. asst. / midwife
Fill Instructions
Special Instructions
Skip Instructions
<1, 2, D, R> [if SEX eq <2> and AGE GE 15 goto CHCSYR7; else goto CHCSYR8]
Hard Edits
Soft Edits
AssocHelp
H_CHCSYR_6
Tuesday, June 13, 2017
Page 42 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.175_6_H
Variable Name
H_CHCSYR_6
Universe
Universe-text
Question Text
A [b] nurse practitioner [b] is a registered nurse who has completed an advanced
program of study leading to an expanded role in health care. Nurse practitioners are
able to take health histories, perform physical examinations, order tests, and prescribe
treatments including medications. Nurse practitioners work under the supervision of a
doctor, but not necessarily in the presence of the doctor.
A [b] nurse midwife [b] is a registered nurse who has completed an advanced program
of study leading to an expanded role in health care for women. Nurse midwives
provide gynecological, pregnancy and delivery care to women. Nurse midwives work
under the supervision of a doctor, but not necessarily in the presence of the doctor.
A [b] physician assistant [b] works under the supervision of a physician to provide
diagnostic, preventative, and therapeutic health care services. Duties may include
examining patients, interpreting and ordering x-rays and lab tests, and the diagnosis
and treatment of minor injuries.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCSYR_6
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 43 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.230
Variable Name
CHCSYR7
Universe
HHSTAT4 = 'C' and AGE GE 15 and SEX=2
Universe-text
Sample children GE 15 who are female
Question Text
?[F1]
DURING THE PAST 12 MONTHS, have you seen or talked to a doctor who
specializes in women's health (an obstetrician/gynecologist) about [fill2: alias]'s
health?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Women's health doctor
Fill Instructions
Special Instructions Form pane: column heading = "Past 12 months"
Skip Instructions
<1, 2, R, D> [goto CHCSYR8_1]
Hard Edits
Soft Edits
AssocHelp
H_CHCSYR7
Tuesday, June 13, 2017
Page 44 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.230_H
Variable Name
H_CHCSYR7
Universe
Universe-text
Question Text
An Obstetrician/Gynecologist is a medical doctor who treats women, pregnancy, and
diseases of the female reproductive system, including the breasts.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCSYR7
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 45 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.240_1
Variable Name
CHCSYR8_1
Universe
HHSTAT4 = 'C' and AGE <18
Universe-text
All sample children <18
Question Text
DURING THE PAST 12 MONTHS, have you seen or talked to the following about
[fill2: alias]'s health?
A medical doctor who specializes in a particular medical disease or problem
[fill3:other than obstetrician/ gynecologist, psychiatrist or ophthalmologist (AHF-thalMOL-oh-jist)? /fill4: other than psychiatrist or ophthalmologist (AHF-thal-MOL-oh-jist)]?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Fill Instructions
Specialist doctor
Fill 3: If [SEX = Female (2) ] Fill 4: If [SEX = Male (1) ]
Special Instructions Formpane: column heading = "Past 12 months"
Skip Instructions
<1, 2, D, R> [goto CHCSYR8_2]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 46 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.240_2
Variable Name
CHCSYR8_2
Universe
HHSTAT4 = 'C' and AGE <18
Universe-text
All sample children <18
Question Text
* Read if necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to the following about
[fill2: alias]'s health?
A general doctor who treats a variety of illnesses (a doctor in general practice,
pediatrics, family medicine, or internal medicine)?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
General doctor
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto CHCSYR10]
<2, D, R> [goto CHPEXYR]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 47 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.260
Variable Name
CHCSYR10
Universe
HHSTAT4 = 'C' and AGE <18 and CHCSYR8_2=1
Universe-text
Sample children <18 who have seen or talked to a general doctor during the past 12
months
Question Text
Does that doctor treat children and adults (a doctor in general practice or family
medicine)?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Doctor treats children and adults
Fill Instructions
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.
Skip Instructions
<1, 2, D, R> [goto CHCSYREM]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 48 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.265
Variable Name
CHCSYREM
Universe
HHSTAT4 = 'C' and AGE <18 and CHCSYR8_2=1
Universe-text
Sample children <18 who have seen a general doctor in the past 12 months
Question Text
Did you see or talk to this general doctor because of an emotional or behavioral
problem that [fill1: alias] may have?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
General doctor for emotional problem
Fill Instructions
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.
