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pdfAppendix A
National Survey of Children’s Health
Longitudinal Cohort (NSCH-LC)
Screener and Topical Questionnaires
National Survey of Children’s Health
Longitudinal Cohort
A study by the U.S. Department of Health and Human Services to better understand the
health and well-being of children and young adults following the COVID-19 pandemic.
Instructions
Responding to this survey is easy:
1. Go to: https://respond.census.gov/nschlc
2. Enter your Login ID:
OR
Answer the questions on this form and mail it back in the postage-paid envelope provided.
The questions on this form are the first of two parts that make up the NSCH-LC. We will contact you again
if your household is selected for the second part. This survey should be completed by an adult.
For help or questions about completing this form, please call 1-877-749-4943. The telephone call is free.
For Telephone Device for the Deaf (TDD) assistance, please call: 1-800-582-8330. The telephone call is
free.
Para completar el cuestionario en español, llame al 1-877-749-4943. Para recibir ayuda con el Dispositivo
Telefónico para Personas Sordas (TDD, por sus siglas en inglés), llame de forma gratuita al
1-800-582-8330.
Start Here
1
AT ANY TIME SINCE 2018, has any adult in this household lived with a child or young adult?
Please include all children and young adults who are currently ages 3-24 and live or have lived with
you or another adult member of your household:
● either full-time or part-time
● at this address or another address
100
1
Yes ➔ SKIP to question
2
No ➔ You do not need to complete this questionnaire. Please mark "No" and RETURN THIS QUESTIONNAIRE
IN THE ENVELOPE PROVIDED. It is important that we receive a response from every household selected for
this survey.
2
on page 2
NSCH-LCS
(09/22/2023) D15
About You and Your Household
2
What is your first and last name?
First Name
Last Name
101
3
102
SINCE 2018, how many children or young adults live or have lived with you or another adult in this household?
Please include all children and young adults who are currently ages 3-24 and live or have lived with
you or another adult member of your household:
● either full-time or part-time
● at this address or another address
103
Number of children or young adults
4
List all children and/or young adults included in question 3 above.
Please list the children and/or young adults from oldest to youngest.
First name, initials, or nickname of child or young adult
105
104
108
107
111
110
114
113
117
116
120
119
123
122
126
125
129
128
NSCH-LCS
2
Sex
Age in Years
106
109
112
115
118
121
124
127
130
1
Male
2
Female
1
Male
2
Female
1
Male
2
Female
1
Male
2
Female
1
Male
2
Female
1
Male
2
Female
1
Male
2
Female
1
Male
2
Female
1
Male
2
Female
Mailing Instructions
Thank you for your participation.
On behalf of the U.S. Department of Health and Human Services, we would like to thank you for the
time and effort you have spent completing this survey.
➜ Place the completed questionnaire in the postage-paid return envelope. If the envelope has been
misplaced, please mail the questionnaire to:
U.S. Census Bureau
ATTN: DCB 60-A
1201 E. 10th Street
Jeffersonville, IN 47132-0001
We estimate that completing the first part of the National Survey of Children’s Health-Longitudinal Cohort will take 5 minutes
on average. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to ADDP.NSCH.List@census.gov; use "Paperwork Project 0607-####" as the subject.
This collection has been approved by the Office of Management and Budget (OMB). The eight-digit OMB approval number that
appears at the upper left of the form confirms this approval. If this number were not displayed, we could not conduct this survey.
NSCH-LCS
3
This page intentionally left blank.
NSCH-LCS
4
26213207
National Survey of Children’s Health
Longitudinal Cohort
A study by the U.S. Department of Health and Human Services to
better understand the health and well-being of children and young
adults following the COVID-19 pandemic.
The U.S. Census Bureau is required by law to protect your information. We are not permitted to publicly release your responses in a way
that could identify your household. The Census Bureau is conducting this survey under the authority of Title 13, United States Code
(U.S.C.), Section 8(b) (13 U.S.C. § 8(b)) and Section 501(a)(2) of the Social Security Act (42 U.S.C. § 701). Federal law protects your privacy
and keeps your answers confidential under Title 13, U.S.C., Section 9 (13 U.S.C. § 9). Per the Federal Cybersecurity Enhancement Act of
2015, your data are protected from cybersecurity risks through screening of the systems that transmit your data.
Under the Privacy Act of 1974 (5 U.S.C. Section 552a), these records are maintained by the Census Bureau under SORN
COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame). Access to records maintained in the system
is restricted to Census Bureau employees and certain individuals authorized by Title 13, U.S. Code (designated as Special Sworn Status
individuals). These individuals are subject to the same confidentiality requirements as regular Census Bureau employees.
Participation in this survey is voluntary and there are no penalties for refusing to answer questions. However, your cooperation in obtaining
this much needed information is extremely important in order to ensure complete and accurate results.
NSCH-LC1
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Start Here
5
What is this child’s sex?
Male
Recently, someone in your household completed a
short survey that asked about children and/or young
adults ages 3 to 24.
Female
NOTE: Answer BOTH question 6 about Hispanic origin
and question 7 about race. For this survey, Hispanic
origins are not races.
Thank you for taking the time to respond.
We now have some important follow-up questions to
ask about:
6
Is this child of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
This survey should be completed by a parent or
caregiver. If the child listed above does not correspond
to a child for whom you or another adult in your
household are a parent or caregiver, please call
1-877-749-4943 for assistance.
We have selected only one child for this follow-up
survey in an effort to minimize the amount of time you
will need to complete the questions.
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin
7
Your participation is important. Thank you.
