Survey questionnaire

State and Local Area Integrated Telephone Survey (SLAITS)

SLAITS 2009 NS-CSHCN survey Att 2 031109

SLAITS for 2009-2010 National Survey of Children with Special Health Care Needs

OMB: 0920-0406

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0406 can be found here:

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Attachment 2

Survey: 2009-2010 NS-CSHCN

Form Approved

OMB No. 0920-0406

Exp. Date 04/30/2011

NOTICE: Public reporting burden of this collection of information is estimated to average 22 minutes per response, including the time for reviewing instructions, searching existing data resources, 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-E11, Atlanta, GA 30333; ATTN: PRA (0920-0406). Data collection conducted under contract to the CDC.

Assurance of Confidentiality: All information which would permit identification of an individual, a practice, or an establishment will be held confidential, and will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with Section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

2009–2010 NATIONAL SURVEY OF

CHILDREN WITH SPECIAL HEALTH CARE NEEDS

DETAILED CSHCN SURVEY INTERVIEW

Section 3. HEALTH AND FUNCTIONAL STATUS

[TIMESTAMP_SECTION31]

C3QINTRO You told me that [S.C.]

IF CSHCN1_B = 1, ADD “needs prescription drugs....”

IF CSHCN2_B = 1, ADD “needs medical care, mental health, or education services....”

IF CSHCN3_B = 1, ADD “is limited or prevented in [his/her] ability to do things....”

IF CSHCN4_B = 1, ADD “needs special therapy....”

IF CSHCN5_A = 1, ADD “needs treatment or counseling....”

If more than one of these items = 1, then add “and” between each additional statement.

If CSHCN1_B, CSHCN2_B, CSHCN3_B, or CSHCN4_B = 1, then continue: “...because of medical, behavioral, or other health conditions.”

IFCSHCN1_B = 2, CSHCN2_B = 2, CSHCN3_B = 2, CSHCN4_B = 2, AND CSHCN5_A = 1, then continue: “because of emotional, developmental, or behavioral problems.”

FOR C3Q02 AND C3Q03 FILLS, IF CSHCN1_B, CSHCN2_B, CSHCN3_B, or CSHCN4_B = 1 USE FIRST FILL. IF CSHCN1_B = 2, CSHCN2_B = 2, CSHCN3_B = 2, CSHCN4_B = 2, AND CSHCN5_A = 1, USE SECOND FILL]

C3Q02 [During the past 12 months/Since [his/her] birth], how often have [S.C.]’s (medical, behavioral, or other health conditions / emotional, developmental, or behavioral problems) affected [his/her] ability to do things other children [his/her] age do? Would you say:

(1) Never [SKIP TO C3Q11]

(2) Sometimes

(3) Usually

(4) Always

(77) DON’T KNOW [SKIP TO C3Q11]

(99) REFUSED [SKIP TO C3Q11]

READ IF NECESSARY: This question asks how often your child's abilities are affected by his/her health. It does not ask about the severity, intensity, or magnitude of the effect.

ADDITIONAL INFO: FOR EXAMPLE, IF A CHILD'S ASTHMA WAS SEVERE BUT THE ATTACKS WERE RARE, THIS QUESTION WOULD BE ANSWERED WITH "SOMETIMES." IF THE CONDITION IS EPISODIC, RESPONDENTS SHOULD THINK ABOUT HOW OFTEN THE CONDITION HAS AFFECTED THE CHILD'S ABILITIES DURING THE PAST ENTIRE 12 MONTHS.

C3Q03 Do [S.C.]’s (medical, behavioral, or other health conditions/emotional, developmental, or behavioral problems) affect [his/her] ability to do things a great deal, some, or very little?

(1) A great deal

(2) Some

(3) Very little

(77) DON’T KNOW

(99) REFUSED

READ IF NECESSARY: You told me your child's health affects his/her ability to do things. When this occurs, how much are your child's abilities affected?

ADDITIONAL INFO: FOR EXAMPLE, IF A CHILD'S ASTHMA WAS SEVERE BUT THE ATTACKS WERE RARE, THIS QUESTION WOULD BE ANSWERED WITH "A GREAT DEAL." IF THE CONDITION IS EPISODIC, RESPONDENTS SHOULD THINK ABOUT HOW SEVERE THE IMPACT HAS BEEN WHEN THE EPISODES OCCURRED OVER THE PAST 12 MONTHS.

C3Q11 Which of the following statements best describes [S.C.]’s health care needs? - [S.C.]’s health care needs change all the time, - [S.C.]’s health care needs change only once in a while, or -[S.C.]’s health care needs are usually stable?

(1) Child’s health care needs change all the time

(2) Child’s health care needs change only once in a while

(3) Child’s health care needs are usually stable

(4) NONE OF THE ABOVE

(77) DON’T KNOW

(99) REFUSED

[TIMESTAMP_SECTION32]

C3Q21 The next questions are about ways [S.C.] might experience difficulties due to [his/her] health. Does [S.C.] have a lot, a little, or no difficulty seeing even when wearing glasses or contact lenses?

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

C3Q22 Does [S.C.] have a lot, a little, or no difficulty hearing even when using a hearing aid or other device?

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

C3Q23 The next questions are about ways [S.C.] might experience difficulties due to [his/her] health.

Would you say [he/she] experiences a lot, a little, or no difficulty with breathing or other respiratory problems, such as wheezing or shortness of breath?

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

READ IF NECESSARY: We are interested in both on-going and intermittent breathing problems. If the problem comes and goes, please think about the child’s breathing throughout the year.

HELP SCREEN: IF RESPONDENT SAYS THAT CHILD HAS MORE THAN A LITTLE DIFFICULTY BUT NOT A LOT OF DIFFICULTY, PLEASE CODE THE ANSWER AS "A LITTLE DIFFICULTY."

C3Q24 Would you say [he/she] experiences a lot, a little, or no difficulty with swallowing, digesting food, or metabolism?

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN: IF RESPONDENT SAYS THAT CHILD HAS MORE THAN A LITTLE DIFFICULTY BUT NOT A LOT OF DIFFICULTY, PLEASE CODE THE ANSWER AS "A LITTLE DIFFICULTY."

C3Q25 Would you say [he/she] experiences a lot, a little, or no difficulty with blood circulation?

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN: IF RESPONDENT SAYS THAT CHILD HAS MORE THAN A LITTLE DIFFICULTY BUT NOT A LOT OF DIFFICULTY, PLEASE CODE THE ANSWER AS "A LITTLE DIFFICULTY."

C3Q26 (READ IF NECESSARY: Would you say [he/she] experiences a lot, a little, or no difficulty with...)

Repeated or chronic physical pain, including headaches?

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN: IF RESPONDENT SAYS THAT CHILD HAS MORE THAN A LITTLE DIFFICULTY BUT NOT A LOT OF DIFFICULTY, PLEASE CODE THE ANSWER AS "A LITTLE DIFFICULTY."

C3Q21 (READ IF NECESSARY: Would you say [he/she] experiences a lot, a little, or no difficulty...)

Seeing even when wearing glasses or contact lenses?

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN: IF RESPONDENT SAYS THAT CHILD HAS MORE THAN A LITTLE DIFFICULTY BUT NOT A LOT OF DIFFICULTY, PLEASE CODE THE ANSWER AS "A LITTLE DIFFICULTY."

C3Q22 (READ IF NECESSARY: Would you say [he/she] experiences a lot, a little, or no difficulty...)

Hearing even when using a hearing aid or other device?

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN: IF RESPONDENT SAYS THAT CHILD HAS MORE THAN A LITTLE DIFFICULTY BUT NOT A LOT OF DIFFICULTY, PLEASE CODE THE ANSWER AS "A LITTLE DIFFICULTY."

C3Q27 [IF S.C. IS YOUNGER THAN 36 MONTHS, SKIP TO C3Q28]

Compared to other [CSHCN_AGE]-year-old children, would you say [he/she] experiences a lot, a little, or no difficulty taking care of [himself/herself], for example, doing things like eating, dressing and bathing?

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN: IF RESPONDENT SAYS THAT CHILD HAS MORE THAN A LITTLE DIFFICULTY BUT NOT A LOT OF DIFFICULTY, PLEASE CODE THE ANSWER AS "A LITTLE DIFFICULTY."

C3Q28 IF CHSCN_AGE < 24 MONTHS, THEN "Compared to other [CHSCN_AGE]-month-old children would you say [he/she] experiences a lot, a little, or no difficulty with coordination or moving around, such as….?"

IF CHSCN_AGE > or = 24 MONTHS, THEN "Compared to other [CHSCN_AGE]-year-old children would you say [he/she] experiences a lot, a little, or no difficulty with coordination or moving around, such as..."

(IF S.C. 0 - 9 MONTHS OLD, SAY: “crawling or moving arms or legs?”

IF S.C. 10 – 23 MONTHS OLD, SAY: “walking or crawling?”

IF S.C. 24+ MONTHS OLD, SAY: “walking or running?”)

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN: IF RESPONDENT SAYS THAT CHILD HAS MORE THAN A LITTLE DIFFICULTY BUT NOT A LOT OF DIFFICULTY, PLEASE CODE THE ANSWER AS "A LITTLE DIFFICULTY."

C3Q29 IF CHSCN_AGE < 24 MONTHS, THEN "Compared to other [CHSCN_AGE]-month-old children would you say [he/she] experiences a lot, a little, or no difficulty using (his or her) hands such as….?"

IF CHSCN_AGE > or = 24 MONTHS, THEN "Compared other [CHSCN_AGE]-year-old children would you say [he/she] experiences a lot, a little, or no difficulty using (his or her) hands such as..."

(IF S.C. 0-7 MONTHS, SAY: “ grabbing small objects?”

IF S.C. 8-23 MONTHS, SAY: “ holding a cup or eating finger foods?”

IF S.C. 24+ MONTHS, SAY: “using scissors, a pencil, or a fork?”)

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN: IF RESPONDENT SAYS THAT CHILD HAS MORE THAN A LITTLE DIFFICULTY BUT NOT A LOT OF DIFFICULTY, PLEASE CODE THE ANSWER AS "A LITTLE DIFFICULTY."

C3Q30 [IF S.C. IS YOUNGER THAN 12 MONTHS, SKIP TO CPC3Q35]

(READ IF NECESSARY: Compared to other [CHSCN_AGE]-year-old children, would you say [he/she] experiences a lot, a little, or no difficulty...)

Learning, understanding, or paying attention?

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN: IF RESPONDENT SAYS THAT CHILD HAS MORE THAN A LITTLE DIFFICULTY BUT NOT A LOT OF DIFFICULTY, PLEASE CODE THE ANSWER AS "A LITTLE DIFFICULTY."

C3Q31 (READ IF NECESSARY: Compared to other [CHSCN_AGE]-year-old children, would you say [he/she] experiences a lot, a little, or no difficulty...)

Speaking, communicating, or being understood?

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN: IF RESPONDENT SAYS THAT CHILD HAS MORE THAN A LITTLE DIFFICULTY BUT NOT A LOT OF DIFFICULTY, PLEASE CODE THE ANSWER AS "A LITTLE DIFFICULTY."

C3Q32 [IF S.C. IS YOUNGER THAN 18 MONTHS, SKIP TO CPC3Q35]

Compared to other [CSHCN_AGE]-year-old children, would you say [he/she] experiences a lot, a little, or no difficulty with feeling anxious or depressed?

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN: IF RESPONDENT SAYS THAT CHILD HAS MORE THAN A LITTLE DIFFICULTY BUT NOT A LOT OF DIFFICULTY, PLEASE CODE THE ANSWER AS "A LITTLE DIFFICULTY."

C3Q33 (READ IF NECESSARY: Compared to other [CSHCN_AGE]-year-old children, would you say [he/she] experiences a lot, a little, or no difficulty...)

With behavior problems, such as acting-out, fighting, bullying, or arguing?

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN: IF RESPONDENT SAYS THAT CHILD HAS MORE THAN A LITTLE DIFFICULTY BUT NOT A LOT OF DIFFICULTY, PLEASE CODE THE ANSWER AS "A LITTLE DIFFICULTY."

C3Q34 [IF S.C. IS YOUNGER THAN 36 MONTHS, SKIP TO CPC3Q35]

(READ IF NECESSARY: Compared to other [CSHCN_AGE]-year-old children, would you say [he/she] experiences a lot, a little, or no difficulty..)

Making and keeping friends?

(1) A LOT OF DIFFICULTY

(2) A LITTLE DIFFICULTY

(3) NO DIFFICULTY

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN: IF RESPONDENT SAYS THAT CHILD HAS MORE THAN A LITTLE DIFFICULTY BUT NOT A LOT OF DIFFICULTY, PLEASE CODE THE ANSWER AS "A LITTLE DIFFICULTY."

[TIMESTAMP_SECTION33]

CPC3Q35 IF ANY C3Q21 THROUGH C3Q34 = 1, 2, THEN SKIP TO K2Q31_INTRO. ELSE, ASK C3Q35.

C3Q35 You reported that [S.C.] does not experience any difficulty in any of the areas just mentioned. In your opinion, would you say this is because [S.C.]’s health problems are being treated and are under control?

(1) YES [SKIP TO K2Q31_INTRO]

(2) NO [SKIP TO C3Q35A]

(77) DON’T KNOW [SKIP TO K2Q31_INTRO]

(99) REFUSED [SKIP TO K2Q31_INTRO]

C3Q35A Why is it that [S.C.]’s health problems do not currently cause [him/her] difficulty?

_______________________[250 CHARACTERS MAX]

[NOTE TO INTERVIEWERS: DO NOT RECORD ONLY THE DIAGNOSIS OR CONDITION. IF THE RESPONDENT GIVES ONLY THE DIAGNOSIS OR CONDITION, ASK: “Why doesn’t that problem cause any difficulty in the areas just mentioned?”]

[TIMESTAMP_SECTION34]

K2Q31_INTRO Now I am going to read you a list of conditions. For each condition, please tell me if a doctor or other health care provider ever told you that [S.C.] had the condition, even if [he/she] does not have the condition now.

HELP SCREEN (K2Q31A-K2Q52A): IF THE RESPONDENT HAS NEVER HEARD OF THE MEDICAL CONDITION OR DOES NOT KNOW WHAT THE CONDITION IS, THEN A DOCTOR OR OTHER HEALTH CARE PROVIDER PROBABLY HAS NOT TOLD THE RESPONDENT THAT THE S.C. HAS THE CONDITION. IF A DOCTOR OR OTHER HEALTH CARE PROVIDER HAS NOT TOLD THE RESPONDENT THAT THE S.C. HAS THE CONDITION, BUT THE RESPONDENT INSISTS THAT THE S.C. HAS THE CONDITION, WE STILL NEED TO CODE THE ANSWER AS “NO.”

CPK2Q31 If SC AGE < 24 MONTHS SKIP TO K2Q40A

CATI INSTRUCTION (K2Q31A-K2Q52A): IF SC AGE < 24 MONTHS SKIP TO K2Q40A

K2Q31A Has a doctor or other health care provider ever told you that [S.C.] had...

Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder, that is, ADD or ADHD?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN : A child with Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder has problems paying attention or sitting still. It may cause the child to be easily distracted.

HELP SCREEN: IF THE RESPONDENT HAS NEVER HEARD OF THE MEDICAL CONDITION OR DOES NOT KNOW WHAT THE CONDITION IS, THEN A DOCTOR OR OTHER HEALTH CARE PROVIDER PROBABLY HAS NOT TOLD THE RESPONDENT THAT THE S.C. HAS THE CONDITION. IF A DOCTOR OR OTHER HEALTH CARE PROVIDER HAS NOT TOLD THE RESPONDENT THAT THE S.C. HAS THE CONDITION, BUT THE RESPONDENT INSISTS THAT THE S.C. HAS THE CONDITION, WE STILL NEED TO CODE THE ANSWER AS “NO.”

K2Q32A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Depression?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q32A): Depression is an illness that involves the body, mood, and thoughts. It is marked by persistent sadness or an anxious or empty mood. It affects how a child feels, and the way a child eats, sleeps, and functions.

K2Q33A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Anxiety problems?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q33A): Anxiety is a feeling of constant worrying. Children with severe anxiety problems may be diagnosed as having anxiety disorders. Anxiety disorders include panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and phobias.

K2Q34A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Behavioral or conduct problems, such as oppositional defiant disorder or conduct disorder?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q34A): Oppositional defiant disorder is an ongoing pattern of defiant and hostile behavior that interferes with a child’s life and daily activities.

K2Q35A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Autism, Asperger's Disorder, pervasive developmental disorder, or other autism spectrum disorder?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q35A): Children with autism have delays in language, communication, and social skills. Children with Asperger’s disorder have impaired social skills but do not have speech or language delays. They often have an intense interest in a single subject or topic. Children with pervasive developmental disorder have severe and persistent delays in language, communication, and social skills.

K2Q36A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Any developmental delay that affects [his/her] ability to learn?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q36A): A child with a developmental delay does not achieve certain skills as quickly other children of the same age. A developmental delay is a major delay in motor, language, social, or thinking skills.

K2Q37A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Intellectual disability or mental retardation?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q37A): Children with intellectual disabilities or mental retardation learn and develop more slowly than a typical child.

K2Q40A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Asthma?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q40A): Asthma is a disease that causes swelling in the tubes that carry air to the lungs. Sometimes asthma blocks or restricts the airways making it difficult to breathe.

K2Q41A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Diabetes?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q41A): Diabetes is a disease in which the body does not properly make or use insulin.

K2Q42A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Epilepsy or seizure disorder?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q42A): Epilepsy is a brain disease that involves recurrent seizures.

K2Q43A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Has a doctor or other health care provider ever told you that [S.C.] had Migraines or frequent headaches?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q43A): A migraine is a type of severe headache that can cause nausea and vomiting.

K2Q44A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

A head injury, concussion, or traumatic brain injury or concussion?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN: A CONCUSSION IS AN INJURY OF THE BRAIN THAT CAUSES A BRIEF DISRUPTION IN BRAIN FUNCTION. DEVELOPMENTAL AND NEUROLOGICAL CONDITIONS (SUCH AS AUTISM OR CEREBRAL PALSY) SHOULD NOT BE INCLUDED AS HEAD OR BRAIN INJURIES. THIS QUESTION REFERS ONLY TO TRAUMATIC INJURIES. BRAIN TUMORS SHOULD NOT BE CONSIDERED BRAIN INJURIES.

K2Q45A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Heart problem, including congenital heart disease?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN: Heart problems are any type of problems with a child’s heart. Congenital heart disease is a defect in the structure of the heart that occurs before birth. Harmless or innocuous heart murmurs should not be included as heart problems.

K2Q46A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Blood problems such as anemia or sickle cell disease? Please do not include Sickle Cell Trait.

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN: Children with anemia have problems with their blood that can cause them to be very tired. Leukemia should be included as a blood problem.

K2Q47A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Cystic Fibrosis?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q47A): Cystic Fibrosis is a disease that causes mucus to build up in the lungs and can cause bronchitis, frequent coughing and pneumonia.

K2Q48A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Cerebral Palsy

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q48A): Cerebral Palsy is caused by damage that occurs to the brain prior to or shortly after birth that can affect body movement and muscle coordination.

K2Q49A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Muscular Dystrophy?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q49A): Muscular dystrophy is a group of genetic muscle diseases that cause muscle weakness and muscle degeneration.

K2Q50A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Down Syndrome?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q50A): Down Syndrome is a condition that causes delays in the way a child develops, both mentally and physically.

K2Q51A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Arthritis or other joint problems?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q51A): Arthritis causes joint problems including pain, stiffness, swelling, and damage to joints.