Skip Instructions
<1, 2, D, R> [goto CHPEXYR]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 49 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.270
Variable Name
CHPEXYR
Universe
HHSTAT4 = 'C' and AGE <18
Universe-text
Sample children <18
Question Text
?[F1]
DURING THE PAST 12 MONTHS, did [fill1: alias] receive a well-child check-up, that
is a general check-up, when [fill2: he/she] was not sick or injured?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Check-up
Fill Instructions
Special Instructions
Skip Instructions
<1, 2, D, R> [goto CHERNOYR]
Hard Edits
Soft Edits
AssocHelp
H_CHPEXYR
Tuesday, June 13, 2017
Page 50 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.270_H
Variable Name
H_CHPEXYR
Universe
Universe-text
Question Text
A general physical exam or check-up is an examination not for a specific condition or
problem. This may include the following: a periodic health examination, a complete
medical examination, an annual health check-up, or a comprehensive physical
examination. It does NOT include dental exams and vision tests.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHPEXYR
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 51 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
Question ID
CAU.280
Variable Name
CHERNOYR
Universe
HHSTAT4 = 'C' and AGE<18
Universe-text
Sample children <18
Question Text
(book) C5 ?[F1]
DURING THE PAST 12 MONTHS, HOW MANY TIMES has [fill1: alias] gone to a
HOSPITAL EMERGENCY ROOM about [fill2: his/her] health? (This includes
emergency room visits that resulted in a hospital admission.)
Answer Codes
0.
1.
2.
3.
4.
5.
6.
7.
8.
Question Type
None
1
2-3
4-5
6-7
8-9
10 - 12
13 - 15
16 or more
Integer
Field Pane Description
Emergency room
Fill Instructions
Special Instructions
Skip Instructions
<0-8,R,D> [goto CHCHYR]
Hard Edits
Soft Edits
AssocHelp
H_CHERNOYR
Tuesday, June 13, 2017
Page 52 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.280_H
Variable Name
H_CHERNOYR
Universe
Universe-text
Question Text
[b] Hospital Emergency Room [b] is an emergency care facility at a hospital. Do NOT
include emergency care received at a clinic or HMO. Include emergency room visits
which resulted in admission for inpatient care.
Do not include visits to outpatient clinics, urgent care facilities and the like.
Always probe for an exact number. If the respondent reports a range or interval,
assist the respondent in making an estimate by probing. For example, you might ask
"Could you give me a more exact number?"
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHERNOYR
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 53 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.290
Variable Name
CHCHYR
Universe
HHSTAT4 = 'C' and AGE <18
Universe-text
Sample children <18
Question Text
?[F1]
DURING THE PAST 12 MONTHS, did [fill1: alias] receive care AT HOME from a
nurse or other health care professional?
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Home care - nurse / hlth. prof.
Fill Instructions
Special Instructions Formpane: column heading = "Past 12 months"
Skip Instructions
<1> [goto CHCHMOYR]
<2, D, R> [goto CHCNOYR]
Hard Edits
Soft Edits
AssocHelp
H_CHCHYR
Tuesday, June 13, 2017
Page 54 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.290_H
Variable Name
H_CHCHYR
Universe
Universe-text
Question Text
At HOME refers to the child's own home and everyone else's home in which the child
was staying at the time. This could be a house, apartment, motor home, houseboat,
trailer, or other dwelling. Do not include visits by a doctor while the child was in a
hospital or institutionalized.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCHYR
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 55 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.300
Variable Name
CHCHMOYR
Universe
HHSTAT4 = 'C' and AGE <18 and CHCHYR=1
Universe-text
Sample children <18 that have received home care from health professional during
the past 12 months
Question Text
?[F1]
DURING THE PAST 12 MONTHS, how many months did [fill: alias] receive care AT
HOME from a health care professional?
Answer Codes
Question Type
Integer
Field Pane Description
Number of months
Fill Instructions
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.
Skip Instructions
<01-12, D, R> [goto CHCHNOYR]
Hard Edits
Soft Edits
AssocHelp
H_CHCHMOYR
Tuesday, June 13, 2017
Page 56 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.300_H
Variable Name
H_CHCHMOYR
Universe
Universe-text
Question Text
At HOME refers to the child's own home and everyone else's home in which the child
was staying at the time. This could be a house, apartment, motor home, houseboat,
trailer, or other dwelling. Do not include visits by a doctor while the child was in a
hospital or institutionalized.