What is this child’s race?
Mark (X) one or more boxes.
White
Black or African American
1
Are you a parent or caregiver who is CURRENTLY
familiar with this child’s health?
American Indian or Alaska Native
Yes ➔ SKIP to question 3
Asian Indian
No
Chinese
This child is deceased ➔ You do not need to complete
this questionnaire. Please mark this response option
and RETURN THIS QUESTIONNAIRE IN THE
ENVELOPE PROVIDED.
Filipino
Japanese
Korean
2
If no, is there another parent or caregiver in this household
who is CURRENTLY familiar with this child’s health?
Vietnamese
Yes ➔ Please have this other parent or caregiver
complete the rest of the survey.
Other Asian
Native Hawaiian
No ➔ You do not need to complete this questionnaire.
Please mark "No" and RETURN THIS
QUESTIONNAIRE IN THE ENVELOPE PROVIDED.
3
Chamorro
Samoan
What is this child’s full name?
First
Other Pacific Islander
8
Last
Where does this child live AT LEAST HALF OF THE TIME?
Mark (X) ALL that apply.
With me
With another parent or caregiver at another address
4
In what month and year was this child born?
Birth Month / 4-Digit Birth Year
/
Institutional setting (such as congregate care,
residential treatment, group home, penal facility)
Other, specify:
2 0
NSCH-LC1
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A. This Child’s Health
A1
In general, how would you describe this child’s
health?
Has a doctor, other health care provider, or educator
EVER told you that this child has...
Examples of educators are teachers and school nurses.
A6 Behavioral or Conduct Problems?
Excellent
Yes
Very good
No
If yes, does this child CURRENTLY have the
condition?
Good
Yes
No
Fair
A7
Poor
Developmental Delay?
Yes
A2
How would you describe the condition of this child’s
teeth?
If yes, does this child CURRENTLY have the
condition?
Excellent
Yes
Very good
A8
Good
No
Intellectual Disability (formerly known as Mental
Retardation)?
Fair
Yes
Poor
If yes, does this child CURRENTLY have the
condition?
A9
Permanent hearing loss?
Yes
No
Yes
Has a doctor or other health care provider EVER told
you that this child has…
A3
No
Speech or other language disorder?
Yes
No
No
No
If yes, does this child CURRENTLY have the
condition?
If yes, is the hearing loss:
Mark (X) ALL that apply.
Yes
Mild
Moderate
No
A10 Learning Disability?
Severe
Yes
Profound
If yes, does this child CURRENTLY have the
condition?
Yes
A4 Anxiety Problems?
Yes
No
No
A11 Has a doctor or other health care provider EVER told
you that this child has Autism or Autism Spectrum
Disorder (ASD)?
Include diagnoses of Asperger’s Disorder or Pervasive
Developmental Disorder (PDD).
If yes, does this child CURRENTLY have the
condition?
Yes
No
Yes
A5 Depression?
Yes
No ➔ SKIP to question A16 on page 4
If yes, does this child CURRENTLY have the
condition?
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
No
No
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A12 SINCE MARCH 2020, has this child received
medication or behavioral treatment for Autism, ASD,
Asperger’s Disorder, or PDD, such as training or an
intervention that you or this child received to help
with their behavior?
A18 SINCE MARCH 2020, has this child experienced any gaps
or delays in receiving medication or behavioral treatment
for ADD or ADHD?
Yes
Yes, this child received all needed medication or
behavioral treatment
Yes, this child received some needed medication or
behavioral treatment
No
A19 Is this child CURRENTLY taking medication for ADD
or ADHD?
No, this child needed but did not receive any medication
or behavioral treatment ➔ SKIP to question A16
Yes
No
No, this child did not need either medication or
behavioral treatment ➔ SKIP to question A16
A20 At any time DURING THE PAST 12 MONTHS, did this
child receive behavioral treatment for ADD or ADHD,
A13 SINCE MARCH 2020, has this child experienced any gaps
such as training or an intervention that you or this
child received to help with their behavior?
or delays in receiving medication or behavioral treatment
for Autism, ASD, Asperger’s Disorder, or PDD?
Yes
Yes
No
No
A14 Is this child CURRENTLY taking medication for Autism,
A21 Thinking of this child today, how often would you say
each of the following describes this child?
ASD, Asperger’s Disorder, or PDD?
Never Sometimes Often
Yes
a. Feels sad, unhappy
No
b. Feels hopeless
A15 At any time DURING THE PAST 12 MONTHS, did this
c. Is down on self
child receive behavioral treatment for Autism, ASD,
Asperger’s Disorder, or PDD, such as training or an
intervention that you or this child received to help with
their behavior?
d. Worries a lot
e. Seems to be having less fun
Yes
f. Fidgety, unable to sit still
No
g. Daydreams too much
A16 Has a doctor or other health care provider EVER told
you that this child has Attention Deficit Disorder or
Attention-Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?
Yes
h. Distracted easily
No ➔ SKIP to question A21
If yes, does this child CURRENTLY have the
condition?
Yes
i.
Has trouble concentrating
j.
Acts as if driven by a motor
A22 Thinking of this child today, how often would you say
each of the following describes this child?
No
Never Sometimes Often
A17 SINCE MARCH 2020, has this child received medication
a. Fights with other children
or behavioral treatment for ADD or ADHD, such as
training or an intervention that you or this child received
to help with their behavior?
b. Does not listen to rules
Yes, this child received all needed medication or
behavioral treatment
c. Does not understand other
people’s feelings
Yes, this child received some needed medication or
behavioral treatment
d. Teases others
e. Blames others for their
troubles
No, this child needed but did not receive any medication
or behavioral treatment ➔ SKIP to question A21
f. Refuses to share
g. Takes things that do not
belong to them
No, this child did not need either medication or
behavioral treatment ➔ SKIP to question A21
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A23 Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?