K2Q52A (READ IF NECESSARY: Has a doctor or other health care provider ever told you that [S.C.] had…)

Allergies?

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN (K2Q52A): An allergy is an abnormal reaction by a person's immune system against a normally harmless substance.

K2Q31B CATI INSTRUCTION (K2Q31B): IF K2Q31A IS NOT “1,” THEN SKIP TO K2Q32B.

Does [S.C.] currently have ADD or ADHD?

(1) YES

(2) NO [SKIP TO K2Q32B]

(77) DON’T KNOW [SKIP TO K2Q32B]

(99) REFUSED [SKIP TO K2Q32B]

K2Q31C Would you describe [his/her] ADD or ADHD as mild, moderate, or severe?

(1) MILD

(2) MODERATE

(3) SEVERE

(77) DON’T KNOW

(99) REFUSED

K2Q32B CATI INSTRUCTION (K2Q32B): IF K2Q32A IS NOT “1,” THEN SKIP TO K2Q33B.

Does [S.C.] currently have depression?

(1) YES

(2) NO [SKIP TO K2Q33B]

(77) DON’T KNOW [SKIP TO K2Q33B]

(99) REFUSED [SKIP TO K2Q33B]

K2Q32C Would you describe [his/her] depression as mild, moderate, or severe?

(1) MILD

(2) MODERATE

(3) SEVERE

(77) DON’T KNOW

(99) REFUSED

K2Q33B CATI INSTRUCTION (K2Q33B): IF K2Q33A IS NOT “1,” THEN SKIP TO K2Q34B.

Does [S.C.] currently have anxiety problems?

(1) YES

(2) NO [SKIP TO K2Q34B]

(77) DON’T KNOW [SKIP TO K2Q34B]

(99) REFUSED [SKIP TO K2Q34B]

K2Q33C Would you describe [his/her] anxiety problems as mild, moderate, or severe?

(1) MILD

(2) MODERATE

(3) SEVERE

(77) DON’T KNOW

(99) REFUSED

K2Q34B CATI INSTRUCTION (K2Q34B): IF K2Q34A IS NOT “1,” THEN SKIP TO K2Q35B.

Does [S.C.] currently have behavioral or conduct problems?

(1) YES

(2) NO [SKIP TO K2Q35B]

(77) DON’T KNOW [SKIP TO K2Q35B]

(99) REFUSED [SKIP TO K2Q35B]

K2Q34C Would you describe [his/her] behavioral or conduct problems as mild, moderate, or severe?

(1) MILD

(2) MODERATE

(3) SEVERE

(77) DON’T KNOW

(99) REFUSED

K2Q35B CATI INSTRUCTION (K2Q35B): IF K2Q35A IS NOT “1,” THEN SKIP TO K2Q36B.

Does [S.C.] currently have autism or ASD?

(1) YES

(2) NO [SKIP TO K2Q36B]

(77) DON’T KNOW [SKIP TO K2Q36B]

(99) REFUSED [SKIP TO K2Q36B]

K2Q35C Would you describe [his/her] autism or ASD as mild, moderate, or severe?

(1) MILD

(2) MODERATE

(3) SEVERE

(77) DON’T KNOW

(99) REFUSED

K2Q36B CATI INSTRUCTION (K2Q36B): IF K2Q36A IS NOT “1,” THEN SKIP TO K2Q37B.

Does [S.C.] currently have developmental delay?

(1) YES

(2) NO [SKIP TO K2Q37B]

(77) DON’T KNOW [SKIP TO K2Q37B]

(99) REFUSED [SKIP TO K2Q37B]

K2Q36C Would you describe [his/her] developmental delay as mild, moderate, or severe?

(1) MILD

(2) MODERATE

(3) SEVERE

(77) DON’T KNOW

(99) REFUSED

K2Q37B CATI INSTRUCTION (K2Q37B): IF K2Q37A IS NOT “1,” THEN SKIP TO K2Q40B.

Does [S.C.] currently have intellectual disability or mental retardation?

(1) YES

(2) NO [SKIP TO K2Q40B]

(77) DON’T KNOW [SKIP TO K2Q40B]

(99) REFUSED [SKIP TO K2Q40B]

K2Q37C Would you describe [his/her] intellectual disability or mental retardation as mild, moderate, or severe?

(1) MILD

(2) MODERATE

(3) SEVERE

(77) DON’T KNOW

(99) REFUSED

K2Q40B CATI INSTRUCTION (K2Q40B): IF K2Q40A IS NOT “1,” THEN SKIP TO K2Q41B.

Does [S.C.] currently have asthma?

(1) YES

(2) NO [SKIP TO K2Q41B]

(77) DON’T KNOW [SKIP TO K2Q41B]

(99) REFUSED [SKIP TO K2Q41B]

K2Q41B CATI INSTRUCTION (K2Q41B): IF K2Q41A IS NOT “1,” THEN SKIP TO K2Q42B.

Does [S.C.] currently have diabetes?

(1) YES

(2) NO [SKIP TO K2Q42B]

(77) DON’T KNOW [SKIP TO K2Q42B]

(99) REFUSED [SKIP TO K2Q42B]

K2Q41C Does [S.C.] use insulin?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

K2Q42B CATI INSTRUCTION (K2Q42B): IF K2Q42A IS NOT “1,” THEN SKIP TO K2Q43B.

Does [S.C.] currently have epilepsy or seizure disorder?

(1) YES

(2) NO [SKIP TO K2Q43B]

(77) DON’T KNOW [SKIP TO K2Q43B]

(99) REFUSED [SKIP TO K2Q43B]

K2Q42C Would you describe [his/her] epilepsy or seizure disorder as mild, moderate, or severe?

(1) MILD

(2) MODERATE

(3) SEVERE

(77) DON’T KNOW

(99) REFUSED

K2Q43B CATI INSTRUCTION (K2Q43B): IF K2Q43A IS NOT “1,” THEN SKIP TO K2Q44B.

Does [S.C.] currently have migraines or frequent headaches?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

K2Q44B CATI INSTRUCTION (K2Q44B): IF K2Q44A IS NOT “1,” THEN SKIP TO K2Q45B.

Does [S.C.] currently have a head injury, concussion, or traumatic brain injury?

(1) YES

(2) NO [SKIP TO K2Q45B]

(77) DON’T KNOW [SKIP TO K2Q45B]

(99) REFUSED [SKIP TO K2Q45B]

K2Q44C Would you describe [his/her] injury as mild, moderate, or severe?

(1) MILD

(2) MODERATE

(3) SEVERE

(77) DON’T KNOW

(99) REFUSED

K2Q45B CATI INSTRUCTION (K2Q45B): IF K2Q45A IS NOT “1,” THEN SKIP TO K2Q46B.

Does [S.C.] currently have a heart problem?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

K2Q46B CATI INSTRUCTION (K2Q46B): IF K2Q46A IS NOT “1,” THEN SKIP TO K2Q47B.

Does [S.C.] currently have a blood problem?

(1) YES

(2) NO [SKIP TO K2Q47B]

(77) DON’T KNOW [SKIP TO K2Q47B]

(99) REFUSED [SKIP TO K2Q47B]

K2Q46C Are [his/her] blood problems related to anemia, sickle cell disease, hemophilia, or something else?

(1) ANEMIA

(2) SICKLE CELL DISEASE

(3) HEMOPHILIA

(4) SOMETHING ELSE

(77) DON’T KNOW

(99) REFUSED

K2Q47B CATI INSTRUCTION (K2Q47B): IF K2Q47A IS NOT “1,” THEN SKIP TO K2Q48B.

Does [S.C.] currently have Cystic Fibrosis?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

K2Q48B CATI INSTRUCTION (K2Q48B): IF K2Q48A IS NOT “1,” THEN SKIP TO K2Q49B.

Does [S.C.] currently have Cerebral Palsy?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

K2Q49B CATI INSTRUCTION (K2Q49B): IF K2Q49A IS NOT “1,” THEN SKIP TO K2Q50B.

Does [S.C.] currently have Muscular Dystrophy?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

K2Q50B CATI INSTRUCTION (K2Q50B): IF K2Q50A IS NOT “1,” THEN SKIP TO K2Q51B.

Does [S.C.] currently have Down Syndrome?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

K2Q51B CATI INSTRUCTION (K2Q51B): IF K2Q51A IS NOT “1,” THEN SKIP TO K2Q52B.

Does [S.C.] currently have arthritis or other joint problems?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

K2Q52B CATI INSTRUCTION (K2Q52B): IF K2Q52A IS NOT “1,” THEN SKIP TO C3Q14.

Does [S.C.] currently have allergies?

(1) YES

(2) NO [SKIP TO C3Q14]

(77) DON’T KNOW [SKIP TO C3Q14]

(99) REFUSED [SKIP TO C3Q14]

K2Q52C Are any of these food allergies?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

[TIMESTAMP_SECTION35]

C3Q14 [IF AGE FROM C2Q01 OR C2Q02 < 60 MONTHS (5 YEARS), SKIP TO C3Q42]

During the past 12 months, that is since (FILL, TODAY – 12 MONTHS), about how many days did [S.C.] miss school because of illness or injury?

[NOTE: A SCHOOL YEAR IS 240 DAYS]

(CATI: 3 NUMERIC-CHARACTER-FIELD, RANGE 000-240, 555, 666, 777,999)

(Date Format for FILL: MONTH NAME/YEAR. Example if this were executed today: "…, that is since February 2004, about how many days…")

______________NUMBER OF DAYS

(000) NONE

(555) DID NOT GO TO SCHOOL

(666) HOME SCHOOLED

(777) DON’T KNOW

(999) REFUSED

IF > 40 AND NOT IN 555, 666, 777, 999, GO TO SC_C3Q14ELSE GO TO C3Q40

SC_C3Q14 YOU ENTERED [FILL WITH ANSWER FROM C3Q14] SCHOOL DAYS. IS THIS CORRECT?

(1) YES [GO TO C3Q40]

(2) NO [GO BACK TO C3Q14]

C3Q40 Do [S.C.]’s (medical, behavioral, or other health conditions / emotional, developmental, or behavioral problems) interfere with [his/her] ability to attend school on a regular basis?

(1) YES
(2) NO
(77) DON’T KNOW
(99) REFUSED

C3Q41 Do [S.C.]’s (medical, behavioral, or other health conditions / emotional, developmental, or behavioral problems) interfere with [his/her] ability to participate in sports, clubs, or other organized activities?

(1) YES [SKIP TO C6Q00]
(2) NO [SKIP TO C6Q00]
(77) DON’T KNOW [SKIP TO C6Q00]
(99) REFUSED [SKIP TO C6Q00]

C3Q42 [IF S.C. IS YOUNGER THAN 12 MONTHS, SKIP TO C3Q43]

Do [S.C.]’s (medical, behavioral, or other health conditions / emotional, developmental, or behavioral problems) interfere with [his/her] ability to participate in play with other children?

(1) YES
(2) NO
(77) DON’T KNOW
(99) REFUSED

C3Q43 Do [S.C.]’s (medical, behavioral, or other health conditions / emotional, developmental, or behavioral problems) interfere with [his/her] ability to go on outings, such as to the park, library, zoo, shopping, church, restaurants, or family gatherings?

(1) YES
(2) NO
(77) DON’T KNOW
(99) REFUSED

C6Q00 [During the past 12 months/Since [his/her] birth], how many times did [S.C.] visit a hospital emergency room?

(CATI: 3 NUMERIC-CHARACTER FIELD, RANGE 000-776)

READ IF NECESSARY: This includes emergency room visits that resulted in a hospital admission.

READ IF NECESSARY: THIS QUESTION IS ASKING SPECIFICALLY ABOUT VISITS TO A HOSPITAL EMERGENCY ROOM. DO NOT INCLUDE VISITS TO URGENT CARE CENTERS OR CLINICS, WHICH TAKE SICK PATIENTS WHO CANNOT BE SEEN BY THEIR REGULAR OR PRIMARY CARE DOCTORS.

ENTER NUMBER OF VISITS

______________NUMBER OF VISITS

(000) NO VISITS IN PAST 12 MONTHS

(777) DON’T KNOW

(999) REFUSED

IF > 10 AND NOT IN 777, 999, GO TO SC_C6Q00 ELSE GO TO CPC3Q50

SC_C6Q00 YOU ENTERED [FILL WITH ANSWER FROM C6Q00] VISITS. IS THIS CORRECT?

(1) YES [GO TO CPC3Q50]

(2) NO [GO BACKTO C6Q00]

[TIMESTAMP_SECTION36]

CPC3Q50 IF CWTYPE=S AND ASK_CALIF=1 THEN GO TO C3Q50, ELSE GO TO NAME_SEC4

C3Q50 [During the past 12 months\ Since [S.C.]’s birth], was [S.C.] admitted to a hospital overnight?

HELP SCREEN: DO NOT INCLUDE OVERNIGHT STAYS IN THE EMERGENCY ROOM.

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

Section 4. ACCESS TO CARE: UTILIZATION AND UNMET NEEDS

[TIMESTAMP_SECTION41]

NAME_SEC4 [SKIP TO C4Q0A IF NAME OF SELECTED CHILD ALREADY GATHERED FROM MULTIAGE, C2Q01N, SELECTION1_NAME, NIS INTERVIEW, OR RESPONDENT REFUSED TO ANSWER NAME QUESTIONS]

INTERVIEWER QUESTION: DO NOT READ TO RESPONDENT!

HAS THE HOUSEHOLD GIVEN YOU A NAME FOR THE CHILD?

(1) YES [GO TO NAME_SEC4_A]

NO [GO TO C4Q0A]

NAME_SEC4_A

ENTER NAME/INITIALS: ____________ > GO TO C4Q0A

[FILL [S.C.] WITH THIS NAME FROM THIS POINT ON IN THE INTERVIEW]

C4Q0A Is there a place that [S.C.] USUALLY goes when [he/she] is sick or you need advice about

[his/her] health?

(1) YES

(2) THERE IS NO PLACE [SKIP TO C4Q0D]

(3) THERE IS MORE THAN ONE PLACE

(77) DON’T KNOW [SKIP TO C4Q0D]

(99) REFUSED [SKIP TO C4Q0D]

C4Q0B IF C4Q0A = 01, SAY “What kind of place is it?”

IF C4Q0A = 03, SAY “What kind of place does [S.C.] go to most often?”

Is it a doctor’s office, emergency room, hospital outpatient department, clinic, or some other place?

(1) Doctor’s office [SKIP TO C4Q0D]

(2) HOSPITAL emergency room [SKIP TO C4Q0D]

(3) Hospital outpatient department [SKIP TO C4Q0D]

(4) Clinic OR HEALTH CENTER [SKIP TO C4Q0D]

(5) SCHOOL (NURSE’S OFFICE, ATHLETIC TRAINER’S OFFICE, ETC) [SKIP TO C4Q0D]

(6) fRIEND/RELATIVE [SKIP TO C4Q0D]

(7) mEXICO/OTHER LOCATIONS OUT OF US [SKIP TO C4Q0D]

(8) Some other place [SKIP TO C4Q0C]

(9) DOES NOT GO TO ONE PLACE MOST OFTEN [SKIP TO C4Q0D]

(77) DON’T KNOW [FILL 77 IN C4Q0A AND SKIP TO C4Q0D]

(99) REFUSED [FILL 99 IN C4Q0A AND SKIP TO C4Q0D]

C4Q0C READ IF NECESSARY

IF C4Q0A = 01, SAY “What kind of place is it?”

IF C4Q0A = 3, SAY “What kind of place does [S.C.] go to most often?”

Record verbatim response________

C4Q0D Is there a place that [S.C.] USUALLY goes when [he/she] needs routine preventive care, such as a physical examination or well-child check-up?

(1) YES

(2) THERE IS NO PLACE [SKIP TO C4Q02A]

(3) THERE IS MORE THAN ONE PLACE

(77) DON’T KNOW [SKIP TO C4Q02A]

(99) REFUSED [SKIP TO C4Q02A]

READ IF NECESSARY: Clinical preventive care includes check-ups, immunizations, health screening tests, and discussions about how to keep your child healthy.

C4Q01 [IF C4Q0A = 2, 7, 9, OR IF C4Q0B = 9, 77, 99, THEN GO TO C4Q02]

[IF C4Q0B = 6, 7, 8, 77, 99 FILL WITH “place”]

Is that the same [place selected in C4Q0B] where [S.C.] goes when [he/she] is sick?

(1) Yes [Skip to c4q02A]

(2) NO

(77) DON’T KNOW [Skip to c4q02A]

(99) REFUSED [Skip to c4q02A]

C4Q02 IF C4Q0D = 01 OR MISSING, SAY “What kind of place does [S.C.] USUALLY go to when [he/she] needs routine preventive care?”

IF C4Q0D = 03, SAY “What kind of place does [S.C.] go to most often when [he/she] needs routine preventive care?”

(1) Doctor’s office

(2) HOSPITAL emergency room

(3) Hospital outpatient department

(4) Clinic OR HEALTH CENTER

(5) SCHOOL (NURSE’S OFFICE, ATHLETIC TRAINER’S OFFICE, ETC)

(6) FRIEND/RELATIVE

(7) MEXICO/OTHER LOCATIONS OUT OF US

(8) Some other place [SKIP TO C4Q02_01]

(9) DOES NOT GO TO ONE PLACE MOST OFTEN

(77) DON’T KNOW

(99) REFUSED

FOR ALL EXCEPT (08), GO TO C4Q02A

C4Q02_01 READ IF NECESSARY

IF C4Q0D = 1, SAY “What kind of place is it?”

IF C4Q0D = 3, SAY “What kind of place does [S.C.] go to most often?”

Record verbatim response________

C4Q02A A personal doctor or nurse is a health professional who knows your child well and is familiar with

your child’s health history. This can be a general doctor, a pediatrician, a specialist doctor, a nurse practitioner, or a physician’s assistant. Do you have one or more persons you think of as [S.C.]’s personal doctor or nurse?

(1) Yes, one person

(2) yes, more than one person

(3) No [Skip to C4Q03]

(77) DON’T KNOW [Skip to C4Q03]

(99) REFUSED [Skip to C4Q03]

C4Q02B IF C4Q02A = 01 THEN READ: “Is this person a general doctor, pediatrician, specialist, nurse practitioner, or physician’s assistant?” [MARK ALL THAT APPLY]

IF C4Q02A = 02 THEN READ: “Are those people general doctors, pediatricians, specialists, nurse practitioners, or physician assistants?” [MARK ALL THAT APPLY]

C4Q02BX01 General doctor (general practice, family or internal medicine)

YES (2) NO (77) DON’T KNOW (99) REFUSED

C4Q02BX02 Pediatrician

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C4Q02BX03 Specialist (FOR EXAMPLE; surgeons, heart doctors, psychiatrists, ob/gyn)

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C4Q02BX04 Nurse Practitioner

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C4Q02BX05 Physician’s Assistant

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C4Q02BX06 MOTHER/FRIEND/RELATIVE

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C4Q02BX07 OTHER [SKIP TO C4Q02B_01]

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C4Q02B_01 READ IF NECESSARY

What type of health professional is this person?

Record verbatim response________

[TIMESTAMP_SECTION42]

C4Q03_INTRO The next questions are about all the types of services children may need or use, such as medical care, dental care, specialized therapies, counseling, medical equipment, special education, and early intervention. These services can be obtained in clinics, schools, child care centers, through community programs, at home, and other places.