Always probe for an exact number.
If the respondent reports a range or interval, assist the respondent in making an
estimate by probing. For example, you might ask "Could you give me a more exact
number?"
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCHMOYR
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 57 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.310
Variable Name
CHCHNOYR
Universe
HHSTAT4 = 'C' and AGE <18 and CHCHYR=1
Universe-text
Sample children <18 that have received home care from health professional during
the past 12 months
Question Text
(book) C6 ?[F1]
What was the total number of home visits received for [fill1: alias] during [fill2: that
month/those months]?
Answer Codes
1.
2.
3.
4.
5.
6.
7.
8.
Question Type
Integer
Field Pane Description
Fill Instructions
1
2-3
4-5
6-7
8-9
10 - 12
13 - 15
16 or more
Number of visits
fill2 = if CHCHMOYR = 1 then "that"; else then "those"
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.
Skip Instructions
<1-8, D, R> [goto CHCNOYR]
Hard Edits
Soft Edits
AssocHelp
H_CDENLONG
Tuesday, June 13, 2017
Page 58 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.320
Variable Name
CHCNOYR
Universe
HHSTAT4 = 'C' and AGE <18
Universe-text
Sample children <18
Question Text
(book) C5 ?[F1]
DURING THE PAST 12 MONTHS, HOW MANY TIMES has [fill1: alias] seen a doctor
or other health care professional about [fill2: his/her] health at A DOCTOR’S OFFICE,
A CLINIC, OR SOME OTHER PLACE? Do not include times [fill1: alias] was
hospitalized overnight, visits to hospital emergency rooms, home visits, dental visits
or telephone calls.
Answer Codes
0. None
1. 1
2. 2 - 3
3. 4 - 5
4. 6 - 7
5. 8 - 9
6. 10 - 12
7. 13 - 15
8. 16 or more
Question Type
Integer
Field Pane Description
Number of office visits
Fill Instructions
Special Instructions
Skip Instructions
<0-8, D, R> [goto CSRGYR]
Hard Edits
Soft Edits
AssocHelp
H_CHCNOYR
Tuesday, June 13, 2017
Page 59 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.320_H
Variable Name
H_CHCNOYR
Universe
Universe-text
Question Text
[b] Doctor [b] includes medical doctors, as well as other health care professionals,
such as general practitioners, psychologists, chiropractors, etc. Do not include
dentists.
Always probe for an exact number. If the respondent reports a range or interval,
assist the respondent in making an estimate by probing. For example, you might ask
'Could you give me a more exact number?'
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCNOYR
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 60 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.330
Variable Name
CSRGYR
Universe
HHSTAT4 = 'C' and AGE <18
Universe-text
Sample children <18
Question Text
DURING THE PAST 12 MONTHS has [fill1: alias] had SURGERY or other surgical
procedures either as an inpatient or outpatient?
* Read if necessary.
This includes both major surgery and minor procedures such as setting bones or
removing growths.
Answer Codes
1. Yes
2. No
Don't know
Refused
Question Type
Yes/No
Field Pane Description
Surgery / surgical procedures
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto CSRGNOYR]
<2, D, R> [goto CMDLONG]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 61 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.340
Variable Name
CSRGNOYR
Universe
HHSTAT4 = 'C' and AGE <18 and CSRGYR=1
Universe-text
All sample children <18 that have undergone surgery during the past 12 months
Question Text
?[F1]
Including any times you may have already told me about, HOW MANY DIFFERENT
TIMES has [fill1: alias] had surgery DURING THE PAST 12 MONTHS?
* Enter '95' for 95 or more times.
Answer Codes
Question Type
Integer
Field Pane Description
Number of surgeries
Fill Instructions
Special Instructions
Skip Instructions
<1-10, D, R> [goto CMDLONG]
<11-95> [goto ERR_CMDLONG]
Hard Edits
Soft Edits
ERR_CMDLONG
[fill2: CSRGNOYR] is an unusually large number. Did [fill1: alias] have [fill2:
CSRGNOYR] surgical procedures?
*Please verify.
AssocHelp
H_CDENLONG
Tuesday, June 13, 2017
Page 62 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
C
Question ID
CAU.345
Variable Name
CMDLONG
Universe
HHSTAT4 = 'C' and AGE <18
Universe-text
Sample children <18
Question Text
(book) C4 ?[F1]
About how long has it been since anyone in the family last saw or talked to a doctor or
other health care professional about [fill1: SC name]'s health? Include doctors seen
while [fill2: he/she] was a patient in a hospital.