Yes
A27 Does this child have any kind of emotional,
developmental, or behavioral problem for which
they need treatment or counseling?
No
Yes
If yes, is this child’s need for prescription
medicine because of ANY medical, behavioral, or
other health condition?
Yes
No
If yes, has their emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?
No
Yes
No
If yes, is this a condition that has lasted or is
expected to last 12 months or longer?
Yes
No
B. Health Care Services
A24 Does this child need or use more medical care,
mental health, or educational services than is usual
for most children of the same age?
Yes
B1
No
If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?
Yes
Yes
No ➔ SKIP to question B3
No
If yes, is this a condition that has lasted or is
expected to last 12 months or longer?
Yes
B2
No
A25 Is this child limited or prevented in any way in their
1 visit
No
2 or more visits
If yes, is this child’s limitation in abilities because
of ANY medical, behavioral, or other health
condition?
Yes
B3
No
If yes, is this a condition that has lasted or is
expected to last 12 months or longer?
Yes
No
No ➔ SKIP to question B6 on page 6
physical, occupational, or speech therapy?
B4
No
If yes, is this because of ANY medical, behavioral,
or other health condition?
Yes
If yes, did the questionnaire ask about your concerns
or observations about:
Mark (X) Yes or No for EACH item.
Yes
a. Words and phrases this child uses
and understands?
No
b. How this child behaves and gets
along with you and others?
If yes, is this a condition that has lasted or is
expected to last 12 months or longer?
Yes
SINCE MARCH 2020, has a doctor or other health care
provider had you or another caregiver fill out a
questionnaire about observations or concerns you may
have about this child’s development, communication,
or social behaviors?
Sometimes a child’s doctor or other health care provider
will ask a parent to do this at home or during a child’s visit.
Yes
A26 Does this child need or get special therapy, such as
Yes
If yes, DURING THE PAST 12 MONTHS, how many times
did this child visit a doctor, nurse, or other health care
professional to receive a PREVENTIVE check-up?
A preventive check-up is when this child was not sick or
injured, such as an annual or sports physical or well-child visit.
0 visits
ability to do the things most children of the same age
can do?
Yes
DURING THE PAST 12 MONTHS, did this child see a
doctor, nurse, or other health care professional for
sick-child care, well-child check-ups, physical exams,
hospitalizations or any other kind of medical care?
Include health care visits done by video or phone.
No
NSCH-LC1
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No
26213157
B5
What happened after you filled out the questionnaire?
Mark (X) Yes or No for EACH item.
Yes
B10 Has this child EVER had a special education or early
intervention plan?
Children receiving these services often have an Individualized
Family Service Plan (IFSP), Individualized Education Plan
(IEP), or 504 Plan.
No
a. The provider discussed the
questionnaire results with me
b. This child was referred for
evaluation for services to help with
concerns
Yes
No, but this child needed
a plan ➔ SKIP to question B13
c. The provider discussed ways to
support this child’s development
with me
B6
B7
No, this child did not need
a plan ➔ SKIP to question B13
Is there a place you or another caregiver USUALLY take B11 The COVID-19 pandemic began in March 2020. Did
this child when they are sick or you need advice about
this child have a special education or early
their health?
intervention plan DURING THE PANDEMIC?
Yes
Yes
No
No, but this child needed
a plan ➔ SKIP to question B13
DURING THE PAST 12 MONTHS, did this child see a
dentist or other oral health care provider for
PREVENTIVE dental care, such as check-ups, dental
cleanings, dental sealants, or fluoride treatments?
No, this child did not need
a plan ➔ SKIP to question B13
B12 Did the pandemic affect this child’s special education
or early intervention services?
No preventive visits in the past 12 months
B8
Yes, 1 visit
Yes, this child received limited or inconsistent
services during the pandemic
Yes, 2 or more visits
Yes, this child did not receive any services during
the pandemic
DURING THE PAST 12 MONTHS, has this child
received any treatment or counseling from a mental
health professional?
Mental health professionals include psychiatrists,
psychologists, psychiatric nurses, and clinical social
workers.
No
B13 SINCE MARCH 2020, has this child received speech
therapy?
Yes
Yes
No, but this child needed
speech therapy ➔ SKIP to question B15
No, but this child needed to see a mental
health professional
No, this child did not need
speech therapy ➔ SKIP to question B15
No, this child did not need to see a mental health
professional ➔ SKIP to question B10
B14 SINCE MARCH 2020, has this child experienced any
B9
gaps or delays in receiving speech therapy?
How difficult was it to get the mental health treatment
or counseling that this child needed?
Yes
Not difficult
No
Somewhat difficult
Very difficult
B15 SINCE MARCH 2020, has this child received health
care related to the use of hearing devices such as
hearing aids or cochlear implants?
It was not possible to obtain care
Yes
No, but this child needed health care related to the use
of hearing devices ➔ SKIP to question B17 on page 7
No, this child did not need health care related to the use
of hearing devices ➔ SKIP to question B17 on page 7
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C. This Child’s Schooling
and Activities
B16 SINCE MARCH 2020, has this child experienced any
gaps or delays in receiving health care related to the
use of hearing devices?
Yes
C1
No
B17 SINCE MARCH 2020, has this child received
language instruction including sign language and/or
cued speech?