C4Q03_A [During the past 12 months / Since [his/her] birth], did you have any difficulties or delays getting services for [S.C.] because [he/she] was not eligible for the services?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN: These questions are about all the types of services children may need or use, such as medical care, dental care, specialized therapies, counseling, medical equipment, special education, and early intervention. These services can be obtained in clinics, schools, child care centers, through community programs, at home, and other places.

C4Q03_B [During the past 12 months / Since [his/her] birth], did you have any difficulties or delays because the services [S.C.] needed were not available in your area?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q03_C [During the past 12 months / Since [his/her] birth], did you have any difficulties or delays because there were waiting lists, backlogs, or other problems getting appointments?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q03_D (READ IF NECESSARY: [During the past 12 months… / Since [his/her] birth…])

Did you have any difficulties or delays because of issues related to cost?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q03_E (READ IF NECESSARY: [During the past 12 months… / Since [his/her] birth…])

Did you have any difficulties or delays because you had trouble getting the information you needed?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q03_F [IF ANY C4Q03_A THROUGH C4Q03_E = YES, THEN SKIP TO C4Q04.]

(READ IF NECESSARY: [During the past 12 months… / Since [his/her] birth…])

Did you have any difficulties or delays for any other reason?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q04 [During the past 12 months / Since [his/her] birth], how often have you been frustrated in your efforts to get services for [S.C.]?

Would you say never, sometimes, usually, or always?

(1) NEVER

(2) SOMETIMES

(3) USUALLY

(4) ALWAYS

(77) DON’T KNOW

(99) REFUSED

[TIMESTAMP_SECTION43]

C4Q05 (4.5)

(CATI: THIS SERIES SHOULD BE ASKED HORIZONTALLY ACROSS THE TABLE. IN OTHER WORDS, IF THEY ANSWER YES TO SOMETHING IN COLUMN 01, THEY SHOULD IMMEDIATELY BE ASKED THE QUESTIONS IN COLUMN 2, 3, 4, 5 AS APPLICABLE)

ALL RECEIVE THE FOLLOWING INTRODUCTION:

[During the past 12 months/ Since [his/her] birth], was there any time when [S.C.] needed any of the following services:

Did [S.C.] receive all the [fill each ‘Yes' item from first column] that [he/she] needed?

Why did [S.C.] not get the [fill each yes item from first column] [he/she] needed?

(CHECK ALL THAT APPLY. READ RESPONSES ONLY IF NECESSARY)

Did [S.C.] get any [fill each yes item from first column] [during the past 12 months/ since [his/her] birth]?

C4Q05_1

[During the past 12 months/ Since [his/her] birth], was there any time when [S.C.] needed…

Routine preventive care, such as a physical examination or well child check-up?

(1) YES

(2) NO [SKIP TO C4Q05_2 ]

(77) DON’T KNOW [SKIP TO C4Q05_2]

(99) REFUSED [SKIP TO C4Q05_2

note: C4Q05_X01a is avariable that is not used.

C4Q05_1A

Did [S.C.] receive all the

routine preventive care

that [he/she] needed?

(1)Yes [SKIP TO C4Q05_2 ]

(2) NO

(77) DON’T KNOW [SKIP TO C4Q05_2 ]

(99) REFUSED [SKIP TO C4Q05_2

C4Q05_1B

Why did [S.C.] not get all the routine preventive care {he/she} needed?

(1) COST WAS TOO MUCH

(2) NO INSURANCE

(3) HEALTH PLAN PROBLEM

(4) CAN’T FIND PROVIDER WHO ACCEPTS CHILD’S INSURANCE

(5) NOT AVAILABLE IN AREA/TRANSPORT PROBLEMS

(6) NOT CONVENIENT TIMES/COULD NOT GET APPOINTMENT

(7) PROVIDER DID NOT KNOW HOW TO TREAT OR PROVIDE CARE

(8) DISSATISFACTION WITH PROVIDER

(9) DID NOT KNOW WHERE TO GO FOR TREATMENT

(10) CHILD REFUSED TO GO

(11) TREATMENT IS ONGOING

(13) NO REFERRAL

(14) LACK OF RESOURCES AT SCHOOL

(15) DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT

(16) OTHER [SKIP TO C4Q05_1_O]

(77) DON’T KNOW

(99) REFUSED

ALL OTHERS, SKIP TO C4Q05_1C

C4Q05_1_O

READ IF NECESSARY: Why did [S.C.] not get all the routine preventive care [he/she] needed ?

Record Verbatim response________

C4Q05_1C

Did [S.C.] get any routine preventive care [during the past 12 months/ since his/her birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q05_2

[During the past 12 months/ Since [his/her] birth], was there any time when [S.C.] needed…)

Care from a specialty doctor?

(1) YES

(2) NO [SKIP TO C4Q05_31]

(77) DON’T KNOW [SKIP TO C4Q05_31]

(99) REFUSED [SKIP TO C4Q05_31]

READ IF NECESSARY: Specialty doctors focus on one part of your child’s health. These include cardiologists, pulmonologists, ear, nose and throat doctors, surgeons, etc. Do not include dentists or psychiatrists. Needs for care from dentists and psychiatrists are asked in other questions.

C4Q05_2A

Did [S.C.] receive all the Care from a specialty doctor that [he/she] needed?

(1)Yes [SKIP TO C4Q05X02AA]

(2) NO

(77) DON’T KNOW [SKIP TO C4Q05_31]

(99) REFUSED [SKIP TO C4Q05_31]

C4Q05_2B

Why did [S.C.] not get all the care from a specialty doctor [he/she] needed?

(1) COST WAS TOO MUCH

(2) NO INSURANCE

(3) HEALTH PLAN PROBLEM

(4) CAN’T FIND PROVIDER WHO ACCEPTS CHILD’S INSURANCE

(5) NOT AVAILABLE IN AREA/TRANSPORT PROBLEMS

(6) NOT CONVENIENT TIMES/COULD NOT GET APPOINTMENT

(7) PROVIDER DID NOT KNOW HOW TO TREAT OR PROVIDE CARE

(8) DISSATISFACTION WITH PROVIDER

(9) DID NOT KNOW WHERE TO GO FOR TREATMENT

(10) CHILD REFUSED TO GO

(11) TREATMENT IS ONGOING

(13) NO REFERRAL

(14) LACK OF RESOURCES AT SCHOOL

(15) DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT

(16) OTHER (SKIP TO C4Q05_2_O)

(77) DON’T KNOW

(99) REFUSED

ALL OTHERS, SKIP TO C4Q05_2C

C4Q05_2_O

READ IF NECESSARY: Why did [S.C.] not get all the care from a specialty doctor [he/she] needed ?

Record verbatim response_________

C4Q05_2C

Did [S.C.] get any care from a specialty doctor [during the past 12 months/ since [his/her] birth]?

(1) YES [SKIP TO C4Q05_2AA]

(2) NO

(77) DON’T KNOW

(99) REFUSED

[SKIP TO C4Q05_31]

C4Q05_2AA

[IF C4Q05_2A = 01 OR C4Q05_2C = 01 THEN ASK]:

How many different specialty doctors did [S.C.] see [during the past 12 months/ since [his/her] birth]?

01-76 ENTER NUMBER

77 - DON’T KNOW

99 – REFUSED

IF > 10 AND NOT IN 77, 99, GO TO SC_C4Q05_2AA

ELSE GO TO C4Q05_31

SC_C4Q05_2AA

INTERVIEWER CHECK: YOU ENTERED [FILL WITH ANSWER FROM C4Q05_2AA] SPECIALTY DOCTORS. IS THIS CORRECT?

(1) YES [GO TO C4Q05_31]

(2) NO [GO BACKTO C4Q05_2AA]

C4Q05_31

[During the past 12 months/ Since [his/her] birth], was there any time when [S.C.] needed…) Preventive dental care, such as check-ups and dental cleanings?

(1) YES

(2) NO [SKIP TO C4Q05_32]

(77) DON’T KNOW [SKIP TO C4Q05_32]

(99) REFUSED [SKIP TO C4Q05_32]

C4Q05_31A

Did [S.C.] receive all the preventive dental care that [he/she] needed?

(1)Yes [SKIP TO C4Q05_32]

(2) NO

(77) DON’T KNOW [SKIP TO C4Q05_32]

(99) REFUSED [SKIP TO C4Q05_32]

C4Q05_31B

Why did [S.C.] not get all the preventive dental care that [he/she] needed?

(1) COST WAS TOO MUCH

(2) NO INSURANCE

(3) HEALTH PLAN PROBLEM

(4) CAN’T FIND PROVIDER WHO ACCEPTS CHILD’S INSURANCE

(5) NOT AVAILABLE IN AREA/TRANSPORT PROBLEMS

(6) NOT CONVENIENT TIMES/COULD NOT GET APPOINTMENT

(7) PROVIDER DID NOT KNOW HOW TO TREAT OR PROVIDE CARE

(8) DISSATISFACTION WITH PROVIDER

(9) DID NOT KNOW WHERE TO GO FOR TREATMENT

(10) CHILD REFUSED TO GO

(11) TREATMENT IS ONGOING

(13) NO REFERRAL

(14) LACK OF RESOURCES AT SCHOOL

(15) DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT

(16) OTHER [SKIP TO C4Q05_31_O]

(77) DON’T KNOW

(99) REFUSED

ALL OTHERS, SKIP TO C4Q05_31C

C4Q05_31_O

READ IF NECESSARY: Why did [S.C.] not get all the preventive dental care that [he/she] needed ?

Record verbatim response_________

C4Q05_31C

Did [S.C.] get any preventive dental care [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q05_32

(READ AS NECESSARY: [During the past 12 months/ Since [his/her] birth,] was there any time when [S.C.] needed…)

Any other dental care or orthodontia?

(1) YES

(2) NO [SKIP TO C4Q05_4]

(77) DON’T KNOW [SKIP TO C4Q05_4]

(99) REFUSED [SKIP TO C4Q05_4]

HELP SCREEN: OTHER DENTAL CARE CAN INCLUDE ORTHODONTIAL CARE SUCH AS BRACES AND RETAINERS, OR PERIODONTIAL CARE SUCH AS TREATMENT FOR GUM DISEASE.

C4Q05_32A

Did [S.C.] receive all the other dental care that [he/she] needed?

(1)Yes [SKIP TO C4Q05_4]

(2) NO

(77) DON’T KNOW [SKIP TO C4Q05_4]

(99) REFUSED [SKIP TO C4Q05_4]

C4Q05_32B

Why did [S.C.] not get all the other dental care [he/she] needed?

(1) COST WAS TOO MUCH

(2) NO INSURANCE

(3) HEALTH PLAN PROBLEM

(4) CAN’T FIND PROVIDER WHO ACCEPTS CHILD’S INSURANCE

(5) NOT AVAILABLE IN AREA/TRANSPORT PROBLEMS

(6) NOT CONVENIENT TIMES/COULD NOT GET APPOINTMENT

(7) PROVIDER DID NOT KNOW HOW TO TREAT OR PROVIDE CARE

(8) DISSATISFACTION WITH PROVIDER

(9) DID NOT KNOW WHERE TO GO FOR TREATMENT

(10) CHILD REFUSED TO GO

(11) TREATMENT IS ONGOING

(13) NO REFERRAL

(14) LACK OF RESOURCES AT SCHOOL

(15) DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT

(16) OTHER (SKIP TO C4Q05_32_O)

(77) DON’T KNOW

(99) REFUSED

ALL OTHERS, SKIP TO C4Q05_32C

C4Q05_32_O

READ IF NECESSARY: Why did [S.C.] not get all the other dental care [he/she] needed ?

Record verbatim response_________

C4Q05_32C

Did [S.C.] get any non-preventive dental care [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q05_4

(READ AS NECESSARY: [During the past 12 months/ Since [his/her] birth,] was there any time when [S.C.] needed…)

Prescription medications?

(1) YES

(2) NO [SKIP TO C4Q05_5]

(77) DON’T KNOW [SKIP TO C4Q05_5]

(99) REFUSED [SKIP TO C4Q05_5]

C4Q05_4A

Did [S.C.] receive all the prescription medications

that [he/she] needed?

(1)Yes [SKIP TO C4Q05_5]

(2) NO

(77) DON’T KNOW [SKIP TO C4Q05_5]

(99) REFUSED [SKIP TO C4Q05_5]

C4Q05_4B

Why did [S.C.] not get the [Prescription medications] {he/she} needed?

(1) COST WAS TOO MUCH

(2) NO INSURANCE

(3) HEALTH PLAN PROBLEM

(4) CAN’T FIND PROVIDER WHO ACCEPTS CHILD’S INSURANCE

(5) NOT AVAILABLE IN AREA/TRANSPORT PROBLEMS

(6) NOT CONVENIENT TIMES/COULD NOT GET APPOINTMENT

(7) PROVIDER DID NOT KNOW HOW TO TREAT OR PROVIDE CARE

(8) DISSATISFACTION WITH PROVIDER

(9) DID NOT KNOW WHERE TO GO FOR TREATMENT

(10) CHILD REFUSED TO GO

(11) TREATMENT IS ONGOING

(13) NO REFERRAL

(14) LACK OF RESOURCES AT SCHOOL

(15) DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT

(16) OTHER (SKIP TO C4Q05_4_O)

(77) DON’T KNOW

(99) REFUSED

ALL OTHERS, SKIP TO C4Q05_4C

C4Q05_4_O

READ IF NECESSARY: Why did [S.C.] not get all the prescription medications [he/she] needed?

Record verbatim response_________

C4Q05_4C

Did [S.C.] get any prescription medications [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q05_5

(READ AS NECESSARY: [During the past 12 months/ Since [his/her] birth,] was there any time when [S.C.] needed…)

Physical, occupational or speech therapy?

(1) YES

(2) NO [SKIP TO C4Q05_6]

(77) DON’T KNOW [SKIP TO C4Q05_6]

(99) REFUSED [SKIP TO C4Q05_6]

C4Q05_5A

Did [S.C.] receive all the therapy [he/she] needed?

(1)Yes [SKIP TO C4Q05_6]

(2) NO

(77) DON’T KNOW [SKIP TO C4Q05_6]

(99) REFUSED [SKIP TO C4Q05_6]

C4Q05_5B

Why did [S.C.] not get all the therapy [he/she] needed?

(1) COST WAS TOO MUCH

(2) NO INSURANCE

(3) HEALTH PLAN PROBLEM

(4) CAN’T FIND PROVIDER WHO ACCEPTS CHILD’S INSURANCE

(5) NOT AVAILABLE IN AREA/TRANSPORT PROBLEMS

(6) NOT CONVENIENT TIMES/COULD NOT GET APPOINTMENT

(7) PROVIDER DID NOT KNOW HOW TO TREAT OR PROVIDE CARE

(8) DISSATISFACTION WITH PROVIDER

(9) DID NOT KNOW WHERE TO GO FOR TREATMENT

(10) CHILD REFUSED TO GO

(11) TREATMENT IS ONGOING

(13) NO REFERRAL

(14) LACK OF RESOURCES AT SCHOOL

(15) DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT

(16) OTHER (SKIP TO C4Q05_5_O)

(77) DON’T KNOW

(99) REFUSED

ALL OTHERS, SKIP TO C4Q05_5C

C4Q05_5_O

READ IF NECESSARY: Why did [S.C.] not get all the therapy [he/she] needed?

Record verbatim response_________

C4Q05_5C

Did [S.C.] get any physical, occupational, or speech therapy [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q05_6

(READ AS NECESSARY: [During the past 12 months/ Since [his/her] birth,], was there any time when [S.C.] needed…)

Mental health care or counseling?

(1) YES

(2) NO [SKIP TO C4Q05_7]

(77) DON’T KNOW [SKIP TO C4Q05_7]

(99) REFUSED [SKIP TO C4Q05_7]

C4Q05_6A

Did [S.C.] receive all the mental health care or counseling that [he/she] needed?

(1)Yes [SKIP TO C4Q05_7]

(2) NO

(77) DON’T KNOW [SKIP TO C4Q05_7]

(99) REFUSED [SKIP TO C4Q05_7]

C4Q05_6B

Why did [S.C.] not get all the mental health care or counseling [he/she] needed?

(1) COST WAS TOO MUCH

(2) NO INSURANCE

(3) HEALTH PLAN PROBLEM

(4) CAN’T FIND PROVIDER WHO ACCEPTS CHILD’S INSURANCE

(5) NOT AVAILABLE IN AREA/TRANSPORT PROBLEMS

(6) NOT CONVENIENT TIMES/COULD NOT GET APPOINTMENT

(7) PROVIDER DID NOT KNOW HOW TO TREAT OR PROVIDE CARE

(8) DISSATISFACTION WITH PROVIDER

(9) DID NOT KNOW WHERE TO GO FOR TREATMENT

(10) CHILD REFUSED TO GO

(11) TREATMENT IS ONGOING

(13) NO REFERRAL

(14) LACK OF RESOURCES AT SCHOOL

(15) DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT

(16) OTHER (SKIP TO C4Q05_6_O)

(77) DON’T KNOW

(99) REFUSED

ALL OTHERS, SKIP TO C4Q05_6C

C4Q05_6_O

READ IF NECESSARY: Why did [S.C.] not get all the mental health care or counseling [he/she] needed?

Record verbatim response_________

C4Q05_6C

Did [S.C.] get any mental health care or counseling [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q05_7

[IF AGE IS LESS THAN 8 YEARS OLD SKIP TO C4Q05_8]

(READ AS NECESSARY: [During the past 12 months/ Since [his/her] birth,], was there any time when [S.C.] needed…)

Substance abuse treatment or counseling?

(1) YES

(2) NO [SKIP TO C4Q05_8]

(77) DON’T KNOW [SKIP TO C4Q05_8]

(99) REFUSED [SKIP TO C4Q05_8]

Help Screen: sUBSTANCE ABUSE TREATMENT INCLUDES TREATMENT FOR ALCOHOL AND TOBACCO ABUSE. Some respondents may find this question inappropriate.

If this occurs, tell the respondent: I understand this question may be more appropriate for older children, but I am required to ask and read verbatim.

C4Q05_7A

Did [S.C.] receive all the substance abuse treatment or counseling that [he/she] needed?

(1)Yes [SKIP TO C4Q05_8]

(2) NO

(77) DON’T KNOW [SKIP TO C4Q05_8]

(99) REFUSED [SKIP TO C4Q05_8]

C4Q05_7B

Why did [S.C.] not get all the substance abuse treatment or counseling [he/she] needed?

(1) COST WAS TOO MUCH

(2) NO INSURANCE

(3) HEALTH PLAN PROBLEM

(4) CAN’T FIND PROVIDER WHO ACCEPTS CHILD’S INSURANCE

(5) NOT AVAILABLE IN AREA/TRANSPORT PROBLEMS

(6) NOT CONVENIENT TIMES/COULD NOT GET APPOINTMENT

(7) PROVIDER DID NOT KNOW HOW TO TREAT OR PROVIDE CARE

(8) DISSATISFACTION WITH PROVIDER

(9) DID NOT KNOW WHERE TO GO FOR TREATMENT

(10) CHILD REFUSED TO GO

(11) TREATMENT IS ONGOING

(13) NO REFERRAL

(14) LACK OF RESOURCES AT SCHOOL

(15) DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT

(16) OTHER (SKIP TO C4Q05_7_O)

(77) DON’T KNOW

(99) REFUSED

ALL OTHERS, SKIP TO C4Q05_7C)

C4Q05_7_O

READ IF NECESSARY: Why did [S.C.] not get all the substance abuse treatment or counseling [he/she] needed?

Record verbatim response_________

C4Q05_7C

Did [S.C.] get any substance abuse treatment or counseling [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q05_8

(READ AS NECESSARY: During the past 12 months/ Since [his/her] birth, was there any time when [S.C.] needed…)

Home health care?