Answer Codes
0. Never
1. 6 months or less
2. More than 6 months, but not more than 1 year ago
3. More than 1 year, but not more than 2 years ago
4. More than 2 years, but not more than 5 years ago
5. More than 5 years ago
Refused
Don't Know
Question Type
Pick One - answer list pane
Field Pane Description
Last saw / talked with doctor / hlth. prof.
Fill Instructions
Special Instructions
Skip Instructions
<0-5, D, R>
If AGE LT 3 [goto CH1N1_1]
If AGE GE 3 [goto CBALWLK]
Hard Edits
Soft Edits
AssocHelp
H_CMDLONG
Tuesday, June 13, 2017
Page 63 of 64
Module
12
Section Name
Child Health Care Access and Utilization
Part
A
Question ID
CAU.345_H
Variable Name
H_CMDLONG
Universe
Universe-text
Question Text
Always probe for an exact number. If the respondent reports a range or interval,
assist the respondent in making an estimate by probing. For example, you might ask
'Could you give me a more exact number?'
[b] Medical doctor [b] refers to both medical doctors (M.D.s) and osteopathic
physicians (D.O.s), including general practitioners and all types of specialists; and
their assistants. Do not include persons who do not have an M.D. or D.O. degree,
such as dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths,
Christian Science healers, opticians, optometrists, psychologists, etc., unless they
assist an M.D. or D.O.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CMDLONG
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 64 of 64
2018 Q1 NHIS Instrument Spec Report
Section name: Child Mental Health Brief Questionnaire
Module
25
Section Name
Child Mental Health Brief Questionnaire
Part
Question ID
CMB.010
Variable Name
CMHCOPY
Universe
HHSTAT4='C' and AGE GE 4
Universe-text
Sample children GE 4
Question Text
* The following statements are not to be read to the respondent. They are displayed
and included here for legal reasons.
* The next 6 items contained in CMHMF_1 through CMHDIFF are included in this
survey with permission as indicated below.
* The SDQ questions are copyrighted by Robert Goodman, Ph.D., FRCPSYCH,
MRCP. State and local agencies may use these questions without charge and without
seeking separate permission provided the wording is not modified, all the questions
are retained, and Dr. Goodman's copyright is acknowledged.
Answer Codes
1. Enter 1 to Continue
Question Type
Enter 1 to Continue
Field Pane Description
Continue
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto CMHMF_1]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 1 of 7
Module
25
Section Name
Child Mental Health Brief Questionnaire
Part
Question ID
CMB.020_1
Variable Name
CMHMF_1
Universe
HHSTAT4='C' and AGE GE 4
Universe-text
Sample children GE 4
Question Text
(book) C7
I am going to read a list of items that describe children. For each item, please tell me if
it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC
name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...is generally well behaved, usually does what adults request.
Answer Codes
1. Not true
2. Somewhat true
3. Certainly true
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Well behaved
Fill Instructions
Special Instructions
Skip Instructions
<1-3,D,R> [goto CMHMF_2]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 2 of 7
Module
25
Section Name
Child Mental Health Brief Questionnaire
Part
Question ID
CMB.020_2
Variable Name
CMHMF_2
Universe
HHSTAT4='C' and AGE GE 4
Universe-text
Sample children GE 4
Question Text
(book) C7
* Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if
it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC
name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...has many worries, or often seems worried.
Answer Codes
1. Not true
2. Somewhat true
3. Certainly true
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Worries
Fill Instructions
Special Instructions
Skip Instructions
<1-3,D,R> [goto CMHMF_3]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 3 of 7
Module
25
Section Name
Child Mental Health Brief Questionnaire
Part
Question ID
CMB.020_3
Variable Name
CMHMF_3
Universe
HHSTAT4='C' and AGE GE 4
Universe-text
Sample children GE 4
Question Text
(book) C7
* Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if
it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC
name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...is often unhappy, depressed or tearful.