SINCE MARCH 2020, has this child EVER received care
for at least 10 hours per week from someone other
than their parent or guardian?
This could be a day care center, preschool, Head Start
program, family child care home, nanny, au pair,
babysitter, or relative.
Yes
Yes
No ➔ SKIP to question
No, but this child needed these types of
language instruction ➔ SKIP to question
B19
No, this child did not need these types of
language instruction ➔ SKIP to question
B19
C2
B18 SINCE MARCH 2020, has this child experienced any
gaps or delays in language instruction?
Yes
No
C5
SINCE MARCH 2020, have you or anyone else in your
family been able to make alternative child care
arrangements for this child when their regular day care
or other child care arrangement was closed or
unavailable?
Alternative arrangements mean that care was provided by a
different day care center, preschool, Head Start program,
family child care home, nanny, au pair, babysitter, or any
relative other than the child’s parent or guardian that is
different from the USUAL care arrangement.
Yes
B19 Is this child CURRENTLY covered by ANY kind of
No
health insurance or health coverage plan?
Yes
Alternative child care was not needed
No ➔ SKIP to question
C1
C3
B20 Is this child CURRENTLY covered by any of the
following types of health insurance or health coverage
plans?
Mark (X) Yes or No for EACH item.
Yes
Yes
No
No
a. Insurance through a current or
former employer or union
b. Insurance purchased directly from
an insurance company
SINCE MARCH 2020, has there ever been a time when
you were concerned about the quality of this child’s
regular or alternative child care arrangements?
C4
c. Medicaid, Medical Assistance, or
any kind of government assistance
plan for those with low incomes or a
disability
Does this child CURRENTLY receive care for at least
10 hours per week from someone other than their
parent or guardian?
This could be a day care center, preschool, Head Start
program, family child care home, nanny, au pair, babysitter
or relative.
Yes
d. TRICARE or other military health care
No
e. Indian Health Service
f. Other, specify:
C
C5
Has this child started school?
Include any formal home schooling.
Yes, preschool
Yes, kindergarten
Yes, first grade
No
NSCH-LC1
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C6
How often can this child recognize the beginning
sound of a word?
For example, can this child tell you that the word "ball"
starts with the "buh" sound?
C11 How high can this child count?
This child cannot count
Up to five
Always
Up to ten
Most of the time
Up to 20
About half the time
Up to 50
Sometimes
Up to 100 or more
Never
C7
About how many letters of the alphabet can this child
recognize?
C12 How often can this child identify basic shapes such as
a triangle, circle, or square?
Always
All of them
Most of the time
Most of them
About half the time
About half of them
Sometimes
Some of them
Never
None of them
C8
C9
Can this child rhyme words?
C13 Can this child identify the colors red, yellow, blue, and
green by name?
Yes
Yes, all of them
No
Yes, some of them
How often can this child explain things they have
seen or done so that you get a very good idea what
happened?
No, none of them
C14 How often is this child easily distracted?
Always
Always
Most of the time
Most of the time
About half the time
About half the time
Sometimes
Sometimes
Never
Never
C10 How often can this child write their first name, even if
some of the letters aren’t quite right or are backwards? C15 How often does this child keep working at something
until they are finished?
Always
Always
Most of the time
Most of the time
About half the time
About half the time
Sometimes
Sometimes
Never
Never
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C16 When this child is paying attention, how often can
they follow instructions to complete a simple task?
C21 When excited or all wound up, how often can this child
calm down quickly?
Always
Always
Most of the time
Most of the time
About half the time
About half the time
Sometimes
Sometimes
Never
Never
C17 How does this child usually hold a pencil?
C22 How often does this child lose control of their temper
when things do not go their way?
Uses fingers to hold the pencil
Always
Grips the pencil in their fist
Most of the time
This child cannot hold a pencil
About half the time
C18 How often does this child play well with others?
Sometimes
Always
Never
Most of the time
About half the time
C23 Compared to other children their age, how much
difficulty does this child have making or keeping friends?
Sometimes
No difficulty
Never
A little difficulty
A lot of difficulty
C19 How often does this child become angry or anxious
when going from one activity to another?
Always
C24 Compared to other children their age, how often is this
child able to sit still?
Most of the time
Always
About half the time
Most of the time
Sometimes
About half the time
Never
Sometimes
Never
C20 How often does this child show concern when others
are hurt or unhappy?
Always
C25 How often…
Always
Usually Sometimes
a. Is this child
affectionate and
tender with you?
Most of the time
About half the time
b. Does this child
bounce back quickly
when things do not
go their way?
Sometimes
Never
c. Does this child
show interest and
curiosity in learning
new things?
d. Does this child
smile and laugh?
NSCH-LC1
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Never
26213116
D. About Your Family
and Household
D5
When your family faces problems, how often are you
likely to do each of the following?
All of
the time
D1 ON MOST WEEKDAYS, about how much time does
Most of
the time
Some of
the time
None of
the time
a. Talk together about
what to do
this child spend in front of a TV, computer, cell
phone or other electronic device watching programs,
playing games, accessing the internet, or using social
media?
Do not include time spent doing schoolwork.
b. Work together to
solve our problems
c. Know we have
strengths to draw
on
1 hour or less
2-3 hours
d. Stay hopeful even
in difficult times
4-6 hours
7-8 hours
D6
More than 8 hours
SINCE MARCH 2020, how many times has this child
moved to a new address?
If none, write 0.
Don’t know
Number of times
D2 DURING THE PAST WEEK, how many days did you or
other family members read to this child?