(1) YES

(2) NO [SKIP TO C4Q05_9]

(77) DON’T KNOW [SKIP TO C4Q05_9]

(99) REFUSED [SKIP TO C4Q05_9]

C4Q05_8A

Did [S.C.] receive all the home health care that [he/she] needed?

(1)Yes

(2) NO [SKIP TO C4Q05_8C]

(77) DON’T KNOW

(99) REFUSED

[IF 01,77,99 THEN SKIP TO C4Q05_09]

C4Q05_8C

Did [S.C.] get any home health care [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q05_9

(READ AS NECESSARY: During the past 12 months/ since [his/her] birth, was there any time when [S.C.] needed…)

Eyeglasses or vision care?

(1) YES

(2) NO [SKIP TO C4Q05_10]

(77) DON’T KNOW [SKIP TO C4Q05_10]

(99) REFUSED [SKIP TO C4Q05_10]

C4Q05_9A

Did [S.C.] receive all the eyeglasses or vision care that [he/she] needed?

(1)Yes

(2) NO [SKIP TO C4Q05_9C]

(77) DON’T KNOW

(99) REFUSED

[IF 01,77,99 THEN SKIP TO C4Q05_10]

C4Q05_9C

Did [S.C.] get any eyeglasses or vision care [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q05_10

(READ AS NECESSARY: During the past 12 months/ Since [his/her] birth, was there any time when [S.C.] needed…)

Hearing aids or hearing care?

(1) YES

(2) NO [SKIP TO C4Q05_11]

(77) DON’T KNOW [SKIP TO C4Q05_11]

(99) REFUSED [SKIP TO C4Q05_11]

C4Q05_10A

Did [S.C.] receive all the hearing aids or hearing care that [he/she] needed?

(1)Yes

(2) NO[SKIP TO C4Q05_10C]

(77) DON’T KNOW

(99) REFUSED

[IF 01,77,99 THEN SKIP TO C4Q05_11]

C4Q05_10C

Did [S.C.] get any hearing aids or hearing care [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q05_11

[IF AGE IS LESS THAN 3 YEARS OLD SKIP TO C4Q05_14]

(READ AS NECESSARY: During the past 12 months/ Since [his/her] birth, was there any time when [S.C.] needed…)

Mobility aids or devices, such as canes, crutches, wheelchairs, or scooters?

(1) YES

(2) NO [SKIP TO C4Q05_12]

(77) DON’T KNOW [SKIP TO C4Q05_12]

(99) REFUSED [SKIP TO C4Q05_12]

C4Q05_11A

Did [S.C.] receive all the mobility aids or devices that [he/she] needed?

(1)Yes

(2) NO [SKIP TO C4Q05_11C]

(77) DON’T KNOW

(99) REFUSED

[IF 01,77,99 THEN SKIP TO C4Q05_12]

C4Q05_11C

Did [S.C.] get any mobility aids or devices [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q05_12

[SKIP IF AGE IS LESS THAN 3 YEARS OLD]

(During the past 12 months / Since [his/her] birth, was there any time when [S.C.] needed)

Communication aids or devices, such as communication boards?

(1) YES

(2) NO [SKIP TO C4Q05_14]

(77) DON'T KNOW [SKIP TO C4Q05_14]

(99) REFUSED [SKIP TO C4Q05_14]

C4Q05_12A

Did [S.C.] receive all the communication aids or devices that [he/she] needed?

(1)YES [SKIP TO C4Q05_14]

(2) NO [SKIP TO C4Q05_12C]

(77) DON'T KNOW [SKIP TO C4Q05_14]

(99) REFUSED [SKIP TO C4Q05_14]

C4Q05_12C

Did [S.C.] get any communication aids or devices [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q05_14

(READ AS NECESSARY: [During the past 12 months/ Since [his/her] birth,] was there any time when [S.C.] needed…)

Durable medical equipment?

(1) YES

(2) NO [SKIP TO C4Q06_1]

(77) DON’T KNOW [SKIP TO C4Q06_1]

(99) REFUSED [SKIP TO C4Q06_1]

READ IF NECESSARY: Some examples of durable medical equipment include nebulizers, blood glucose monitors, hospital beds, oxygen tanks, pressure machines, and orthotics. These are items that are not disposable.

C4Q05_14A

Did [S.C.] receive all the durable medical equipment that [he/she] needed?

(1)Yes

(2) NO [SKIP TO C4Q05_14C]

(77) DON’T KNOW

(99) REFUSED

[IF 01,77,99 THEN SKIP TO C4Q06_1]

C4Q05_14C

Did [S.C.] get any durable medical equipment [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

[TIMESTAMP_SECTION44]

C4Q06 (4.6) [IF CWTYPE = ‘N’ THEN SKIP TO C3Q12]

During the past 12 months/ Since [his/her] birth, was there any time when you or other family members needed any of the following services because of {S.C.’s} health:

Did you or your family receive all the [fill with underlined words from first column] that was needed?

Why did you or your family not get the [fill with underlined words from first column] that was needed?

(CHECK ALL THAT APPLY. READ RESPONSES ONLY IF NECESSARY)

Did you or your family get any [fill with underlined words from first column] during the past 12 months?

C4Q06_1

[During the past 12 months/ Since [his/her] birth], was there any time when you or other family members needed…Respite care?

(1) YES

(2) NO [SKIP TO C4Q06_2]

(77) DON’T KNOW [SKIP TO C4Q06_2]

(99) REFUSED [SKIP TO C4Q06_2]

READ IF NECESSARY: Respite care is care for the child so the family can have a break from ongoing care of the child. Respite care can be thought of as child care or babysitting by someone trained to meet any special needs the child may have. Both professional and non-professional respite care should be included.

C4Q06_1A

Did you or your family receive all the respite care that was needed?

(1) Yes [SKIP TO C4Q06_2]

(2) NO

(77) DON’T KNOW [SKIP TO C4Q06_2]

(99) REFUSED [SKIP TO C4Q06_2]

C4Q06_1B

Why did you or your family not get all the respite care that was needed?

(1) COST WAS TOO MUCH

(2) NO INSURANCE

(3) HEALTH PLAN PROBLEM

(4) CAN’T FIND DOCTOR WHO ACCEPTS CHILD’S INSURANCE

(5) NOT AVAILABLE IN AREA/TRANSPORT PROBLEMS

(6) NOT CONVENIENT TIMES/COULD NOT GET APPOINTMENT

(7) DOCTOR DID NOT KNOW HOW TO TREAT OR PROVIDE CARE

(8) DISSATISFACTION WITH DOCTOR

(9) DID NOT KNOW WHERE TO GO FOR TREATMENT

(10) CHILD REFUSED TO GO

(11) TREATMENT IS ONGOING

(13) NO REFERRAL

(14) LACK OF RESOURCES AT SCHOOL

(15) DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT

(16) OTHER [GO TO C4Q06_1_O]

(77) DON’T KNOW

(99) REFUSED

ALL EXCEPT 16 GO TO C4Q06_1C

C4Q06_1_O

READ IF NECESSARY: Why did you or your family not get all the respite care that was needed?

ENTER OTHER_______

C4Q06_1C

Did you or your family get any respite care [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q06_2

(During the past 12 months/ Since [his/her] birth, was there any time when you or other family members needed…)

Genetic counseling for advice about inherited conditions related to (SC)’s medical, behavioral, or other health conditions?

(1) YES

(2) NO [SKIP TO C4Q06_3]

(77) DON’T KNOW [SKIP TO C4Q06_3]

(99) REFUSED [SKIP TO C4Q06_3]

C4Q06_2A

Did you or your family receive all the genetic counseling that was needed?

(1) Yes [SKIP TO C4Q06_3]

(2) NO

(77) DON’T KNOW [SKIP TO C4Q06_3]

(99) REFUSED [SKIP TO C4Q06_3]

C4Q06_2B

Why did you or your family not get all the genetic counseling that was needed?

(1) COST WAS TOO MUCH

(2) NO INSURANCE

(3) HEALTH PLAN PROBLEM

(4) CAN’T FIND DOCTOR WHO ACCEPTS CHILD’S INSURANCE

(5) NOT AVAILABLE IN AREA/TRANSPORT PROBLEMS

(6) NOT CONVENIENT TIMES/COULD NOT GET APPOINTMENT

(7) DOCTOR DID NOT KNOW HOW TO TREAT OR PROVIDE CARE

(8) DISSATISFACTION WITH DOCTOR

(9) DID NOT KNOW WHERE TO GO FOR TREATMENT

(10) CHILD REFUSED TO GO

(11) TREATMENT IS ONGOING

(13) NO REFERRAL

(14) LACK OF RESOURCES AT SCHOOL

(15) DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT

(16) OTHER [SKIP C4Q06_2_O]

(77) DON’T KNOW

(99) REFUSED

ALL EXCEPT 16 GO TO C4Q06_2C

c4q06_2_O

READ IF NECESSARY: Why did you or your family not get all the genetic counseling that was needed?

ENTER OTHER_______

C4Q06_2C

Did you or your family get any genetic counseling [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C4Q06_3

(During the past 12 months/ Since [his/her] birth, was there any time when you or other family members needed…)

Mental health care or counseling related to (SC)’s medical, behavioral, or other health conditions?

(1) YES

(2) NO [SKIP TO C3Q12]

(77) DON’T KNOW [SKIP TO C3Q12]

(99) REFUSED [SKIP TO C3Q12]

C4Q06_3A

Did you or your family receive all the mental health care counseling that was needed?

(1) Yes [SKIP TO C3Q12]

(2) NO

(77) DON’T KNOW [SKIP TO C3Q12]

(99) REFUSED [SKIP TO C3Q12]

C4Q06_3B

Why did you or your family not get all the mental health care or counseling that was needed? For each below:

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

(1) COST WAS TOO MUCH

(2) NO INSURANCE

(3) HEALTH PLAN PROBLEM

(4) CAN’T FIND DOCTOR WHO ACCEPTS CHILD’S INSURANCE

(5) NOT AVAILABLE IN AREA/TRANSPORT PROBLEMS

(6) NOT CONVENIENT TIMES/COULD NOT GET APPOINTMENT

(7) DOCTOR DID NOT KNOW HOW TO TREAT OR PROVIDE CARE

(8) DISSATISFACTION WITH DOCTOR

(9) DID NOT KNOW WHERE TO GO FOR TREATMENT

(10) CHILD REFUSED TO GO

(11) TREATMENT IS ONGOING

(13) NO REFERRAL

(14) LACK OF RESOURCES AT SCHOOL

(15) DID NOT GO TO APPT/NEGLECTED APPT/FORGOT APPT

(16) OTHER [SKIP C4Q06_3_O]

(77) DON’T KNOW

(99) REFUSED

ALL EXCEPT 16 GO TO C4Q06_3C

c4q06_3_O

READ IF NECESSARY: Why did you or your family not get all the mental health care or counseling that was needed? ENTER OTHER_______

C4Q06_3C

Did you or your family get any mental health care or counseling [during the past 12 months/ since [his/her] birth]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C3Q12 [IF AGE FROM C2Q01 OR C2Q02 IS 36 MONTHS (3 YEARS) OR GREATER, SKIP TO C3Q13]

Does [S.C.] receive services from a program called Early Intervention Services? Children receiving these services often have an Individualized Family Service Plan.

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

[ALL SKIP TO C3Q15]

READ IF NECESSARY: Early Intervention Services are defined as: family training, counseling, and home visits; health services; medicine; nursing; nutrition; occupational therapy; physical therapy; psychological services; service coordination services; social work services; special instruction; speech-language therapy; transportation, communication or mobility devices; and vision and hearing services.

C3Q13 Does [S.C.] receive services from a program called Special Educational Services? Children receiving these services often have an Individualized Education Plan.

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

READ IF NECESSARY: Special Education is any kind of special school, classes or tutoring.

C3Q15 Alternative health care includes acupuncture, chiropractic care, relaxation therapies, herbal supplements, and others. Some therapies involve seeing a practitioner, while others can be done on your own.

[During the past 12 months/ Since [his/her] birth], did [S.C.] use any type of alternative health care or treatment?

HELP SCREEN: RESPONDENTS SHOULD INCLUDE ANY ALTERNATIVE CARE OR THERAPIES REGARDLESS OF WHETHER THE CARE IS FOR THE CHILD'S CONDITIONS. IF THE RESPONDENT CONSIDERS THE HEALTH CARE TO BE ALTERNATIVE, IT SHOULD BE INCLUDED. DO NOT TRY TO DETERMINE IF ANY PARTICULAR TYPE OF TREATMENT IS AN "ALTERNATIVE" TREATMENT.

READ IF NECESSARY: Generally, alternative care and treatments are those not typically provided in conventional medical care settings. Examples of relaxation therapies include biofeedback, deep breathing exercises, and yoga. Examples of herbal supplements include any non-vitamin and non-mineral supplement, as well as homeopathic treatments. Other examples of alternative health care could include chelation therapy, energy healing therapy, hypnosis, massage, naturopathy, and use of traditional healers such as an espiritista or a Native American medicine man.

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

Section 5. CARE COORDINATION

[TIMESTAMP_SECTION51]

C5Q00 IF NONE C4Q05_1A THROUGH C4Q05_14A = 01 AND NONE C4Q05_1C THROUGH C4Q05_14C = 01 AND NONE C3Q12, C3Q13, OR C3Q15 = 01, SKIP TO C5Q01]

[IF ANY C4Q05_1A THROUGH C4Q05_14A = 01 OR ANY C4Q05_1C THROUGH C4Q05_14C = 01 OR ANY C3Q12, C3Q13, OR C3Q15 = 01, SAY:

“You told me that, [in the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] since [his/her] birth], [S.C.] used [FILL WITH ALL NAMES OF SERVICES USED AS REPORTED IN SECTION 4, INCLUDING C3Q12 AND C3Q13 AND C3Q15].”

[SUM UP HOW MANY TIMES THE RESPONSE (01) IS USED IN THE FOLLOWING VARIABLES: C4Q05_1A THROUGH C4Q05_14A, C4Q05_1C THROUGH C4Q05_14C, C3Q12, C3Q13, AND C3Q15. IF THE SUM IS GE 2 THEN SKIP TO C5Q11, ELSE SKIP TO C5Q01]

C5Q01 Did [S.C.] use any other health-related medical, educational, or social services [in the past 12 months/ [since [his/her] birth]?

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

READ IF NECESSARY: There are many types of services children might use to improve their education, their health, or their well-being. We listed 15 of these services earlier, but there could be others that your child uses.

C5Q11 (During the past 12 months/ Since [his/her] birth), did [S.C.] need a referral to see any doctors or receive any services?

(1) Yes

(2) NO [SKIP TO C5Q12]

(77) DON’T KNOW [SKIP TO C5Q12]

(99) REFUSED [SKIP TO C5Q12]

C4Q07 Was getting referrals a big problem, a small problem, or not a problem?

(1) Big problem

(2) Small problem

(3) Not a problem

(77) DON’T KNOW

(99) REFUSED

[TIMESTAMP_SECTION52]

C5Q12 [SUM UP HOW MANY TIMES THE RESPONSE (01) IS USED IN THE FOLLOWING

VARIABLES: C4Q05_1A THROUGH C4Q05_14A, C4Q05_1C THROUGH C4Q05_14C, C5Q01, C3Q12, C3Q13, AND C3Q15. IF THE SUM IS LT 2 AND C4Q05_2AA is (missing,0,1,77,99) THEN SKIP TO C6Q01]

Does anyone help you arrange or coordinate [S.C.]’s care among the different doctors or services that [he/she] uses?

READ IF NECESSARY: By “arrange or coordinate,” I mean: Is there anyone who helps you make sure that [S.C.] gets all the health care and services [he/she] needs, that health care providers share information, and that these services fit together and are paid for in a way that works for you?

READ IF NECESSARY: Anyone means anyone.

(1) Yes

(2) NO [SKIP TO C5Q17]

(77) DON’T KNOW [SKIP TO C5Q17]

(99) REFUSED [SKIP TO C5Q17]

C5Q13 Does a doctor or someone in a doctor’s office provide this help arranging or coordinating [S.C.]’s care?

(1) Yes [SKIP TO C5Q15]

(2) NO

(77) DON’T KNOW

(99) REFUSED

C5Q14 Who does provide help arranging or coordinating [S.C.]’s care? A parent, guardian, other family member, friend, nurse, therapist, social worker, hospital discharge planner, case manager, or someone else? [MARK ALL THAT APPLY]

C5Q14X01 PARENT

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q14X02 GUARDIAN

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q14X03 OTHER FAMILY MEMBER

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q14X04 FRIEND

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q14X05 NURSE

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q14X06 THERAPIST

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q14X07 SOCIAL WORKER

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q14X08 HOSPITAL DISCHARGE PLANNER

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q14X09 CASE MANAGER

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q14X10 SOMEONE ELSE [SKIP to C5Q14_XOE]

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

[SKIP TO C5Q17]

C5Q14_XOE Who would that be?

ENTER RESPONSE ___________________ [30 CHARACTERS MAX]

[SKIP TO C5Q17]

C5Q15 Is there anyone else who helps arrange or coordinate [S.C.]’s care?

(1) Yes

(2) NO [SKIP TO C5Q17]

(77) DON’T KNOW [SKIP TO C5Q17]

(99) REFUSED [SKIP TO C5Q17]

C5Q16 IF C5Q13=01 THEN DISPLAY: Is this person a parent, guardian, other family member, friend, nurse, therapist, social worker, hospital discharge planner, case manager, or someone else?

IF C5Q13=02,77,99 THEN DISPLAY:

Who does provide help arranging or coordinating [S.C.]’s care?

A parent, guardian, other family member, friend, nurse, therapist, social worker, hospital discharge planner, case manager, or someone else? [MARK ALL THAT APPLY]

C5Q16X01 PARENT

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q16X02 GUARDIAN

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q16X03 OTHER FAMILY MEMBER

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q16X04 FRIEND

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q16X05 NURSE

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q16X06 THERAPIST

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q16X07 SOCIAL WORKER

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q16X08 HOSPITAL DISCHARGE PLANNER

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q16X09 CASE MANAGER

YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q16X10 SOMEONE AT CHILD’S SCHOOL

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q16X11 SOMEONE ELSE [SKIP to C5Q16_XOE]

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C5Q16_XOE Who would that be?

ENTER RESPONSE ___________________ [30 CHARACTERS MAX]

C5Q17 (During the past 12 months/ Since [his/her] birth), have you felt that you could have used extra help arranging or coordinating [S.C.]’s care among these different health care providers or services?

(1) Yes

(2) NO [SKIP TO C5Q10]

(77) DON’T KNOW [SKIP TO C5Q10]

(99) REFUSED [SKIP TO C5Q10]

C5Q09 (During the past 12 months/ Since [his/her] birth), how often did you get as much help as you wanted with arranging or coordinating [S.C.]’s care? Would you say never, sometimes, or usually?

(1) Never

(2) Sometimes

(3) Usually

(77) Don’t know

(99) Refused

C5Q10 Overall, are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied with the communication among [S.C.]’s doctors and other health care providers?

(1)Very satisfied

(2) Somewhat satisfied

(3) Somewhat dissatisfied

(4) Very dissatisfied

(5) NO COMMUNICATION NEEDED OR WANTED

(77) DON’T KNOW

(99) REFUSED

C5Q05 Do [S.C.]’s doctors or other health care providers need to communicate with [his/her] school, early intervention program, child care providers, vocational education or rehabilitation program?