Answer Codes
1. Not true
2. Somewhat true
3. Certainly true
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Unhappy
Fill Instructions
Special Instructions
Skip Instructions
<1-3,D,R> [goto CMHMF_4]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 4 of 7
Module
25
Section Name
Child Mental Health Brief Questionnaire
Part
Question ID
CMB.020_4
Variable Name
CMHMF_4
Universe
HHSTAT4='C' and AGE GE 4
Universe-text
Sample children GE 4
Question Text
(book) C7
* Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if
it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC
name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...gets along better with adults than with other [fill3: children/youth].
Answer Codes
1. Not true
2. Somewhat true
3. Certainly true
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Gets along
fill3 = [if AGE 4-11 "children" ; if AGE GE 12 "youth"]
Special Instructions
Skip Instructions
<1-3,D,R> [goto CMHMF_5]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 5 of 7
Module
25
Section Name
Child Mental Health Brief Questionnaire
Part
Question ID
CMB.020_5
Variable Name
CMHMF_5
Universe
HHSTAT4='C' and AGE GE 4
Universe-text
Sample children GE 4
Question Text
(book) C7
* Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if
it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC
name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...has good attention span, sees chores or homework through to the end.
Answer Codes
1. Not true
2. Somewhat true
3. Certainly true
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Attention
Fill Instructions
Special Instructions
Skip Instructions
<1-3,D,R> [goto CMHDIFF]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 6 of 7
Module
25
Section Name
Child Mental Health Brief Questionnaire
Part
Question ID
CMB.060
Variable Name
CMHDIFF
Universe
HHSTAT4='C' and AGE GE 4
Universe-text
Sample children GE 4
Question Text
(book) C8
Overall, do you think that [fill1: SC name] has difficulties in any of the following areas:
emotions, concentration, behavior, or being able to get along with other people?
Answer Codes
1. No
2. Yes, minor difficulties
3. Yes, definite difficulties
4. Yes, severe difficulties
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Difficulties
Fill Instructions
Special Instructions
Skip Instructions
<1-4,R,D> [goto next section]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 7 of 7
2018 Q1 NHIS Instrument Spec Report
Section name: Child Influenza Immunization
Module
33
Section Name
Child Influenza Immunization
Part
Question ID
CFI.005_00.010
Variable Name
CH1N1_1
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')
Universe-text
Sample Child LE 17 years
Question Text
?[F1]
DURING THE PAST 12 MONTHS, has {SC name} had a flu vaccination? A flu
vaccination is usually given in the fall and protects against influenza for the flu season.
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Flu Vaccine
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto CH1N1_2]
<2,R,D> [goto SCSSN4]
Hard Edits
Soft Edits
AssocHelp
CFI.005_00.010_H
Tuesday, June 13, 2017
Page 1 of 9
Module
33
Section Name
Child Influenza Immunization
Part
Question ID
CFI.005_00.010_H
Variable Name
H_CH1N1_1
Universe
Universe-text
Question Text
This includes a new type of flu shot called the Fluzone Intradermal vaccine that
features an ultra-fine needle that is 90 percent shorter than the typical needle used for
flu injections.
Answer Codes
Question Type
Help Screen
Field Pane Description
Fill Instructions
Special Instructions Associated Screen:
CH1N1_1
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 2 of 9
Module
33
Section Name
Child Influenza Immunization
Part
Question ID
CFI.005_00.020
Variable Name
CH1N1_2
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CH1N1_1(e)='1'
Universe-text
Sample Child LE 17 years who have had an vaccine dose
Question Text
How many vaccinations has {S.C. name} received?
Answer Codes
1. 1 vaccination or dose
2. 2 or more vaccination doses
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
How many
Fill Instructions
Special Instructions
Skip Instructions
<1,2> [goto CH1N1_3M]
[goto SCSSN4]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 3 of 9
Module
33
Section Name
Child Influenza Immunization
Part
Question ID
CFI.005_00.030
Variable Name
CH1N1_3M
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CH1N1_2(e) IN ('1','2')
Universe-text
Sample Child LE 17 who have had one or more vaccine doses
Question Text
1 of 2
During what month and year did {S.C. name} receive {fill: his/her} most recent flu
vaccine?
Answer Codes
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Month
Fill1: IFCH1N1_2=1 and SEX=1 then fill "his";
IFCH1N1_2=1 and SEX=2 then fill "her"
Special Instructions
Skip Instructions
<1-12,D> [ goto CH1N1_4Y] [goto CH1N1_5]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 4 of 9
Module
33
Section Name
Child Influenza Immunization
Part
Question ID
CFI.005_00.040
Variable Name
CH1N1_4Y
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (('01' <= CH1N1_3M(e) <= '12')
or (CH1N1_3M(e)=‘99’))
Universe-text
Sample Child LE 17 years who have had one or more vaccine doses and gave
month/don't know month of vaccine dose
Question Text
2 of 2
*Enter year of most recent flu vaccine.