D7
Is the house, apartment, or mobile home where you live...
Mark (X) ONE box.
0 days
Owned by you or someone in this household with a
mortgage or loan? Include home equity loans.
1-3 days
Owned by you or someone in this household free and
clear (without a mortgage or loan)?
4-6 days
Rented?
Every day
Occupied without payment of rent?
D3 DURING THE PAST WEEK, how many days did you or
other family members tell stories or sing songs to this
child?
D8
0 days
DURING THE PAST 12 MONTHS, was there a time
when you were not able to pay the mortgage or rent
on time?
Yes
1-3 days
No
4-6 days
D9
Every day
D4 What is the primary language spoken in the
SINCE MARCH 2020, has this child ever been homeless
or lived in a shelter?
Include living in a shelter, motel, temporary or transitional
living situation, scattered site housing, or having no steady
place to sleep at night.
household?
Yes
English
No
Spanish
Other language, specify:
D10 DURING THE PAST 12 MONTHS, how often has it been
very hard to cover the basics, like food or housing,
on your family’s income?
C
Never
Rarely
Somewhat often
Very often
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E. This Child’s Parents or
Caregivers
D11 Which of these statements best describes your
household’s ability to afford the food you need DURING
THE PAST 12 MONTHS?
We could always afford to eat good nutritious meals
Complete these questions for UP TO TWO ADULTS
who are this child’s parents or caregivers. Please only
include adults who are currently active in this child’s
life.
We could always afford enough to eat but not always
the kinds of food we should eat
Sometimes we could not afford enough to eat
About You
Often we could not afford enough to eat
E1
D12 At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive…
Mark (X) Yes or No for EACH item.
Yes
Biological or Adoptive Parent
No
Step-parent
a. Cash assistance from a government
welfare program?
Grandparent
b. Food Stamps or Supplemental
Nutrition Assistance Program
(SNAP) benefits?
Foster Parent
Other: Relative
c. Free or reduced-cost breakfasts or
lunches at school?
Other: Non-Relative
d. School meal debit/Electronic
Benefits Transfer (EBT) cards?
E2
What is your sex?
Male
e. Benefits from the Women,
Infants, and Children (WIC)
Program?
Female
f. Unemployment Insurance (UI)?
E3
D13 The next questions are about events that may have
E4
Where were you born?
In the United States
To the best of your knowledge, has this child EVER
experienced any of the following?
Mark (X) Yes or No for EACH item.
Yes
What is your age?
Age in years
happened during this child’s life. These things can
happen in any family, but some people may feel
uncomfortable with these questions. You may skip
any questions you do not want to answer.
a. Parent or guardian divorced or
separated
How are you related to this child?
Outside of the United States
No
E5
What is the highest grade or level of school you have
completed?
Mark (X) ONE box.
b. Parent or guardian died
8th grade or less
c. Parent or guardian served time in
jail or prison
9th-12th grade; No diploma
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home
High school graduate or GED completed
e. Was a victim of violence or
witnessed violence in their
neighborhood
Some college credit, but no degree
Completed a vocational, trade, or business school
program
Associate Degree (AA, AS)
f. Lived with anyone who was mentally
ill, suicidal, or severely depressed
Bachelor’s Degree (BA, BS, AB)
g. Lived with anyone who had a
problem with alcohol or drugs
Master’s Degree (MA, MS, MSW, MBA)
Doctorate (PhD, EdD) or Professional Degree (MD,
DDS, DVM, JD)
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E6
What is your marital status?
E11 Does this child have another parent or caregiver who
is active in their life?
Married
Yes
Not married, but living with a partner
No ➔ SKIP to question F1 on page 14
Never married
Other Parent or Caregiver
Divorced
Separated
E12 How is this other parent or caregiver currently related
to you?
Mark (X) ONE box.
Widowed
E7
Spouse or partner
Has there been a change in your marital status SINCE
2018?
Ex-spouse or ex-partner
Yes
Parent (include adoptive or foster parent)
No
Grandparent
E8
In general, how is your physical health?
In-law (include parent or grandparent)
Excellent
Other: Relative
Very good
Other: Non-Relative
Good
E13 Does this parent or caregiver live with you?
Fair
Yes
Poor
No
E9
In general, how is your mental or emotional health?
E14 How is this parent or caregiver related to this child?
Excellent
Biological or Adoptive Parent
Very good
Step-parent
Good
Grandparent
Fair
Foster Parent
Poor
Other: Relative
E10 Which of the following best describes your current
Other: Non-Relative
employment status?
Mark (X) ONE box.
Employed full-time
E15 What is this parent or caregiver’s sex?
Male
Employed part-time
Female
Working without pay
Not employed but looking for work
E16 What is this parent or caregiver’s age?
Not employed and not looking for work
Age in years
Don’t know
Retired
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E17 Where was this parent or caregiver born?
E21 In general, how is this parent or caregiver’s mental or
emotional health?
In the United States
Excellent
Outside of the United States
Very good
Don’t know
Good
E18 What is the highest grade or level of school this
Fair
parent or caregiver has completed?
Mark (X) ONE box.
Poor
8th grade or less
Don’t know
9th-12th grade; No diploma
High school graduate or GED completed
E22 Which of the following best describes this parent or
caregiver’s current employment status?
Mark (X) ONE box.