(1) YES

(2) NO [SKIP TO CPC5Q20]

(77) DON’T KNOW [SKIP TO CPC5Q20]

(99) REFUSED [SKIP TO CPC5Q20]

C5Q06 Overall, are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied with that communication?

(1) Very satisfied

(2) Somewhat satisfied

(3) Somewhat dissatisfied

(4) Very dissatisfied

(77) DON’T KNOW

(99) REFUSED

[TIMESTAMP_SECTION52A]

CPC5Q20 IF CWTYPE=S AND ASK_CALIF=1 THEN GO TO C5Q20, ELSE GO TO C6Q01

C5Q20 If there were a web site that could help you arrange or coordinate [S.C.]'s care, would you say that it is very likely, somewhat likely, somewhat unlikely, or very unlikely that you would use it?

(1) VERY LIKELY

(2) SOMEWHAT LIKELY

(3) SOMEWHAT UNLIKELY

(4) VERY UNLIKELY

(77) DON’T KNOW

(99) REFUSED

Section 6A. FAMILY CENTERED CARE AND SHARED DECISION MAKING

[TIMESTAMP_SECTION61]

C6Q01 [SUM UP HOW MANY TIMES THE RESPONSE (1) IS USED IN THE FOLLOWING VARIABLES: C4Q05_1 A THROUGH C4Q05_10A, C4Q05_1C THROUGH C4Q05_10C. IF THE SUM IS GREATER THAN ZERO, THEN SKIP TO C6Q02]

Did [S.C.] visit any doctors or other health care providers [in the past 12 months/ since [his/her] birth]?

(1) YES [SKIP TO C6Q02]

(2) NO [SKIP TO C6Q07]

(77) DON’T KNOW [SKIP TO C6Q07]

(99) REFUSED [SKIP TO C6Q07]

C6Q02 (During the past 12 months/ Since [his/her] birth), how often did [S.C.]’s doctors and other health care providers spend enough time with [him/her]? Would you say never, sometimes, usually, or always?

(1) Never

(2) Sometimes

(3) Usually

(4) Always

(77) DON’T KNOW

(99) REFUSED

C6Q03 (During the past 12 months/ Since [his/her] birth), how often did [S.C.]’s doctors and other health care providers listen carefully to you? Would you say never, sometimes, usually, or always?

(1) Never

(2) Sometimes

(3) Usually

(4) Always

(77) DON’T KNOW

(99) REFUSED

C6Q04 When [S.C.] is seen by doctors or other health care providers, how often are they sensitive to your family’s values and customs? Would you say never, sometimes, usually, or always?

(1) Never

(2) Sometimes

(3) Usually

(4) Always

(77) DON’T KNOW

(99) REFUSED

C6Q05 Information about a child’s health or health care can include things such as the causes of any health problems, how to care for a child now, and what changes to expect in the future. [In the past 12 months/ Since [his/her] birth], how often did you get the specific information you needed from [S.C.]’s doctors and other health care providers? Would you say never, sometimes, usually, or always?

(1) Never

(2) Sometimes

(3) Usually

(4) Always

(77) DON’T KNOW

(99) REFUSED

C6Q06 (During the past 12 months/ Since [his/her] birth), how often did [S.C.]’s doctors or other health care providers help you feel like a partner in [his/her] care? Would you say never, sometimes, usually, or always?

(1) Never

(2) Sometimes

(3) Usually

(4) Always

(77) DON’T KNOW

(99) REFUSED

[TIMESTAMP_SECTION61A]

CPC6Q11 IF CWTYPE=S AND ASK_CALIF=1 THEN GO TO C6Q11, ELSE GO TO C6Q21

C6Q11 IF S.C. >36 MONTHS, FILL [or S.C.]. ELSE, DO NOT FILL.

An interpreter is someone who repeats what one person says in a language used by another person.

[During the past 12 months\Since [S.C.]’s birth], did you [or S.C.] need an interpreter to help speak with [his/her] doctors or other health care providers?

(1) YES

(2) NO [SKIP TO C6Q21]

(77) DON’T KNOW [SKIP TO C6Q21]

(99) REFUSED [SKIP TO C6Q21]

C6Q12 IF S.C. >36 MONTHS, FILL [or S.C.]. ELSE, DO NOT FILL.

When you [or S.C.] needed an interpreter, how often were you able to get someone other than a family member to help you speak with [his/her] doctors or other health care providers? Would you say never, sometimes, usually, or always?

(1) NEVER

(2) SOMETIMES

(3) USUALLY

(4) ALWAYS

(77) DON’T KNOW

(99) REFUSED

[TIMESTAMP_SECTION62]

C6Q21 We want to know about how you and [S.C.]’s doctors or other health care providers work together to make decisions about health care services and treatment for [him/her].

[During the past 12 months/ Since [his/her] birth], how often did [S.C.]’s doctors or other health care providers talk with you about the range of options to consider for [his/her] health care or treatment?

Would you say never, sometimes, usually, or always?

READ IF NECESSARY: The options may include things like whether or not to start, stop or change a medication, treatment or therapy; whether to have certain tests or procedures, see a specialist, consent for surgery, and so on.

(1) NEVER

(2) SOMETIMES

(3) USUALLY

(4) ALWAYS

(5) THERE WERE NO OPTIONS TO CONSIDER

(77) DON’T KNOW

(99) REFUSED

C6Q22 How often did they encourage you to ask questions or raise concerns?

READ IF NECESSARY: [During the past 12 months/ Since [his/her] birth], how often did [S.C.]’s doctors or other health care providers encourage you to ask questions or raise concerns? Would you say never, sometimes, usually, or always?

(1) NEVER

(2) SOMETIMES

(3) USUALLY

(4) ALWAYS

(77) DON’T KNOW

(99) REFUSED

C6Q23 How often did they make it easy for you to ask questions or raise concerns?

READ IF NECESSARY: [During the past 12 months/ Since [his/her] birth], how often did [S.C.]’s doctors or other health care providers make it easy for you to ask questions or raise concerns? Would you say never, sometimes, usually, or always?

(1) Never

(2) Sometimes

(3) Usually

(4) Always

(77) DON’T KNOW

(99) REFUSED

C6Q24 How often did they consider and respect what health care and treatment choices you thought would work best for [S.C.]?

READ IF NECESSARY: [During the past 12 months/ Since [his/her] birth], how often did [S.C.]’s doctors or other health care providers consider and respect what health care and treatment choices you thought would work best for [him/her]? Would you say never, sometimes, usually, or always?

(1) Never

(2) Sometimes

(3) Usually

(4) Always

(77) DON’T KNOW

(99) REFUSED

Section 6B. TRANSITION ISSUES

[TIMESTAMP_SECTION63]

C6Q07 [If child is less than 5 years of age, skip to C6Q30. If child is 5-11 years of age, skip to C6Q08]

The next questions are about preparing for [S.C.]’s health care needs as [he/she] becomes an adult. Do any of [S.C.]’s doctors or other health care providers treat only children?

(1) Yes

(2) NO [SKIP TO C6Q0A]

(77) DON’T KNOW [SKIP TO C6Q0A]

(99) REFUSED [SKIP TO C6Q0A]

C6Q0A_B Have they talked with you about having [S.C.] eventually see doctors or other health care providers who treat adults?

(1) Yes [SKIP TO C6Q0A]

(2) NO

(77) DON’T KNOW [SKIP TO C6Q0A]

(99) REFUSED [SKIP TO C6Q0A]

HELP SCREEN: THIS QUESTION REFERS TO DISCUSSIONS BETWEEN THE RESPONDENT AND THE DOCTORS OR OTHER HEALTH CARE PROVIDERS WHO TREAT ONLY CHILDREN.

C6Q0A_C Would a discussion about doctors who treat adults have been helpful to you?

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

C6Q0A Have [S.C.]’s doctors or other health care providers talked with you about [his/her] health care needs as [he/she] becomes an adult?

(1) Yes [SKIP TO C6Q0A_E]

(2) NO

(77) DON’T KNOW [SKIP TO C6Q0A_E]

(99) REFUSED [SKIP TO C6Q0A_E]

C6Q0A_D Would a discussion about [S.C.]’s health care needs have been helpful?

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

C6Q0A_E Eligibility for health insurance often changes as children reach adulthood. Has anyone discussed with you how to obtain or keep some type of health insurance coverage as [S.C.] becomes an adult?

(1) Yes [SKIP TO C6Q08]

(2) NO

(77) DON’T KNOW [SKIP TO C6Q08]

(99) REFUSED [SKIP TO C6Q08]

HELP SCREEN: Anyone means anyone.

C6Q0A_F Would a discussion about health insurance have been helpful to you?

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

C6Q08 How often do [S.C.]’s doctors or other health care providers encourage [him/her] to take responsibility for [his/her] health care needs, such as:

IF SAMPLE_USE_CODE = 3 AND CWTYPE = N, THEN:

[If child is 5-11 years of age, THEN READ: “learning about [his/her] health or helping with treatments and medications?”

[If child is 12+ years of age, THEN READ: “taking medication, understanding [his/her] health, or following medical advice?”

ELSE:

[If child is 5-11 years of age, THEN READ: “learning about [his/her] conditions or helping with treatments and medications?”

[If child is 12+ years of age, THEN READ: “taking medication, understanding [his/her] diagnosis, or following medical advice?”

Would you say never, sometimes, usually, or always?

(1) Never

(2) Sometimes

(3) Usually

(4) Always

(77) DON’T KNOW

(99) REFUSED

Section 6C. DEVELOPMENTAL SCREENING

[TIMESTAMP_SECTION64]

CPC6Q30 IF AGE >= 48 MONTHS, SKIP TO CPSEC7. IF AGE < 12 MONTHS, SKIP TO CPSEC7.

C6Q30 Sometimes a child’s doctor or other health care provider will ask a parent to fill out a questionnaire at home or during their child’s visit. During the past 12 months, did a doctor or other health care provider have you fill out a questionnaire about specific concerns or observations you may have about [S.C.]’s development, communication, or social behaviors?

(1) YES

(2) NO [SKIP TO CPSEC7]

(77) DON’T KNOW [SKIP TO CPSEC7]

(99) REFUSED [SKIP TO CPSEC7]

HELP SCREEN (C6Q30): IF ANOTHER PERSON READ THE QUESTIONNAIRE TO THE PARENT AND FILLED IN THE ANSWERS FOR THE PARENT, THEN THIS QUESTION SHOULD BE ANSWERED YES. BUT IF A DOCTOR OR NURSE JUST ASKED ABOUT CONCERNS AND DID NOT FILL OUT A QUESTIONNAIRE, THEN THIS QUESTION SHOULD BE ANSWERED NO.

CPC6Q31A IF AGE = 24-47 MONTHS, SKIP TO C6Q32A.

C6Q31A Did this questionnaire ask about your concerns or observations about how [S.C.] talks or makes speech sounds?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C6Q31B Did this questionnaire ask about your concerns or observations about how [S.C.] interacts with you and others?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

[ALL SKIP TO CPSEC7]

C6Q32A Did this questionnaire ask about your concerns or observations about words and phrases [S.C.] uses and understands?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C6Q32B Did this questionnaire ask about your concerns or observations about how [S.C.] behaves and gets along with you and others?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

Section 7. HEALTH INSURANCE

[TIMESTAMP_SECTION71]

CPSEC7 [SKIP TO C7Q03 IF NAME OF SELECTED CHILD ALREADY GATHERED FROM MULTIAGE, C2Q01N, SELECTION1_NAME, NAME_SEC4_A, NIS INTERVIEW, OR RESPONDENT REFUSED TO ANSWER NAME QUESTIONS]

NAME_SEC7 INTERVIEWER QUESTION: DO NOT READ TO RESPONDENT!

HAS THE HOUSEHOLD GIVEN YOU A NAME FOR THE CHILD?

(1) YES [GO TO NAME_SEC7_A]
(2) NO [GO TO C7Q03]

NAME_SEC7_A

ENTER NAME/INITIALS: ____________ GO TO C7Q03

[FILL [S.C.] WITH THIS NAME FROM THIS POINT ON IN THE INTERVIEW]

C7Q03 Now I have a few questions about health insurance and health care coverage for [S.C.].

[IF IAP = 095 and (S.C. = NIS-ELIG CHILD OR S.C.=S.T.) THEN DISPLAY: "They may sound similar to questions I have asked previously, but they are slightly different. Please bear with me."]

At this time, is [S.C.] covered by health insurance that is provided through an employer or union?

(1) Yes

(2) NO [skip to c7q01]

(77) DON’T KNOW [skip to c7q01]

(99) REFUSED [skip to c7q01]

READ ONLY IF NECESSARY: These plans may be provided in art or fully by a current employer, a former employer, a union, or a professional organization.

IF ONLY PLAN NAME OFFERED, PROBE (READ IF NECESSARY): Is this insurance provided through an employer or union? Do not include dental, vision, school, or accident insurance.

IF NECESSARY, TO HELP THE RESPONDENT DETERMINE WHAT KIND OF INSURANCE THEY HAVE, PROBE (READ IF NECESSARY): Did you get that insurance through an employer? Does it help pay for both doctor visits and hospital stays?

C7Q03A [IF IAP not equal 095 and INS-1 = 1 AND S.C. = ‘NIS-ELIG CHILD’, THEN FILL WITH INS-1A]

IF IAP not equal 095 and SC=ST then FILL WITH TIS_INS_1A

Does this health insurance help pay for both doctor visits and hospital stays?

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

C7Q01 [IF STATE = AK, CT, DC, FL, HI, IL, IN, KS, LA, ME, MN, MO, NE, NJ, NM, NY, OH, OK, RI, SC, SD, VI, WI, THEN SKIP TO C7Q04]

[IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD,’ THEN FILL WITH INS-2]

IF IAP not equal 095 and SC=ST then FILL WITH TIS_INS_2

At this time, is [S.C.] covered by any Medicaid plan? Medicaid is a health insurance program for persons with certain income levels and persons with disabilities. [FILL IF APPLICABLE: In this state, the program is sometimes called [FILL NAME FROM “TEXT FILLS” SPREADSHEET].

READ IF NECESSARY: Medicaid is a federal-state medical assistance program. It serves low-income people of every age. Medical bills are paid from federal, state and local tax funds. It is run by state and local governments within federal guidelines.

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

C7Q02 [IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD,’ THEN FILL WITH INS-3]

IF IAP not equal 095 and SC=ST then FILL WITH TIS_INS_3

At this time, is [S.C.] covered by the State Children’s Health Insurance Program or S-CHIP? In this state, the program is sometimes called [FILL NAME FROM “TEXT FILLS” SPREADSHEET].

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

READ IF NECESSARY: The State Children's Health Insurance Program (SCHIP), created under Title XXI of the Social Security Act, expands health coverage to uninsured children whose families earn too much for Medicaid but too little to afford private coverage.

[ALL SKIP TO C7Q05]

C7Q04 [IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD,’ THEN FILL WITH INS-3A]

IF IAP not equal 095 and SC=ST then FILL WITH TIS_INS_3A

At this time, is [S.C.] covered by any Medicaid plan or the State Children’s Health Insurance Program, which are health insurance programs for persons with certain income levels and persons with disabilities? In this state, it is sometimes called [FILL NAME FROM “TEXT FILLS” SPREADSHEET].

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

READ IF NECESSARY: Medicaid and SCHIP are federal-state medical assistance programs. They serve low-income people of every age. Medical bills are paid from federal, state and local tax funds. Patients usually pay little or no part of costs for covered medical expenses. These programs are run by state and local governments within federal guidelines.

C7Q05 [IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD,’ THEN FILL WITH INS-5]

IF IAP not equal 095 and SC=ST then FILL WITH TIS_INS_5

At this time, is [S.C.] covered by military health care, TRICARE, CHAMPUS, OR CHAMP-VA?

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

READ IF NECESSARY: CHAMPUS, CHAMP-VA, and TRICARE are health care plans that are offered to persons in the military (and their dependents). TRICARE is a managed health care program for active duty and retired members of the uniformed services, their families, and survivors. CHAMPUS is a program of medical care for dependents of active or retired military personnel. CHAMP-VA is medical insurance for dependents or survivors of disabled veterans..

C7Q07 [IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD,’ THEN FILL WITH INS-6 AND USE CSHCN LOGIC]

IF IAP not equal 095 and SC=ST then FILL WITH TIS_INS_6

IF C7Q01, C7Q02, C7Q03, C7Q04, OR C7Q05 = 01, THEN SHOW: “Besides what you have already told me about,”

Is [S.C.] covered by any other health insurance or health care plan?

INTERVIEWER INSTRUCTION: IF RESPONDENT REPORTS DENTAL, VISION, SCHOOL, OR ACCIDENT INSURANCE, MARK NO

(1) Yes

(2) NO [Skip to c7q09]

(77) DON’T KNOW [Skip to c7q09]

(99) REFUSED [Skip to c7q09]

C7Q08A [IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD,’ THEN FILL WITH INS-6A AND USE CSHCN LOGIC]

IF IAP not equal 095 and SC=ST then FILL WITH TIS_INS_6A

Does this health insurance help pay for both doctor visits and hospital stays?

(1) Yes

(2) NO [Skip to c7q09]

(77) DON’T KNOW [Skip to c7q09]

(99) REFUSED [Skip to c7q09]

C7Q08B [IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD,’ THEN FILL WITH INS-6B AND USE CSHCN LOGIC]

IF IAP not equal 095 and SC=ST then FILL WITH TIS_INS_6B

Is this health insurance provided through an employer or union?

(1) Yes [SKIP TO C7Q11]

(2) NO

(77) DON’T KNOW

(99) REFUSED

C7Q08C [IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD,’ THEN FILL WITH INS-6C]

IF IAP not equal 095 and SC=ST then FILL WITH TIS_INS_6C

Is this health insurance purchased directly from an insurance company?

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

C7Q09 (IF C7Q01, C7Q02, C7Q03A, C7Q04, C7Q05, OR C7Q08A = 01, SKIP TO C7Q11; ELSE IF ( (S.C. = ‘NIS-ELIG CHILD’ AND INS-4 = 1) OR (S.C. = S.T. AND TIS_INS_4 = 1) ), THEN GO TO C7Q10; ELSE ASK C7Q09)

[IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD,’ THEN FILL WITH INS-7]

IF IAP not equal 095 and SC=ST then FILL WITH TIS_INS_7

It appears that [S.C.] does not have any health insurance coverage to pay for both hospitals and doctors and other health professionals. Is that correct?

(1) Yes [Skip to c7q13]

(2) NO

(77) DON’T KNOW [Skip to C9Q01]

(99) REFUSED [Skip to C9Q01]

C7Q10 [IF IAP not equal 095 and ( (S.C. = ‘NIS-ELIG CHILD’ AND INS-4 = 1) OR (S.C. = S.T. AND TIS_INS_4 = 1) ), THEN FILL “Now I have a few questions about health insurance and health care coverage for [S.C.]. Earlier you told me that [S.C.] is covered by Indian Health Service. Does [S.C.] have any other kind of health coverage?”/

ELSE FILL “At this time, what kind of health coverage does [S.C.] have? Any other kind?”

INTERVIEWER INSTRUCTION: MARK ALL THAT APPLY. MARK SINGLE SERVICE PLAN ONLY IF VOLUNTEERED AS TYPE OF HEALTH INSURANCE.

IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD,’ AND INS-7A NE MISSING, THEN FILL WITH INS-7A

IF IAP not equal 095 and S.C. = S.T. AND TIS_INS_7A NE MISSING, THEN FILL WITH TIS_INS_7A

[CATI INSTRUCTIONS: IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD’ AND INS-4 = 1, THEN PRE-FILL C7Q10 = 6]

[CATI INSTRUCTIONS: IF IAP not equal 095 and S.C. = S.T. AND TIS_INS_4 = 1, THEN PRE-FILL C7Q10 = 6]

IF ONLY (8) IS SELECTED, SKIP TO C7Q13

C7Q10X01 Medicaid [state Name]

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q10X02 Medicare (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q10X04 SCHIP [state name]

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q10X05 Medigap (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q10X06 Military (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q10X07 INDIAN HEALTH SERVICE

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q10X08 Private INSURANCE

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q10X09 Single service plan (dental, vision, prescriptions, etc)

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q10X10 Other (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q10B [IF IAP not equal 095 and S.C. = 'NIS-ELIG CHILD,' AND INS-7A-1, INS-7A-3, INS-7A-5, OR INS-7A-6 = 1, THEN FILL C7Q10B = 1.

IF IAP not equal 095 and S.C. = 'NIS-ELIG CHILD,' INS-7A-2, INS-7A-4, INS-7A-7 OR INS-7A-9 = 1, THEN FILL WITH INS-7B.]

[IF IAP not equal 095 and S.C. = S.T., AND TIS_INS_7A-1, TIS_INS_7A-3, TIS_INS_7A-5, OR TIS_INS_7A-6 = 1, THEN FILL C7Q10B = 1.

IF IAP not equal 095 and S.C. = S.T., AND TIS_INS_7A-2, TIS_INS_7A-4, TIS_INS_7A-7 OR TIS_INS_7A-9 = 1, THEN FILL WITH TIS_INS_7B.]

Does this health insurance help pay for both doctor visits and hospital stays?

(1) Yes

(2) NO [skip to c7q13]

(77) DON’T KNOW [skip to c9q01]

(99) REFUSED [skip to c9q01]

C7Q11 IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD,’ AND INS-11 = 1, THEN DISPLAY “Earlier you told me that since [S.C.]’s birth there was a time when [he/she] was not covered by any health insurance. DURING THE PAST 12 MONTHS, was there any time when [S.C.] was not covered by any health insurance?” /

ELSE DISPLAY:

IF IAP not equal 095 and S.C. = S.T. AND TIS_INS_11 = 1, THEN DISPLAY “Earlier you told me that since [S.C.] was 11 years old there was a time when [he/she] was not covered by any health insurance. DURING THE PAST 12 MONTHS, was there any time when [S.C.] was not covered by any health insurance?” /

ELSE DISPLAY:

During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS: Since [his/her] birth], was there any time when [S.C.] was not covered by ANY health insurance?

(1) YES

(2) NO [SKIP TO C8Q01_A]

[DISPLAY RESPONSE (03) IF (S.C. = ‘NIS-ELIG CHILD’ AND INS-11 =1) OR (S.C. = S.T. AND TIS_INS_11=1)]

(3) CHILD ALWAYS COVERED BY INSURANCE [SKIP TO C8Q01_A]

(77) DON’T KNOW [SKIP TO C8Q01_A]

(99) REFUSED [SKIP TO C8Q01_A]

IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD’ AND INS-11 = 2, 77, 99, THEN FILL 2, 77, 99 AND USE CURRENT LOGIC

IF IAP not equal 095 and S.C. = S.T. AND TIS_INS_11 = 2, 77, 99, THEN FILL 2, 77, 99 AND USE CURRENT LOGIC

C7Q12 [IF S.C. = ‘NIS-ELIG CHILD,’ AND C7Q11 = 1 AND IF INS-8 = 1, THEN FILL WITH ‘12’]

During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since [his/her] birth, about how many months was [S.C.] without any health insurance or coverage?

[IF LESS THAN ONE MONTH, ROUND UP TO ONE MONTH,

IF VALUE LT CWAGE, DISPLAY WARNING: ‘TIME WITHOUT INSURANCE CAN’T BE GREATER THAN CHILD’S AGE’]

RANGE 01-12, 77, 99

[CATI: 02 NUMERIC-CHARACTER-FIELD, RANGE 01-12, 7, 9]

_____ _____ MONTHS

(77) DON’T KNOW

(99) REFUSED

[IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD,’ AND C7Q11 = 1 AND IF INS-8 = 1, THEN FILL WITH ‘12’]

[IF IAP not equal 095 and S.C. = S.T, AND C7Q11 = 1 AND IF TIS_INS_8 = 1, THEN FILL WITH ‘12’]

[All skip to c8q01_a]

C7Q13 [IF IAP not equal 095 and ( (S.C. = ‘NIS-ELIG CHILD’ AND INS-8 = 2, 77, 99) OR (S.C. = S.T. AND TIS_INS_8 = 1, 2, 77, 99) ) THEN DISPLAY: “Earlier you told me that [S.C.] is not covered by health insurance that pays for all types of care.”]

IF C7Q10X08 = 1 OR C7Q10B = 2, THEN SAY: About how long has it been since [S.C.] last had health coverage that helps pay for all types of care?]

[ELSE, READ: About how long has it been since [S.C.] last had health coverage?]

[IF (C7Q13 GE 2 AND CWAGE LT 6) OR (C7Q13 GE 3 AND CWAGE LT 12) OR (C7Q13 GE 4 AND CWAGE LT 36) OR (CWAGE=6 and (02) CHOSEN), DISPLAY WARNING: ‘TIME WITHOUT INSURANCE CAN’T BE GREATER THAN CHILD’S AGE’]

(1) 6 MONTHS OR LESS

(2) MORE THAN 6 MONTHS, BUT NOT MORE THAN 01 YEAR AGO

(3) MORE THAN 1 YEAR, BUT NOT MORE THAN 3 YEARS AGO [GO TO C9Q01]

(4) MORE THAN 3 YEARS [GO TO C9Q01]

(5) NEVER [GO TO C9Q01]

[DISPLAY RESPONSE (66) IF (S.C. = ‘NIS ELIG CHILD’ AND INS-8 = 2, 77, OR 99) OR (S.C. = S.T. AND TIS_INS_8= 1, 2, 77, 99)]

(66) CHILD IS COVERED BY INSURANCE (GO TO C7Q10 AND FOLLOW CSHCN LOGIC)

(77) DON’T KNOW [GO TO C9Q01]

(99) REFUSED [GO TO C9Q01]

IF IAP not equal 095 and S.C. = ‘NIS-ELIG CHILD,’ AND IF INS-8 = 1, THEN FILL C7Q13=5

C7Q14 (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since [his/her] birth), about how many months was [S.C.] without any health insurance or coverage?

[IF LESS THAN ONE MONTH, ROUND UP TO ONE MONTH

IF VALUE GT CWAGE, DISPLAY WARNING: ‘TIME WITHOUT INSURANCE CAN’T BE GREATER THAN CHILD’S AGE’]

RANGE 01-12, 77, 99

[CATI: 02 NUMERIC-CHARACTER-FIELD, RANGE 01-12, 6, 7]

_____ _____ MONTHS

(77) DON’T KNOW

(99) REFUSED

C7Q15 [IF S.C. AGE=0 MONTHS, THEN GO TO C9Q01]

[IF C7Q14=12, DK, OR REF, GO TO C9Q01]

[WHEN S.C. IS YOUNGER THAN 12 months, IF C7Q14=AGE OF S.C. IN MONTHS, GO TO C9Q01]

(During the (12 - C7Q14) / [IF S.C. IS YOUNGER THAN 12 MONTHS, During the (S.C. AGE IN MONTHS –C7Q14)] months) when [S.C.] DID have health coverage, what kind of health coverage did [S.C.] have?

[PROBE: Any other kind?]

C7Q15X01Medicaid [STATE NAME] (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q15X02 Medicare (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q15X04 SCHIP [State name] (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q15X05 Medigap (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q15X06 Military (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q15X07 INDIAN HEALTH SERVICE (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q15X08 Private INSURANCE (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q15X09 Single service plan (dental, vision, prescriptions, etc.)

(1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q15X10 Other [SKIP TO C7Q15A] (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C7Q15A ENTER OTHER______ [CATI: 255 CHARACTER-FIELD]

IF ONLY (8) IS SELECTED, SKIP TO C9Q01

C7Q15b Did this health insurance help pay for both doctor visits and hospital stays?

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

[ALL SKIP TO C9Q01]

Section 8. ADEQUACY OF HEALTH CARE COVERAGE

[TIMESTAMP_SECTION81]

C8Q01_A The next questions are about [S.C.]’s health insurance or health care plans. Does [S.C.]’s health insurance offer benefits or cover services that meet [his/her] needs? Would you say:

(1) NEVER

(2) SOMETIMES

(3) USUALLY

(4) ALWAYS

(77) DON’T KNOW

(99) REFUSED

C8Q01_B Are the costs not covered by [S.C.]’s health insurance reasonable?

Would you say:

(1) NEVER

(2) SOMETIMES

(3) USUALLY

(4) ALWAYS

(5) NO OUT OF POCKET COSTS

(77) DON’T KNOW

(99) REFUSED

IF THE PARENT SEEMS CONFUSED BY HOW TO ANSWER, ASK: Do you have any out-of-pocket costs for your child's health care?

IF YES, THEN ASK: Are those costs reasonable?

C8Q01_C Does [S.C.]’s health insurance allow [him/her] to see the health care providers [he/she] needs?

Would you say:

(1) NEVER

(2) SOMETIMES

(3) USUALLY

(4) ALWAYS

(77) DON’T KNOW

(99) REFUSED

Section 9. IMPACT ON THE FAMILY

[TIMESTAMP_SECTION91]

C9Q01 The next question is about the amount of money paid (during the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] since [his/her] birth) for [S.C.]’s medical care. Please do not include health insurance premiums or costs that were or will be reimbursed by insurance or another source. But do include out-of-pocket payments for all types of health-related needs such as co-payments, dental or vision care, medications, special foods, adaptive clothing, durable equipment, home modifications, and any kind of therapy. (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since [his/her] birth), would you say that the family paid more than $500, $250-$500, less than $250, or nothing for [S.C.]’s medical care?

(1) MORE THAN $500

(2) $250-$500 [SKIP TO C9Q02]

(3) LESS THAN $250 [SKIP TO C9Q02]

(4) NOTHING, $0 [SKIP TO C9Q02]

(77) DON’T KNOW [SKIP TO C9Q02]

(99) REFUSED [SKIP TO C9Q02]

Help Screen: Respondent may give a range as an answer to this question. Be prepared to probe for a more accurate answer.

C9Q01_A (During the past 12 months/ [WHEN S.C. IS YOUNGER THAN 12 MONTHS] Since [his/her] birth), would you say that the family paid more than $5000, $1000 to $5000, or less than $1000 for [S.C.]’s medical care?

(1) MORE THAN $5000

(2) $1000-$5000

(3) LESS THAN $1000

(77) DON’T KNOW

(99) REFUSED

C9Q02 Many families provide health care at home such as changing bandages, care of feeding or breathing equipment, and giving medication and therapies.

Do you or other family members provide health care at home for [S.C.]?

READ IF NECESSARY: Please base your answer on the last several weeks.

READ IF NECESSARY: Only include care related to the child’s condition.

(1) Yes

(2) NO [Skip to c9q04]

(77) DON’T KNOW [Skip to c9q04]

(99) REFUSED [Skip to c9q04]

C9Q03 How many hours per week do you or other family members spend providing this kind of care?

READ IF NECESSARY: It is fine to provide an average number of hours per week based on several weeks. Please give your best estimate.

READ IF NECESSARY: Only include care related to the child’s condition.

(CATI: 3 NUMERIC-CHARACTER-FIELD, RANGE 000-168, 777, 999)

_____ _____ HOURS PER WEEK

(000) LESS THAN ONE HOUR

(168) AROUND THE CLOCK

(777) DON’T KNOW

(999) REFUSED

[IF C9Q03 < 30 OR = 168, 777, 999, SKIP TO C9Q04]

C9Q03_A I have (ANSWER FROM C9Q03) hours. Is that correct?

(1) YES

(2) NO [SKIP BACK TO C9Q03]

C9Q04 How many hours per week do you or other family members spend arranging or coordinating [S.C.]’s care? By this I mean making appointments, making sure that care providers are exchanging information, and following up on [S.C.]’s care needs.

READ IF NECESSARY: It is fine to provide an average number of hours per week based on several weeks. Please give your best estimate.

[CATI: 3 NUMERIC-CHARACTER-FIELD, RANGE 000-168, 555, 777, 999]

_ _ _ HOURS PER WEEK

(000) NONE / LESS THAN ONE HOUR

(168) AROUND THE CLOCK

(777) DON'T KNOW

(999) REFUSED

[IF C9Q04 = 000 OR 555, OR IF C9Q04 < 30 or C9Q04 = 168, 777, 999, SKIP TO C9Q05]

C9Q04_A I have [ANSWER FROM C9Q04] hours. Is that correct?

(1) YES

(2) NO [SKIP BACK TO C9Q04]

C9Q05 Have [S.C.]’s health conditions caused financial problems for your family?

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

C9Q10 Have you or other family members stopped working because of [S.C.]’s health

conditions?

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

C9Q06 (IF C9Q10 = 01, THEN SHOW: Not including the family members who stopped working,)

Have you or other family members cut down on the hours you work because of [S.C.]’s health

conditions?

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

C9Q11 Have you or other family members avoided changing jobs because of concerns about maintaining health insurance for [S.C.]?

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

Section 10. DEMOGRAPHICS

[TIMESTAMP_SECTION101]

CPC10 IF CWTYPE = S, THEN SKIP TO C10Q01 ELSE GO TO C10START

C10START Next, I have some more general questions about you and your household. The rest of the survey will take about 5 minutes.

IF RESPONDENT IS CONCERNED ABOUT THE TIME ESTIMATE, READ ANY OF THE FOLLOWING:

We know your time is valuable, and we will get through the questions as quickly as possible.

Let’s get started and see how far we get. If you have to go, let me know.

(1) CONTINUE WITH INTERVIEW

C10Q01 [IF NIS IS DONE, FILL C10Q01 FROM NIS DATA C1, SKIP TO C10Q02A]

[IF CWTYPE = S, THEN DISPLAY: Now I have some questions about your household.]

Including the adults and all the children, how many people live in your household?

[CATI: 02 NUMERIC-CHARACTER FIELD, RANGE 01-30, 77, 99

VALUE MUST BE =/> S_UNDR18 + 1] [DISPLAY WARNING IF VALUE < S_UNDR18+1 -> “NUMBER OF PEOPLE IN THIS HOUSEHOLD CANNOT BE LESS THAN NUMBER OF KIDS + 1.”

_______ persons

(77) DON’T KNOW

(99) Refused

READ AS NECESSARY: Please include anyone who normally lives there even if they are not there now, like someone who is away traveling or in a hospital.

HELP SCREEN: EACH PERSON IN THE HOUSEHOLD MUST BE A CURRENT RESIDENT OF THE HOUSEHOLD. A CURRENT RESIDENCE IS DEFINED AS A PLACE WHERE THE PERSON IS STAYING FOR MORE THAN TWO MONTHS AT THE TIME OF THE SURVEY CONTACT. IF A PERSON HAS NO PLACE WHERE HE OR SHE USUALLY STAYS, THE PERSON SHOULD BE CONSIDERED A CURRENT RESIDENT REGARDLESS OF THE LENGTH OF THE CURRENT STAY.

PERSONS AWAY FROM THEIR RESIDENCE FOR TWO MONTHS OR LESS, WHETHER TRAVELING OR IN THE HOSPITAL, ARE CONSIDERED “IN RESIDENCE.”

PERSONS AWAY FROM THEIR RESIDENCE FOR MORE THAN TWO MONTHS ARE CONSIDERED “NOT IN RESIDENCE” UNLESS THE PERSON IS AWAY AT SCHOOL (I.E., BOARDING SCHOOL, MILITARY ACADEMY, PREP SCHOOL, ETC.).

CPC10Q02A IF CWTYPE = N, THEN SKIP TO C10Q14.

C10Q02A What is your relationship to [S.C.]?

IF R RESPONDS “Mother” or “Father,” YOU MUST PROBE:: Are you [S.C.]’s biological, step, foster, or adoptive mother/father?

IF R RESPONDS “Partner,” PROBE IF NOT SURE: Are you male or female?

PARENT

(01) BIOLOGICAL MOTHER (06) BIOLOGICAL FATHER

(02) STEP MOTHER (07) STEP FATHER

(03) FOSTER MOTHER (08) FOSTER FATHER

(04) ADOPTIVE MOTHER (09) ADOPTIVE FATHER

(05) MOTHER, but TYPE REFUSED (10) FATHER, but TYPE REFUSED

OLDER RELATIVES OR GUARDIANS

(11) GRANDMOTHER (14) UNCLE

(12) GRANDFATHER (15) FEMALE GUARDIAN

(13) AUNT (16) MALE GUARDIAN

OTHER RELATIVES

(17) SISTER (BIOLOGICAL, STEP, FOSTER, HALF, ADOPTIVE)

(18) BROTHER (BIOLOGICAL, STEP, FOSTER, HALF, ADOPTIVE)

(19) COUSIN

(20) IN-LAW OF ANY TYPE

(21) OTHER RELATIVE / FAMILY MEMBER

OTHER NON-RELATIVES

(22) PARENT’S BOYFRIEND / MALE PARTNER

(23) PARENT’S GIRLFRIEND / FEMALE PARTNER

(24) PARENT’S PARTNER, but SEX REFUSED

(25) OTHER NON-RELATIVE OR FRIEND

(77) DON’T KNOW

(99) REFUSED

C10Q02B CATI INSTRUCTION (C10Q02B): [IF C10Q01= 2, SKIP TO C10Q02C.]

IF C10Q01=77,99 THEN READ:
For the other people that live in your household with you and [S.C.], what is their relationship to [S.C.]?

IF C10Q01 NOT 77,99 THEN READ:
In addition to you and [S.C.], I have that [FILL: C10Q01 ? 2] (other person lives/other people live) in your household. What is their relationship to [S.C.]? [MARK ALL THAT APPLY]

IF R RESPONDS “Mother” or “Father,” YOU MUST PROBE: Is that [S.C.]’s biological, step, foster, or adoptive mother/father?

IF R RESPONDS “Partner,” PROBE: Is the partner male or female?

PARENT

(01) BIOLOGICAL MOTHER (06) BIOLOGICAL FATHER

(02) STEP MOTHER (07) STEP FATHER

(03) FOSTER MOTHER (08) FOSTER FATHER

(04) ADOPTIVE MOTHER (09) ADOPTIVE FATHER

(05) MOTHER, but TYPE REFUSED (10) FATHER, but TYPE REFUSED

OLDER RELATIVES OR GUARDIANS

(11) GRANDMOTHER (14) UNCLE

(12) GRANDFATHER (15) FEMALE GUARDIAN

(13) AUNT (16) MALE GUARDIAN

OTHER RELATIVES

(17) SISTER

(18) BROTHER

(19) COUSIN

(20) IN-LAW OF ANY TYPE

(21) [S.C.]’S CHILD, SON, OR DAUGHTER

(22) OTHER RELATIVE / FAMILY MEMBER

OTHER NON-RELATIVES

(23) PARENT’S BOYFRIEND / MALE PARTNER

(24) PARENT’S GIRLFRIEND / FEMALE PARTNER

(25) PARENT’S PARTNER, but SEX REFUSED

(26) OTHER NON-RELATIVE OR FRIEND

(77) DON’T KNOW

(99) REFUSED

IF C10Q02A = 1 and C10Q02B = 1, THEN DISPLAY WARNING TEXT.

