Demographic Survey

OMB No: ???: Exp Date: ???

D

Public reporting burden of this collection of information is estimated to average 5 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 Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (???).

emographic Survey

1. Do you consider your child to be Hispanic or Latino? Yes No 2. What race do you consider your child to be? (Mark all that apply) Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Asian White 3. Are you currently married, widowed, divorced, separated, never married, or living with a partner? Married Go to Question 4 Widowed Divorced Separated Never married Living with a partner 4. Is your spouse living in the household? Yes No 5. Is your spouse biologically related to the child in this study? Yes No

6. How many brothers does the child in this study have? brothers 7. How many sisters does the child in this study have? sisters 8A. The next questions are about health insurance. Is the child in this study covered by any kind of health insurance or some other kind of health care plan? O Yes O No  If No then go to Question 11D 8B. What kind of health insurance or health care coverage does the child in this study have? INCLUDE those that pay for only one type of service (nursing home care, accidents, or dental care), and exclude private plans that only provide extra cash while hospitalized. Fill in all that apply. Private health insurance plan from employer or workplace, purchased directly, or provided through a state, local government or community program O Yes O No Medicaid, CHIP (Children’s Health Insurance Program) or Sooner Care/Sooner Choice O Yes O No Questionnaire is continued on back

Military health care/VA or TRICARE/CHAMPUS/CHAMP-VA O Yes O No Indian Health Service O Yes O No Other O Yes O No 8C. In the past 12 months, was your child ever without health insurance? O Yes O No  If No then go to Question 12 8D. In the past 12 months, about how long was your child without health insurance? Months 9. Total combined income for your family in the last calendar year, including income from all sources such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. O Less than $20,000 O $20,000 - $24,999 O $25,000 - $29,999 O $30,000 - $34,999 O $35,000 - $39,999 O $40,000 - $44,999 O $45,000 - $49,999 O $50,000 - $54,999 O $55,000 - $59,999 O $60,000 - $64,999 O $65,000 - $69,999 O $70,000 - $74,999 O $75,000 & over

10. How many people depend upon your family’s total combined family income? dependents 11. How many years of formal education have you completed? O Less than/equal to 8th grade O 9-12th grade, no high school diploma O High school graduate/GED recipient O Some college, no degree O AA degree or technical or vocational degree O Bachelor's degree O Master's, professional, or doctoral degree 12. Is the child in this study eligible for free or reduced priced lunch at school? O Yes O No

FOR STUDY USE ONLY

Date Interviewed

Month			Day			Year

Interviewed by