Completed a vocational, trade, or business school
program
Employed full-time
Some college credit, but no degree
Employed part-time
Associate Degree (AA, AS)
Working without pay
Bachelor’s Degree (BA, BS, AB)
Not employed but looking for work
Master’s Degree (MA, MS, MSW, MBA)
Not employed and not looking for work
Doctorate (PhD, EdD) or Professional Degree (MD,
DDS, DVM, JD)
Retired
Don’t know
Don’t know
E19 What is this parent or caregiver’s marital status?
Married
Not married, but living with a partner
Never married
Divorced
Separated
Widowed
Don’t know
E20 In general, how is this parent or caregiver’s physical
health?
Excellent
Very good
Good
Fair
Poor
Don’t know
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F. COVID-19 Pandemic
F6
Yes
The questions in this section ask about this child’s and
your family’s experiences during the COVID-19
pandemic, which began in March 2020.
F1
Has this child ever tested positive for COVID-19 or
been told by a doctor or other health care provider
they had COVID-19?
No ➔ SKIP to question
F7
Yes
F8
Which of the following best describes the vaccine
doses this child received?
A primary vaccine series includes the initial number of
recommended doses, which may differ by vaccine type.
All doses of a primary series and at least one booster
No ➔ SKIP to question
F2
Has this child received a COVID-19 vaccine?
All doses of a primary series but no boosters
F6
If yes, how many times has this child tested positive
for COVID-19 or been told by a doctor or other health
care provider that they had COVID-19?
Some but not all doses of a primary series
F8
Number of times
Have you ever tested positive for COVID-19 or been
told by a doctor or other health care provider you had
COVID-19?
Yes
F3
How long did this child’s COVID-19 symptoms last?
If this child has had multiple COVID-19 infections, report
about the time when the symptoms lasted the longest.
Symptoms can include fever, fatigue, cough, difficulty
breathing, brain fog, headache, problems sleeping, fast
heartbeat, or loss of smell.
This child did not experience
any symptoms ➔ SKIP to question
No ➔ SKIP to question
F9
F6
Less than 1 month
Less than 1 month
3-5 months
1-2 months
6-12 months
3-5 months
More than 12 months
F5
Has a doctor or other health care provider EVER told
you that this child had long COVID?
Long COVID is also referred to as post-COVID conditions,
post-acute COVID-19, or long-term effects of COVID-19.
How long did your COVID-19 symptoms last?
If you have had multiple COVID-19 infections, report about
the time when the symptoms lasted the longest. Symptoms
can include fever, fatigue, cough, difficulty breathing, brain
fog, headache, problems sleeping, fast heartbeat, or loss of
smell.
I did not experience any symptoms
1-2 months
F4
6-12 months
More than 12 months
F10 Have you received a COVID-19 vaccine?
Yes
Yes
No
No ➔ SKIP to question
Has this child EVER been hospitalized for a COVID-19
infection or because of complications from a
COVID-19 infection?
F10
F12
on page 15
F11 Which of the following best describes the vaccine
doses you received?
A primary vaccine series includes the initial number of
recommended doses, which may differ by vaccine type.
Yes
All doses of a primary series and at least one booster
No
All doses of a primary series but no boosters
Some but not all doses of a primary series
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F12 Answer questions F12 to F15 if this child has
F17
another parent or caregiver who is active in the
child’s life. Otherwise, SKIP to question F16 .
Yes
Has this child’s other parent or caregiver ever tested
positive for COVID-19 or been told by a doctor or
other health care provider they had COVID-19?
Yes
No ➔ SKIP to question
No
F18
F14
Don’t know ➔ SKIP to question
DURING THE PANDEMIC, did this child’s behavior
EVER leave you concerned about their mental or
emotional health?
Yes
F14
No ➔ SKIP to question
F13 How long did this other parent or caregiver’s
symptoms last?
If they have had multiple COVID-19 infections, report about
the time when the symptoms lasted the longest. Symptoms
can include fever, fatigue, cough, difficulty breathing, brain
fog, headache, problems sleeping, fast heartbeat, or loss of
smell
Did any of this child’s parents or caregivers die from
a COVID-19 infection or because of complications from
a COVID-19 infection?
F19
F20
If yes, did this child seem to...
Mark (X) Yes or No for EACH item.
b. Feel depressed?
Less than 1 month
c. Struggle with eating?
1-2 months
d. Struggle to stay focused?
3-5 months
e. Show unusual anger or outbursts?
F20
More than 12 months
Don’t know
DURING THE PANDEMIC, did this child receive any
treatment or counseling from a mental health
professional?
Mental health professionals include psychiatrists,
psychologists, psychiatric nurses, and clinical social workers.
Yes
F14 Has this other parent or caregiver received a COVID-19
No, but this child needed to see a mental health
professional
vaccine?
Yes
No ➔ SKIP to question
No
a. Feel anxious?
This other parent or caregiver did not experience any
symptoms
6-12 months
Yes
No, this child did not need to see a mental health
professional ➔ SKIP to question F22
F16
Don’t know ➔ SKIP to question
F21
F16
How difficult was it to get the mental health treatment
or counseling that this child needed?
Not difficult
F15 Which of the following best describes the vaccine
doses this other parent or caregiver received?
A primary vaccine series includes the initial number of
recommended doses, which may differ by vaccine type.
Somewhat difficult
Very difficult
All doses of a primary series and at least one booster
It was not possible to obtain care
All doses of a primary series but no boosters
Some but not all doses of a primary series
F22
Don’t know
F16 Have you or another parent or caregiver EVER been
hospitalized for a COVID-19 infection or because of
complications from a COVID-19 infection?
DURING THE PANDEMIC, was there any time when
health care for this child was not received or was
delayed by at least three months?