IF C10Q02A = 6 and C10Q02B = 6, THEN DISPLAY WARNING TEXT.

C10Q02B_ [ASK IF NUMBER OF SELECTIONS IN C10Q02B IS DIFFERENT THAN (C10Q01 – 2) CONF OTHERWISE SKIP TO C10Q02C]

I have that...

[LIST OF FAMILY ROSTERED IN C10Q02]

live in this household with [S.C.].

(1) Confirm – this is correct [GO TO C10Q02B_WARNING]

(2) Not correct – return to relationship list [GO TO C10Q02B]

(3) Not correct – return to total number of people in household and start process again

[GO TO C10Q01]

CPC10Q02C IF ANY BIOLOGICAL MOTHER OR BIOLOGICAL FATHER IN HH [(C10Q02A = 1 OR C10Q02B = 1) OR (C10Q02A = 6 OR C10Q02B = 6)], SKIP TO C10Q03.

IF RESPONDENT IS ADOPTIVE MOTHER OR ADOPTIVE FATHER (C10Q02A = 4 or 9), SKIP TO C10Q03 ELSE, ASK C10Q02C.

C10Q02B_ Earlier you told me that there are [VALUE FROM C10Q01] people living in your household.

WARNING However, based on the relationships you just gave, I have [ ] people including you and [S.C.]. Am I missing anyone or have I miscounted?

(1) Counts incorrect – change needed [GO TO C10Q02B_CONF]

(2) Total people and relationships confirmed as correct [CONTINUE]

C10Q02C CATI INSTRUCTION (C10Q02C): IF ANY BIOLOGICAL MOTHER OR BIOLOGICAL FATHER IN HH [(C10Q02A = 1 OR C10Q02B = 1) OR (C10Q02A = 6 OR C10Q02B = 6)], SKIP TO C10Q03. IF RESPONDENT IS ADOPTIVE MOTHER OR ADOPTIVE FATHER (C10Q02A = 4 or 9), SKIP TO C10Q03.

ELSE, ASK C10Q02C

Have you legally adopted [S.C.]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C10Q03 IF C10Q02A = 01 OR 06 OR C10Q02B = 01 OR 06, SKIP TO CPC10Q10. ELSE, IF C10Q02A = 04 OR 09 OR C10Q02B = 04 OR 09 OR C10Q02C = 1, CONTINUE WITH C10Q03. ELSE, SKIP TO C10Q10.

The next questions will help us better understand the health needs of adopted children.

How old was [S.C.] when the adoption was finalized? By “finalized,” I mean when the court papers were signed that completed the adoption process.

HELP SCREEN: IF CHILD WAS LESS THAN 1 MONTH AT THE TIME OF ADOPTION, ENTER 0 MONTHS.

HELP SCREEN: ENTER AGE IN MONTHS FOR 0 TO 23 MONTHS. IF 2 YEARS OR OLDER, ENTER AGE IN YEARS.

___ ____ VALUE (MUST BE LESS THAN OR EQUAL TO AGE OF CHILD)

(55) ADOPTION NOT FINALIZED

(77) DON’T KNOW

(99) REFUSED

C10Q03A Months (00-23)

Years (Range 02-17)

(1) MONTHS

(2) YEARS

(77) DON'T KNOW

(99) REFUSED

C10Q04 Was [S.C.] adopted from another country?

IF RESPONDENT SEEMS UPSET BY THIS QUESTION, READ: We ask this question for all children with adoptive parents.

(1) YES [SKIP TO C10Q10]

(2) NO

(77) DON’T KNOW

(99) REFUSED

C10Q05 Prior to being adopted, was [S.C.] in the legal custody of a state or county child welfare agency in the United States? That is, was [S.C.] in the U.S. foster care system?

IF THE CHILD WAS ADOPTED THROUGH A PRIVATE AGENCY AND THE PRIVATE AGENCY WAS ACTING IN ASSOCIATION WITH OR IN COOPERATION WITH A STATE OR COUNTY WELFARE AGENCY, THEN THIS QUESTION SHOULD BE ANSWERED "YES."

IF A FOSTER PARENT ADOPTED ONE OF THEIR OWN FOSTER CHILDREN, THEN THIS QUESTION SHOULD BE ANSWERED "YES."

IF RESPONDENT SEEMS UPSET BY THIS QUESTION, READ: We ask this question for all children with adoptive parents.

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

CPC10Q10 IF HOUSEHOLD INCLUDES A MOTHER (C10Q02A = 1-5 OR C10Q02B = 1-5) AND A FATHER (C10Q02A = 6-10 OR C10Q02B = 6-10), ASK C10Q10. ELSE, SKIP TO C10Q11A.

C10Q10 CATI INSTRUCTION (C10Q10): IF THE RESPONDENT IS THE MOTHER (C10Q02A = 1-5), THEN READ: Are you and [S.C.]’s [FATHER TYPE] currently married, separated, divorced, or never married?

IF THE RESPONDENT IS THE FATHER (C10Q02A = 6-10), THEN READ: Are you and [S.C.]’s [MOTHER TYPE] currently married, separated, divorced, or never married?

IF THE RESPONDENT IS NEITHER THE MOTHER NOR THE FATHER, THEN READ: Are [S.C.]’s [MOTHER TYPE] and [FATHER TYPE] currently married, separated, divorced, or never married?

(1) MARRIED [SKIP TO C10Q14]

(2) SEPARATED [SKIP TO C10Q10A]

(3) DIVORCED [SKIP TO C10Q10A]

(4) NEVER MARRIED [SKIP TO C10Q10A]

(77) DON’T KNOW [SKIP TO C10Q10A]

(99) REFUSED [SKIP TO C10Q10A]

HELP SCREEN: THIS QUESTION ASKS ABOUT THE MARITAL STATUS OF THE CHILD’S PARENTS WHO LIVE IN THE HOUSEHOLD.

C10Q10A IF THE RESPONDENT IS THE MOTHER (C10Q02A = 1-5), THEN READ: Are you and [S.C.]’s [FATHER TYPE] currently living together as partners?

IF THE RESPONDENT IS THE FATHER (C10Q02A = 6-10), THEN READ: Are you and [S.C.]’s [MOTHER TYPE] currently living together as partners?

IF THE RESPONDENT IS NEITHER THE MOTHER NOR THE FATHER, THEN READ: Are [S.C.]’s [MOTHER TYPE] and [FATHER TYPE] currently living together as partners?

(1) YES [SKIP TO C10Q14]

(2) NO [SKIP TO C10Q14]

(77) DON'T KNOW [SKIP TO C10Q14]

(99) REFUSED [SKIP TO C10Q14]

CPC10Q11A IF HOUSEHOLD INCLUDES A MOTHER (C10Q02A = 1-5 OR C10Q02B = 1-5) BUT NOT A FATHER (C10Q02A <> 6-10 AND C10Q02B <> 6-10), ASK C10Q11A. ELSE, SKIP TO C10Q12A.

C10Q11A IF THE RESPONDENT IS THE MOTHER (C10Q02A = 1-5), THEN READ: Are you currently married, separated, divorced, widowed, or never married?

IF THE RESPONDENT IS NOT THE MOTHER, THEN READ: Is [S.C.]’s [MOTHER TYPE] currently married, separated, divorced, widowed, or never married?

(1) MARRIED

(2) SEPARATED [SKIP TO C10Q11C]

(3) DIVORCED [SKIP TO C10Q11C]

(4) WIDOWED [SKIP TO C10Q11C]

(5) NEVER MARRIED [SKIP TO C10Q11C]

(77) DON’T KNOW [SKIP TO C10Q11C]

(99) REFUSED [SKIP TO C10Q11C]

CPC10Q11B IF MOTHER TYPE IS FOSTER OR ADOPTIVE (C10Q02A = 3-4 OR C10Q02B = 3-4), THEN SKIP TO C10Q14.

C10Q11B CATI INSTRUCTION (C10Q11B): IF RESPONDENT IS THE MOTHER (C10Q02A = 1, 2, or 5), FILL “Are you”; ELSE FILL “Is [S.C.]’S [MOTHER TYPE]”.

(Are you / Is [S.C.]’s [MOTHER TYPE]) married to [S.C.]’s biological father?

(1) YES [SKIP TO C10Q14]

(2) NO [SKIP TO C10Q14]

(77) DON’T KNOW [SKIP TO C10Q14]

(99) REFUSED [SKIP TO C10Q14]

C10Q11C IF THE RESPONDENT IS THE MOTHER (C10Q02A = 1-5), THEN READ: Are you currently living with anyone as partners?

IF THE RESPONDENT IS NOT THE MOTHER, THEN READ: Is [S.C.]’s [MOTHER TYPE] currently living with anyone as partners?

(1) YES [SKIP TO C10Q14]

(2) NO [SKIP TO C10Q14]

(77) DON’T KNOW [SKIP TO C10Q14]

(99) REFUSED [SKIP TO C10Q14]

CPC10Q12A IF HOUSEHOLD INCLUDES A FATHER (C10Q02A = 6-10 OR C10Q02B = 6-10) BUT NOT A MOTHER (C10Q02A <> 6-10 OR C10Q02B <> 6-10), ASK C10Q12A. ELSE, SKIP TO C10Q13A.

C10Q12A CATI INSTRUCTION (C10Q12A): IF THE RESPONDENT IS THE FATHER (C10Q02A= 6-10), THEN READ: Are you currently married, separated, divorced, widowed, or never married?

IF THE RESPONDENT IS NOT THE FATHER, THEN READ: Is [S.C.]’s [FATHER TYPE] currently married, separated, divorced, widowed, or never married?

(1) MARRIED

(2) SEPARATED [SKIP TO C10Q12C]

(3) DIVORCED [SKIP TO C10Q12C]

(4) WIDOWED [SKIP TO C10Q12C]

(5) NEVER MARRIED [SKIP TO C10Q12C]

(77) DON’T KNOW [SKIP TO C10Q12C]

(99) REFUSED [SKIP TO C10Q12C]

CPC10Q12B IF FATHER TYPE IS FOSTER OR ADOPTIVE (C10Q02A = 8-9 OR C10Q02B = 8-9), THEN SKIP TO C10Q14.

C10Q12B CATI INSTRUCTION (C10Q12B): IF RESPONDENT IS THE FATHER (C10Q02A = 6, 7, or 10) FILL “Are you”; ELSE FILL “Is [S.C.]’s [FATHER TYPE]”.

(Are you / Is [S.C.]’s [FATHER TYPE]) married to [S.C.]’s biological mother?

(1) YES [SKIP TO C10Q14]

(2) NO [SKIP TO C10Q14]

(77) DON’T KNOW [SKIP TO C10Q14]

(99) REFUSED [SKIP TO C10Q14]

C10Q12C IF THE RESPONDENT IS THE FATHER (C10Q02A= 6-10), THEN READ: Are you currently living with anyone as partners?

IF THE RESPONDENT IS NOT THE FATHER, THEN READ: Is [S.C.]’s [FATHER TYPE] currently living with anyone as partners?

(1) YES [SKIP TO C10Q14]

(2) NO [SKIP TO C10Q14]

(77) DON’T KNOW [SKIP TO C10Q14]

(99) REFUSED [SKIP TO C10Q14]

C10Q13A Are you currently married, separated, divorced, widowed, or never married?

(1) MARRIED

(2) SEPARATED [SKIP TO C10Q13C]

(3) DIVORCED [SKIP TO C10Q13C]

(4) WIDOWED [SKIP TO C10Q13C]

(5) NEVER MARRIED [SKIP TO C10Q13C]

(77) DON’T KNOW [SKIP TO C10Q13C]

(99) REFUSED [SKIP TO C10Q13C]

C10Q13B Does your spouse currently live in the household with [S.C.]?

(1) YES [SKIP TO C10Q14]

(2) NO [SKIP TO C10Q14]

(77) DON’T KNOW [SKIP TO C10Q14]

(99) REFUSED [SKIP TO C10Q14]

C10Q13C Are you currently living with a partner?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

C10Q14 What is the age of the oldest adult living in the household?

____ YEARS

(777) DON’T KNOW

(999) REFUSED

SC_C10Q14 INTERVIEWER CHECK:

YOU ENTERED [FILL WITH ANSWER FROM C10Q14] YEARS OLD. IS THIS CORRECT?

(1) YES [GO TO CPC10Q20]

(2) NO [GO BACKTO C10Q14]

CPC10Q20 IF CWTYPE = N, THEN SKIP TO C10Q23.

IF C10Q02A = 1-5 OR C10Q02B = 1-5, ASK C10Q20. ELSE, SKIP TO C10Q21.

C10Q20 IF S.C. = NIS-ELIG CHILD AND (C10Q02A=1 OR C10Q02B=1), THEN FILL with NIS variable C6_06Q3_x as appropriate.

IF S.C. = S.T. AND (C10Q02A=1 OR C10Q02B=1), THEN FILL FROM TIS_C6

CATI INSTRUCTION (C10Q20): IF C10Q02A = 1-5, FILL “you have”. ELSE, FILL “[S.C.]’s [MOTHER TYPE] has”

What is the highest grade or year of school [you have / [S.C.]’s [MOTHER TYPE] has] completed?

(1) 8th GRADE OR LESS
(2) 9th-12th GRADE NO DIPLOMA
(3) HIGH SCHOOL GRADUATE OR GED COMPLETED
(4) COMPLETED A VOCATIONAL, TRADE, OR BUSINESS SCHOOL PROGRAM
(5) SOME COLLEGE CREDIT BUT NO DEGREE
(6) ASSOCIATE DEGREE (AA, AS)
(7) BACHELOR’S DEGREE (BA, BS, AB)
(8) MASTER’S DEGREE (MA, MS, MSW, MBA)
(9) DOCTORATE (PhD, EdD) or PROFESSIONAL DEGREE (MD, DDS, DVM, JD)

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN (C10Q20): AT THIS QUESTION, COLLECT INFORMATION ABOUT THE MOTHER (BIOLOGICAL, STEP, FOSTER, ADOPTIVE) LIVING IN THIS HOUSE.

CPC10Q21 IF C10Q02A = 6-10 OR C10Q02B = 6-10, ASK C10Q21. ELSE, SKIP TO C10Q22.

C10Q21 CATI INSTRUCTION (C10Q21): IF C10Q20 NOT BLANK AND C10Q02A = 6-10, ASK: “And how about you?”

READ AS NECESSARY: “What is the highest grade or year of school you have completed?”

IF C10Q20 NOT BLANK AND C10Q02A <> 6-10, ASK: “And how about [S.C.]’s [FATHER TYPE]?”

READ AS NECESSARY: “What is the highest grade or year of school [S.C.]’s [FATHER TYPE] has completed?”

IF C10Q20 IS BLANK AND C10Q02A = 6-10, ASK: “What is the highest grade or year of school you have completed?”

IF C10Q20 IS BLANK AND C10Q02A <> 6-10, ASK: “What is the highest grade or year of school [S.C.]’s [FATHER TYPE] has completed?”

IF C10Q20 FILLED FROM NIS AND C10Q02A = 6-10, ASK: "What is the highest grade or year of school you have completed?"

IF C10Q20 FILLED FROM NIS AND C10Q02A <> 6-10, ASK: "What is the highest grade or year of school [S.C.]'s [FATHER TYPE] has completed?"

HELP SCREEN: AT THIS QUESTION, COLLECT INFORMATION ABOUT THE FATHER (BIOLOGICAL, STEP, FOSTER, ADOPTIVE) LIVING IN THIS HOUSE.

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN (C10Q21): AT THIS QUESTION, COLLECT INFORMATION ABOUT THE FATHER (BIOLOGICAL, STEP, FOSTER, ADOPTIVE) LIVING IN THIS HOUSE.

CPC10Q22 IF C10Q02A <> 1-10, ASK C10Q22. ELSE SKIP TO ETH.

C10Q22 CATI INSTRUCTION (C10Q22): IF (C10Q20 IS NOT BLANK AND NOT FILLED FROM NIS OR TEEN) OR C10Q21 IS NOT BLANK, ASK: “And how about you?”

READ AS NECESSARY: “What is the highest grade or year of school you have completed?”

IF C10Q20 AND C10Q21 ARE BLANK, ASK: “What is the highest grade or year of school you have completed?”

HELP SCREEN: AT THIS QUESTION, COLLECT INFORMATION ABOUT THE [TEXTFILL: answer from C10Q02A (see TEXTFILL logic)] LIVING IN THIS HOUSE.

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN (C10Q22): AT THIS QUESTION, COLLECT INFORMATION ABOUT THE RESPONDENT.

CPC10Q23 IF CWTYPE = S, THEN SKIP TO ETH ELSE GO TO C10Q23

C10Q23 What is the highest level of school that any parent in the household has completed or the highest degree any parent in the household has received?

(77) DON’T KNOW

(99) REFUSED

HELP SCREEN (C10Q23): IF RESPONDENT INDICATES THAT NO PARENTS LIVE IN THE HOUSEHOLD, THEN ASK FOR THE HIGHEST LEVEL OF SCHOOL COMPLETED BY ANY ADULT IN THE HOUSEHOLD.

ETH If S_UNDR18 > 1 THEN DISPLAY: My next questions are about all of the children in your household.

Are any of the [S_UNDR18] children in your household of Hispanic or Latino origin?

IF S_UNDR18=1 THEN DISPLAY: Is [S.C./AGEID] of Hispanic or Latino origin?

(1) YES [IF S_UNDR18 > 1 GO TO ETH_B ]

(2) NO [GO TO C10Q32 _X]

(77) DON’T KNOW [GO TO C10Q32 _X]

(99) REFUSED [GO TO C10Q32 _X]

ETH_B Is that [PICKLIST CONSISTING OF CHILDREN LISTED AS IN AGEID]?

C10Q32_X DISPLAY ONLY FOR C10Q32 _1: Please choose one or more of the following categories to describe [FILL IN S.C./AGEID for Roster Position 1]’s race.

FIRST TIME THROUGH:

Is [FILL IN S.C./AGEID for Roster Position 1] White, Black or African American, American Indian, Alaska Native, Asian, Native Hawaiian, or other Pacific Islander?

SUBSEQUENT TIMES THROUGH:

And how about [FILL IN S.C./AGEID]?

[MARK ALL THAT APPLY]

C10Q32X01 WHITE/CAUCASIAN (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C10Q32X02 BLACK/

AFRICAN AMERICAN (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C10Q32X03 AMERICAN INDIAN (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C10Q32X04 ALASKA NATIVE (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C10Q32X05 ASIAN (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C10Q32X06 NATIVE HAWAIIAN (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C10Q32X07 PACIFIC ISLANDER (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

C10Q32X08 OTHER (SPECIFY) (1) YES (2) NO (77) DON’T KNOW (99) REFUSED

HELP SCREEN: Be sure to read the entire question as written (including all response categories).

Race information is collected by self-identification. It is “whatever race you consider yourself to be.” Do not try to explain or define any of the groups. Multiple races may be selected.

ASK FOR ALL CHILDREN IN THE HOUSEHOLD.

[IF C10Q32X08 = 1, ASK C10Q32A. ELSE SKIP TO C10Q40].

C10Q32A_X ENTER OTHER DESCENT

[CATI: ALL 2 TEXT BOXES FOR OTHER DESCENT - 50 ALPHANUMERIC CHARACTERS EACH]

C10Q40 What is the primary language spoken in your home?

[READ RESPONSES ONLY IF NECESSARY]

(1) English

(2) Spanish

(3) Any other language

(77) DON’T KNOW

(99) REFUSED

C10Q41 Do you own or rent your home?