Answer Codes
Question Type
Integer
Field Pane Description
Year
Fill Instructions
Special Instructions
Skip Instructions
[goto CH1N1_5]
[If CH1N1_3M and CH1N1_4Y = a future date] goto ERR1_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to birth] goto ERR2_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to 12 months ago] goto ERR3_
CH1N1_4Y]
Hard Edits
ERR1_ CH1N1_4Y
*Future date invalid.
ERR2_ CH1N1_4Y
*Date before birth.
ERR3_ CH1N1_4Y
*Date before 12 months ago.
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 5 of 9
Module
33
Section Name
Child Influenza Immunization
Part
Question ID
CFI.005_00.050
Variable Name
CH1N1_5
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CH1N1_2 IN ('1','2')
Universe-text
Sample Child LE 17 years who have had one or more vaccine doses
Question Text
Was this a shot, or was it a vaccine sprayed in the nose?
*Read if necessary: The flu nasal spray is called FluMist(trademark).
Answer Codes
1. Flu shot
2. Flu nasal spray (Spray, mist or drop in nose)
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Type
Fill Instructions
Special Instructions
Skip Instructions
<1-2,R,D> IF CH1N1_2=1 [go to SCSSN4];
else if CH1N1_2=2 [goto CH1N1_6M]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 6 of 9
Module
33
Section Name
Child Influenza Immunization
Part
Question ID
CFI.005_00.060
Variable Name
CH1N1_6M
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CH1N1_2(e)='2'
Universe-text
Sample Child LE 17 years who have had more than one vaccine doses
Question Text
1 of 2
During what month and year did {S.C. name} receive {fill: his/her} next most recent flu
vaccine?
Answer Codes
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Month - 2nd
Fill Instructions
Special Instructions
Skip Instructions
<1-12,D> [ goto CH1N1_7Y] [goto CH1N1_8]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 7 of 9
Module
33
Section Name
Child Influenza Immunization
Part
Question ID
CFI.005_00.070
Variable Name
CH1N1_7Y
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (('01' <= CH1N1_6M(e) <= '12')
or (CH1N1_6M(e)=‘99’))
Universe-text
Sample Child LE 17 years who have had more than one vaccine doses and gave
month/don't know month of vaccine dose
Question Text
2 of 2
*Enter year of next most recent flu vaccine.
Answer Codes
Question Type
Integer
Field Pane Description
Year - 2nd
Fill Instructions
Special Instructions
Skip Instructions
[goto CH1N1_8]
[If CH1N1_6M and CH1N1_7Y = a future date] goto ERR1_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to birth] goto ERR2_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to 12 months ago] goto ERR3_
CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a month and year after month and year given in
CH1N1_3M and CH1N1_4Y] goto ERR4_CH1N1_7Y]
Hard Edits
ERR1_ CH1N1_7Y
*Future date invalid.
ERR2_ CH1N1_7Y
*Date before birth.
ERR3_ CH1N1_7Y
*Date before 12 months ago.
Soft Edits
ERR4_ CH1N1_7Y
* The date entered for the most recent flu vaccine is before the date of the next most
recent flu vaccine. Please verify.
AssocHelp
Tuesday, June 13, 2017
Page 8 of 9
Module
33
Section Name
Child Influenza Immunization
Part
Question ID
CFI.005_00.080
Variable Name
CH1N1_8
Universe
HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CH1N1_2='2'
Universe-text
Sample Child LE 17 years who have more than one vaccine dose
Question Text
Was this a shot, or was it a vaccine sprayed in the nose?
*Read if necessary: The flu nasal spray is called FluMist(trademark).
Answer Codes
1. Flu shot
2. Flu nasal spray (spray, mist or drop in nose)
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Type - 2nd
Fill Instructions
Special Instructions
Skip Instructions
<1-2,R,D> [go to SCSSN4]
Hard Edits
Soft Edits
AssocHelp
Tuesday, June 13, 2017
Page 9 of 9
| File Type | application/pdf |
| File Modified | 2017-11-01 |
| File Created | 2017-06-15 |