By health care, we mean medical care as well as other
kinds of care like dental care, vision care, and mental
health services.
Yes
No ➔ SKIP to question F25 on page 16
Yes
No
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F23 Did any of the following reasons contribute to this child F28
not receiving or delaying needed health services
DURING THE PANDEMIC?
Mark (X) Yes or No for EACH item.
Yes
No
DURING THE PANDEMIC, was your mental or emotional
health better, worse, or about the same as it was before
the pandemic began?
Better ➔ SKIP to question
a. There were problems getting an
appointment when this child needed
one
F30
About the same ➔ SKIP to question
b. The clinic or doctor’s office wasn’t
open when this child needed care
F30
Worse
c. There were concerns about
exposure to COVID-19 by going to
the clinic or doctor’s office
F29 Please indicate how true the following statements are
about your mental or emotional health DURING THE
PANDEMIC.
d. This child or someone in this child’s
household had COVID-19 or was
exposed to COVID-19
a. I experienced an increase
in feeling nervous, anxious, on
edge, or worried
F24 Which of the following statements best describes how
Not
true
Somewhat Very
true
true
b. I experienced an increase in
feeling down, depressed, or
hopeless
this child’s health was impacted by not receiving or
delaying health care DURING THE PANDEMIC?
There was no impact on this child’s health
F30
There was mild or minimal impact on this child’s health
There was moderate impact on this child’s health
DURING THE PANDEMIC, did you or another parent or
caregiver EVER experience any of the following changes
in employment?
Mark (X) Yes or No for EACH item.
Yes
There was significant or severe impact on this child’s
health
No
a. Shift to remote work/telework
b. Decreased hours
F25 DURING THE PANDEMIC, was this child covered by
ANY kind of health insurance or health coverage plan?
c. Decreased pay
Yes, this child was covered during the entire pandemic
d. Furloughed (temporary job loss)
Yes, but this child had a gap in coverage during the
pandemic
e. Loss of job
No
f. Decreased job security
g. Increased hours
F26 DURING THE PANDEMIC, how well do you think you
handled the day-to-day demands of parenting or raising
children?
h. Left workforce
Very well
F31
Somewhat well
Not very well
Not well at all
DURING THE PANDEMIC, were you or another parent or
caregiver EVER considered an essential worker?
Essential workers are those workers who provide services or
conduct operations deemed essential to the ongoing critical
functions in the community, including work related to health
care, infrastructure, food, and other essential products.
Yes
F27 DURING THE PANDEMIC, how often did the following
happen?
a. Parents or caregivers insulted,
swore, shouted, or yelled at
each other
Not at
all
A few
times
a week
Very
often
No
F32
DURING THE PANDEMIC, was there a time when you
were not able to pay the mortgage or rent on time?
Yes
b. Parents or caregivers said mean
things, shouted, yelled, or
screamed at this child
No
c. Parents or caregivers were not
able to pay attention to this
child’s needs
NSCH-LC1
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G. Household Information
F33 DURING THE PANDEMIC, was your family evicted from
your home or was your home foreclosed on?
A landlord not renewing the lease should not be counted as
an eviction.
G1 How many people are living or staying at this address?
Include everyone who usually lives or stays at this address.
Do NOT include anyone who is living somewhere else for
more than two months, such as a college student living away
or someone in the Armed Forces on deployment.
Yes
No
F34
DURING THE PANDEMIC, how often was it very hard
to cover the basics, like food or housing, on your family’s
income?
Number of people
G2 How many of these people in your household are family
Never
members?
Family is defined as anyone related to this child by blood,
marriage, adoption, or through foster care.
Rarely
Somewhat often
Number of people
Very often
G3 How many children 0-17 years old usually live or stay at
this address?
F35 Which of these statements best describes your
household’s ability to afford the food you needed
DURING THE PANDEMIC?
We could always afford to eat good
nutritious meals ➔ SKIP to question
Number of children living or staying at this address
G1
We could always afford enough to eat but not always
the kinds of food we should eat
Sometimes we could not afford enough to eat
Often we could not afford enough to eat
F36 How long did your household experience difficulty
affording the food you needed DURING THE PANDEMIC?
Less than 1 month
1 month
2-3 months
4-6 months
More than 6 months
NSCH-LC1
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H. Contact Information
G4 Income in 2022.
Mark (X) the "Yes" box for each type of income this child’s
family received, and give your best estimate of the TOTAL
AMOUNT IN THE LAST CALENDAR YEAR. Mark (X) the
"No" box to show types of income NOT received.
You have reached the end of the survey. In case we
have additional follow-up questions about this child in
the future, we would like to get some information to
help us contact you. This information, like your
responses to all questions in the survey, is confidential
and voluntary.
a. Wages, salary, commissions, bonuses, or tips for
all jobs.
Yes ➔
$
,
.00
,
H1
TOTAL AMOUNT in 2022
No
b. Self-employment income from own nonfarm
businesses or farm business, including
proprietorships and partnerships.
Yes ➔
$
,
.00
,
Please provide your name and contact information.
We will only contact you if needed for official
Census Bureau business.
First Name
Loss
Last Name
TOTAL AMOUNT in 2022
No
Street
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Yes ➔
$
,
.00
,
Loss
Apt.
City
State
ZIP
TOTAL AMOUNT in 2022
No
d. Social Security or Railroad Retirement; retirement,
survivor, or disability pensions.
Yes ➔
$
,
Phone
–
.00
,
TOTAL AMOUNT in 2022
No
–
Email Address
e. Supplemental Security Income (SSI); any public
assistance or welfare payments from the state or
local welfare office.
Yes ➔
$
,
.00
,
TOTAL AMOUNT in 2022
No
f. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support, or alimony.
Yes ➔
$
,
.00
,
TOTAL AMOUNT in 2022
No
G5 The following question is about your 2022 income. Think
about your total combined family income IN THE LAST
CALENDAR YEAR for all members of the family. What is
that amount before taxes?
Include money from jobs, child support, social security,
retirement income, unemployment payments, public
assistance, and so forth. Also, include income from interest,
dividends, net income from business, farm or rent, and any
other money income received.
$
,
,
.00
Loss
TOTAL AMOUNT in 2022
NSCH-LC1
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H2 In case we have difficulty getting in touch with you in
the future, what is the name, address, and phone
number of one person who will always know your
whereabouts?
Providing this information is voluntary.
First Name
Last Name
Street
Apt.
City
State
ZIP
Phone
–
–
Email Address
NSCH-LC1
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Mailing Instructions
Thank you for your participation.
On behalf of the U.S. Department of Health and Human Services, we would like to thank you for the time
and effort you have spent sharing information about this child and your family.
Your answers are important to us and will help researchers, policymakers, and family advocates to better
understand the health and health care needs of children and young adults in our diverse population.
Place the completed questionnaire in the postage-paid return envelope. If the envelope has been
misplaced, mail the questionnaire to:
U.S. Census Bureau
ATTN: DCB 60-A
1201 E. 10th Street
Jeffersonville, IN 47132-0001
We estimate that completing the second part of the National Survey of Children’s Health-Longitudinal Cohort will take
40 minutes on average. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to ADDP.NSCH.List@census.gov; use "Paperwork Project
0607-####" as the subject. This collection has been approved by the Office of Management and Budget (OMB). The eightdigit OMB approval number that appears at the upper left of the form confirms this approval. If this number were not
displayed, we could not conduct this survey.
NSCH-LC1
20
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The U.S. Census Bureau is required by law to protect your information. We are not permitted to publicly release your responses in a way
that could identify your household. The Census Bureau is conducting this survey under the authority of Title 13, United States Code
(U.S.C.), Section 8(b) (13 U.S.C. § 8(b)) and Section 501(a)(2) of the Social Security Act (42 U.S.C. § 701). Federal law protects your privacy
and keeps your answers confidential under Title 13, U.S.C., Section 9 (13 U.S.C. § 9). Per the Federal Cybersecurity Enhancement Act of
2015, your data are protected from cybersecurity risks through screening of the systems that transmit your data.
Under the Privacy Act of 1974 (5 U.S.C. Section 552a), these records are maintained by the Census Bureau under SORN
COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame). Access to records maintained in the system
is restricted to Census Bureau employees and certain individuals authorized by Title 13, U.S. Code (designated as Special Sworn Status
individuals). These individuals are subject to the same confidentiality requirements as regular Census Bureau employees.
Participation in this survey is voluntary and there are no penalties for refusing to answer questions. However, your cooperation in obtaining
this much needed information is extremely important in order to ensure complete and accurate results.
NSCH-LC2_3
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26223198
Start Here
Recently, someone in your household completed a
short survey that asked about children and/or young
adults ages 3 to 24.
NOTE: Answer BOTH question 6 about Hispanic origin
and question 7 about race. For this survey, Hispanic
origins are not races.
6
Is this child of Hispanic, Latino, or Spanish origin?
Thank you for taking the time to respond.
No, not of Hispanic, Latino, or Spanish origin
We now have some important follow-up questions to
ask about:
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
This survey should be completed by a parent or
caregiver. If the child listed above does not correspond
to a child for whom you or another adult in your
household are a parent or caregiver, please call
1-877-749-4943 for assistance.
Yes, another Hispanic, Latino, or Spanish origin
7
What is this child’s race?
Mark (X) one or more boxes.
White
We have selected only one child for this follow-up
survey in an effort to minimize the amount of time you
will need to complete the questions.
Black or African American
American Indian or Alaska Native
Your participation is important. Thank you.
Asian Indian
1
Chinese
Are you a parent or caregiver who is CURRENTLY
familiar with this child’s health?
Filipino
Yes ➔ SKIP to question 3
Japanese
No
Korean
This child is deceased ➔ You do not need to complete
this questionnaire. Please mark this response option
and RETURN THIS QUESTIONNAIRE IN THE
ENVELOPE PROVIDED.
2
3
Vietnamese
Other Asian
If no, is there another parent or caregiver in this household
who is CURRENTLY familiar with this child’s health?
Native Hawaiian
Yes ➔ Please have this other parent or caregiver
complete the rest of the survey.
Chamorro
No ➔ You do not need to complete this questionnaire.
Please mark "No" and RETURN THIS
QUESTIONNAIRE IN THE ENVELOPE PROVIDED.
Samoan
What is this child’s full name?
First
Other Pacific Islander
8
Where does this child live AT LEAST HALF OF THE TIME?
Mark (X) ALL that apply.
With me
Last
With another parent or caregiver at another address
Campus/dorm room
4
In what month and year was this child born?
Birth Month / 4-Digit Birth Year
/
Institutional setting (such as congregate care,
residential treatment, group home, penal facility)
Somewhere else with roommates
2 0
Somewhere else on their own
5
What is this child’s sex?
Other, specify:
Male
C
Female
NSCH-LC2_3
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| File Type | application/pdf |
| Author | OneFormUser |
| File Modified | 2023-09-22 |
| File Created | 2022-10-24 |