HELP SCREEN: IF THE HOME IS OWNED OR BEING BOUGHT BY SOMEONE IN THE HOUSEHOLD, THE ANSWER SHOULD BE MARKED AS “OWNED.” IF THE HOME IS NOT OWNED BY SOMEONE IN THE HOUSEHOLD AND IS BEING OCCUPIED WITHOUT PAYMENT OF RENT, THE ANSWER SHOULD BE MARKED AS “SOME OTHER ARRANGEMENT.”

(1) owned or being bought

(2) rented

(3) some other arrangement

(77) DON’T KNOW

(99) REFUSED

Section 11. INCOME

IF ANY NIS INTERVIEW WAS DONE IN THIS HH, SKIP TO C11Q12 – fill data from nis variable – CFAMINC; ELSE CONTINUE

[TIMESTAMP_SECTION111]

C11Q01 What was the total combined income of your household in [CATI: FILL LAST CALENDAR YEAR], including income from all sources such as wages, salaries, unemployment payments, public assistance, Social Security or retirement benefits, help from relatives and so forth? Can you tell me that amount before taxes?

[CATI: 9 NUMERIC-CHARACTER FIELD]

RECORD INCOME $___________________

(77) DON’T KNOW [SKIP TO C11Q01_DONT_KNOW]

(99) REFUSED [SKIP TO C11Q01_REFUSED]

HELP SCREEN: RESPONDENT MAY GIVE A RANGE AS AN ANSWER TO THIS QUESTION. BE PREPARED TO PROBE FOR A MORE ACCURATE ANSWER.

C11CONF (NIS VARIABLE - CINC)

Just to confirm that I entered it correctly, your income was about (FILL AMOUNT FROM C11Q01). Is that correct?

(1) YES [SKIP TO C11Q12]

(2) NO [SKIP BACK TO C11Q01]

C11Q01 _ You may not be able to give us an exact figure for your total combined household income, but was DON’T your total household income during [FILL LAST CALENDAR YEAR] more or less than

KNOW $20,000.

(1) MORE THAN $20,000 [SKIP TO W9Q06]

(2) $20,000 [SKIP TO CPC11Q12]

(3) LESS THAN $20,000 [SKIP TO W9Q03]

(77) DON'T KNOW [SKIP TO CPC11Q12]

(99) REFUSED [SKIP TO CPC11Q12]

C11Q01_ Income is important in analyzing the health care information we collect. For example, this

REFUSED information helps us to learn whether persons in one group use these medical services more or less than those in another group. Now you may not be able to give us an exact figure for your total combined household income, but was your total household income during [FILL LAST CALENDAR YEAR] more or less than $20,000?

(1) MORE THAN $20,000 [SKIP TO W9Q06]

(2) $20,000 [SKIP TO CPC11Q12]

(3) LESS THAN $20,000 [SKIP TO W9Q03]

(77) DON'T KNOW [SKIP TO CPC11Q12]

(99) REFUSED [SKIP TO CPC11Q12]

W9Q03 (NIS VARIABLE - C13)

Was the total combined household income more or less than $10,000?

(1) MORE THAN $10,000 [SKIP TO W9Q05]

(2) $10,000 [SKIP TO C11Q12]

(3) LESS THAN $10,000 [SKIP TO W9Q04]

(77) DON’T KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

W9Q04 (NIS VARIABLE - C14A)

Was it more than $7,500?

(1) YES [SKIP TO W9Q12]

(2) NO [SKIP TO W9Q12]

(77) DON’T KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

W9Q05 (NIS VARIABLE - C15)

Was it more than $15,000?

(1) YES [SKIP TO W9Q05A]

(2) NO [SKIP TO W9Q05B]

(77) DON’T KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

W9Q05A (NIS VARIABLE - C15A)

Was it more than $17,500?

(1) YES [SKIP TO W9Q12]

(2) NO [SKIP TO W9Q12]

(77) DON’T KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

W9Q05B (NIS VARIABLE - C15B)

Was it more than $12,500?

(1) YES [SKIP TO W9Q12]

(2) NO [SKIP TO W9Q12]

(77) DON’T KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

W9Q06 (NIS VARIABLE - C16)

(READ IF NECESSARY: Was the total combined household income)

more or less than $40,000?

(1) MORE THAN $40,000 [SKIP TO W9Q06A]

(2) $40,000 [SKIP TO C11Q12]

(3) LESS THAN $40,000 [SKIP TO W9Q07]

(77) DON’T KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

W9Q06A (NIS VARIABLE - C16A)

(READ IF NECESSARY: Was the total combined household income)

more or less than $60,000?

(1) MORE THAN $60,000 [SKIP TO W9Q08]

(2) $60,000 [SKIP TO C11Q12]

(3) LESS THAN $60,000 [SKIP TO W9Q06B]

(77) DON’T KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

W9Q06B (NIS VARIABLE - C16B)

(READ IF NECESSARY: Was the total combined household income)

more or less than $50,000?

(1) MORE THAN $50,000 [SKIP TO W9Q12]

(2) $50,000 [SKIP TO C11Q12]

(3) LESS THAN $50,000 [SKIP TO W9Q06C]

(77) DON’T KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

W9Q06C (NIS VARIABLE - C16C)

(READ IF NECESSARY: Was the total combined household income)

more or less than $45,000?

(1) MORE THAN $45,000 [SKIP TO W9Q12]

(2) $45,000 [SKIP TO C11Q12]

(3) LESS THAN $45,000 [SKIP TO W9Q12]

(77) DON’T KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

W9Q07 (NIS VARIABLE - C17)

(READ IF NECESSARY: Was the total combined household income)

income more or less than $30,000?

(1) MORE THAN $30,000 [SKIP TO W9Q07A]

(2) $30,000 [SKIP TO C11Q12]

(3) LESS THAN $30,000 [SKIP TO W9Q07B]

(77) DONT KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

W9Q07A (NIS VARIABLE - C17A)

(READ IF NECESSARY: Was the total combined household income)

more or less than $35,000?

(1) MORE THAN $35,000 [SKIP TO W9Q12]

(2) $35,000 [SKIP TO C11Q12]

(3) LESS THAN $35,000 [SKIP TO W9Q12]

(77) DON’T KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

W9Q07B (NIS VARIABLE - C17B)

(READ IF NECESSARY: Was the total combined household income)

more or less than $25,000?

(1) MORE THAN $25,000 [SKIP TO W9Q12]

(2) $25,000 [SKIP TO C11Q12]

(3) LESS THAN $25,000 [SKIP TO W9Q12]

(77) DONT KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

W9Q08 (NIS VARIABLE - C18)

(READ IF NECESSARY: Was the total combined household income)

more or less than $75,000?

(1) MORE THAN $75,000 [SKIP TO W9Q12]

(2) $75,000 [SKIP TO C11Q12]

(3) LESS THAN $75,000 [SKIP TO W9Q12]

(77) DONT KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

W9Q12 (CHECK_I12)

BASED ON THE RANGE ALREADY IDENTIFIED, THIS NEXT QUESTION WILL BE FILLED WITH A DOLLAR AMOUNT THAT FALLS WITHIN THE RANGE AND IS EQUIVALENT TO 50%, 100%, 133%, 150%, 185%, 200%, 300%, OR 400% OF THE FEDERAL POVERTY LEVEL BASED ON THE NUMBER OF FAMILY MEMBERS. IF THE RANGE IDENTIFIED IS NARROW ENOUGH THAT NONE OF THESE POVERTY LEVEL CUTOFFS FALL WITHIN THE RANGE, THEN SKIP TO C11Q12. FOR A FEW RANGES, TWO ADDITIONAL QUESTIONS WILL BE NEEDED.

Would you say this income was above or below [$REF]?

(1) MORE THAN [$REF] [WHEN INDICATED, ASK W9Q12A]

(2) EXACTLY [$REF] [SKIP TO C11Q12]

(3) LESS THAN [$REF] [SKIP TO C11Q12]

(77) DON’T KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

W9Q12A Would you say this income was above or below [$REF]?

(1) MORE THAN [$REF] [SKIP TO C11Q12]

(2) EXACTLY [$REF] [SKIP TO C11Q12]

(3) LESS THAN [$REF] [SKIP TO C11Q12]

(77) DON’T KNOW [SKIP TO C11Q12]

(99) REFUSED [SKIP TO C11Q12]

CPC11Q12 [IF CWTYPE=N, SKIP TO C11Q11]

C11Q12 Does [S.C.] receive SSI, that is, Supplemental Security Income?

(1) YES

(2) NO [SKIP TO C11Q11]

(77) DON’T KNOW [SKIP TO C11Q11]

(99) REFUSED [SKIP TO C11Q11]

C11Q13 Is this for a disability [he/she] has?

(1) Yes

(2) NO

(77) DON’T KNOW

(99) REFUSED

CPC11Q11 IF CWTYPE = N, GO TO CPC11Q14 ELSE ASK C11Q11 ONLY IN HH WITH INCOME UNDER 200% POVERTY, BASED ON RESULTS FROM TABLE, ELSE SKIP TO CPK11Q30

C11Q11 At any time during the past 12 months, even for one month, did anyone in this household receive any cash assistance from a state or county welfare program, such as [FILL STATE NAME]?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

CPK11Q30 IF CWTYPE=S AND ASK_CALIF=1 THEN GO TO K11Q30, ELSE GO TO CPC11Q14

K11Q30 IF C10Q02A=1-5, FILL “Were you”. ELSE, FILL “Was [S.C.]’s [MOTHER TYPE] ”

[Were you / Was [S.C.]’s [MOTHER TYPE]] born in the United States?

HELP SCREEN: AT THIS QUESTION, COLLECT INFORMATION ABOUT THE MOTHER (BIOLOGICAL, STEP, FOSTER, ADOPTIVE) LIVING IN THIS HOUSE.

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

IF (C10Q02A=1-5 OR C10Q02B=1-5), ASK K11Q30. ELSE, SKIP TO K11Q31.

K11Q31 IF K11Q30 NOT BLANK AND C10Q02A=6-10, ASK: “And how about you?”

READ AS NECESSARY: “Were you born in the United States?”

IF K11Q30 NOT BLANK AND C10Q02A NOT equal 6-10, ASK: “And how about [S.C.]’s [FATHER TYPE]?”

READ AS NECESSARY: “Was [S.C.]’s [FATHER TYPE] born in the United States?”

IF K11Q30 IS BLANK AND C10Q02A=6-10, ASK: “Were you born in the United States?”

IF K11Q30 IS BLANK AND C10Q02A not equal 6-10, ASK: “Was [S.C.]’s [FATHER TYPE] born in the United States?”

HELP SCREEN: AT THIS QUESTION, COLLECT INFORMATION ABOUT THE FATHER (BIOLOGICAL, STEP, FOSTER, ADOPTIVE) LIVING IN THIS HOUSE.

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

IF (C10Q02A=6-10 OR C10Q02B=6-10), ASK K11Q31. ELSE, SKIP TO CPK11Q32.

CPK11Q32 IF C10Q02A NOT equal 1-10, ASK K11Q32. ELSE SKIP TO K11Q33.

K11Q32 IF K11Q30 OR K11Q31 ARE NOT BLANK, ASK: “And how about you?”

READ AS NECESSARY: “Were you born in the United States?”

IF K11Q30 AND K11Q31 ARE BLANK, ASK: “Were you born in the United States?”

HELP SCREEN: AT THIS QUESTION, COLLECT INFORMATION ABOUT THE [TEXTFILL: answer from C10Q02A (see TEXTFILL logic)] LIVING IN THIS HOUSE.

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

K11Q33 And how about [S.C.]?

READ AS NECESSARY: Was [S.C.] born in the United States?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

K11Q34A IF C10Q02A=1-5, FILL “have you”. ELSE, FILL “has [S.C.]’s [MOTHER TYPE]”

How long [have you / has [S.C.]’s [MOTHER TYPE]] been in the United States?

HELP SCREEN: AT THIS QUESTION, COLLECT INFORMATION ABOUT THE MOTHER(BIOLOGICAL, STEP, FOSTER, ADOPTIVE) LIVING IN THIS HOUSE.

ENTER NUMBER: ________

(777) DON’T KNOW

(999) REFUSED

K11Q34B [MARK PERIOD]

(1) DAYS

(2) WEEKS

(3) MONTHS

(4) YEARS

K11Q35A IF K11Q34A NOT BLANK AND C10Q02A=6-10, ASK: “And how about you?”

READ AS NECESSARY: “How long have you been in the United States?”

IF K11Q34A NOT BLANK AND C10Q02A NOT equal 6-10, ASK: “And how about [S.C.]’s [FATHER TYPE]?”

READ AS NECESSARY: “How long has [S.C.]’s [FATHER TYPE] been in the United States?”

IF K11Q34A IS BLANK AND C10Q02A=6-10, ASK: “How long have you been in the United States?”

IF K11Q34A IS BLANK AND C10Q02A NOT equal 6-10, ASK: “How long has [S.C.]’s [FATHER TYPE] been in the United States?”

HELP SCREEN: AT THIS QUESTION, COLLECT INFORMATION ABOUT THE FATHER (BIOLOGICAL, STEP, FOSTER, ADOPTIVE) LIVING IN THIS HOUSE.

ENTER NUMBER: ________

(777) DON’T KNOW

(999) REFUSED

K11Q35B [MARK PERIOD]

(1) DAYS

(2) WEEKS

(3) MONTHS

(4) YEARS

CPK11Q36A IF C10Q02A NOT equal 1-10 AND K11Q32 = 2, ASK K11Q36A. ELSE SKIP TO K11Q37A.

K11Q36A IF K11Q34A OR K11Q35A ARE NOT BLANK, ASK: “And how about you?”

READ AS NECESSARY: “How long have you been in the United States?”

IF K11Q34A AND K11Q35A ARE BLANK, ASK: “How long have you been in the United States?”

HELP SCREEN: AT THIS QUESTION, COLLECT INFORMATION ABOUT THE [TEXTFILL: answer from C10Q02A (see TEXTFILL logic)] LIVING IN THIS HOUSE.

ENTER NUMBER: ________

(777) DON’T KNOW

(999) REFUSED

K11Q36B [MARK PERIOD]

(1) DAYS

(2) WEEKS

(3) MONTHS

(4) YEARS

K11Q37A IF K11Q33 = 2, ASK K11Q37A. ELSE SKIP TO CPC11Q14

IF K11Q34A, K11Q35A, OR K11Q36A ARE NOT BLANK, ASK: “And how about [S.C.]?”

READ AS NECESSARY: “How long has [S.C.] been in the United States?”

IF K11Q34A, K11Q35A, AND K11Q36A ARE BLANK, ASK: “How long has [S.C.] been in the

United States?”

ENTER NUMBER: ________

(777) DON’T KNOW

(999) REFUSED

K11Q37B [MARK PERIOD]

(1) DAYS

(2) WEEKS

(3) MONTHS

(4) YEARS

Section 11A. TELEPHONE LINE AND HOUSEHOLD INFORMATION

[TIMESTAMP_SECTION112]

CPC11Q14 IF NIS OR TEEN INTERVIEW PERFORMED IN THIS HOUSEHOLD, FILL DATA FROM NIS OR TEEN VARIABLES AND SKIP TO CPC11Q17 ELSE GO TO C11Q15

C11Q15 IF NIS DONE THEN FILL FROM C21_06Q3_CELL AS FOLLOWS:

IF C21_06Q3_CELL=0, THEN C11Q15=02

IF C21_06Q3_CELL=1,2,3, THEN C11Q15=01

IF C21_06Q3_CELL=77, THEN C11Q15=77

IF C21_06Q3_CELL=99, THEN C11Q15=99

IF NIS IS NOT DONE AND TEEN IS DONE THEN FILL FROM TIS_C21_06Q3_CELL AS FOLLOWS:

IF TIS_C21_06Q3_CELL=0, THEN C11Q15=02

IF TIS_C21_06Q3_CELL=1,2,3, THEN C11Q15=01

IF TIS_C21_06Q3_CELL=77, THEN C11Q15=77

IF TIS_C21_06Q3_CELL=99, THEN C11Q15=99

The next few questions are about the telephones in your household.

Do you or anyone in your household have a working cell phone?

READ IF NECESSARY: We need to be able to make comparisons between people who use cell phones and those who do not.

(1) Yes

(2) NO [SKIP TO C11Q20]

(77) DON’T KNOW [SKIP TO C11Q20]

(99) REFUSED [SKIP TO C11Q20]

C11Q16 (NIS VARIABLE – C11Q78)

Of all the telephone calls that you and your household receive, are nearly all received on cell phones, nearly all received on regular phones, or some received on cell phones and some received on regular phones?

IF ASKED ABOUT INCLUDING BUSINESS CALLS: Please do not include any business-related calls in your answer.

(1) NEARLY ALL RECEIVED ON CELL PHONES
(2) NEARLY ALL RECEIVED ON REGULAR PHONES
(3) SOME RECEIVED ON CELL PHONES AND SOME RECEIVED ON REGULAR PHONES
(77) DON’T KNOW
(99) REFUSED

C11Q20 (NIS VARIABLE – CNOSERV)

Not including cell phones, has your household been without telephone service for 1 week or more during the past 12 months?

(1) YES

(2) NO [SKIP TO CPC11Q17]

(77) DON’T KNOW [SKIP TO CPC11Q17]

(99) REFUSED [SKIP TO CPC11Q17]

C11Q21_A (NIS VARIABLE – CHOWLONG1)

For how long was your household without telephone service in the past 12 months?

(ENTER THE DAYS, WEEKS, OR MONTHS THEN CONTINUE TO THE NEXT SCREEN TO ENTER TIME PERIOD.)

[CATI: TWO NUMERIC-CHARACTER FIELD]

ENTER NUMBER ___ ___ ___

(777) DON’T KNOW

(999) REFUSED

C11Q21_B (NIS VARIABLE – CHOWLONG2)

ENTER PERIOD

(1) DAYS

(2) WEEK(S)

(3) MONTH(S)

(IF DAYS ARE THE CHOSEN TIME PERIOD, RANGE IS 01-99;

IF WEEKS ARE THE CHOSEN TIME PERIOD, RANGE IS 01-52;

IF MONTHS ARE THE CHOSEN TIME PERIOD, RANGE IS 01-12.

VERIFY VALUE WITH POP-UP SCREEN EXPRESSING VALUE IN WORDS, AS DONE IN NIS INCOME QUESTION)

[TIMESTAMP_SECTION113]

C11Q17 IF CWTYPE=S AND ASK_CALIF=1 THEN GO TO C11Q17, ELSE GO TO CPV_ISLAND

Do you have access to the internet at home?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

[TIMESTAMP_SECTION114]

CPV_ISLAND IF IAP=95 THEN GO TO V_ISLAND, ELSE GO TO C11Q22

V_ISLAND IF NIS COMPLETE FILL FROM C_ISLAND

IF TEEN COMPLETE FROM TIS_C_ISLAND

On what island do you live?

(1) SAINT CROIX [GO TO CP_ADDRESS]

(2) SAINT THOMAS [GO TO CP_ADDRESS]

(3) SAINT JOHN [GO TO CP_ADDRESS]

(4) WATER ISLAND [GO TO CP_ADDRESS]

(5) DON’T LIVE IN VIRGIN ISLANDS [GO TO C11Q22]

(77) DON’T KNOW [GO TO C11Q22]

(99) REFUSED [GO TO C11Q22]

C11Q22 (NIS VARIABLE – C19A)

Please tell me your zip code.

[CATI: 5 NUMERIC-CHARACTER-FIELD, RANGE 00001-99998]

_____ _____ _____ ____ _____ (00001-99998)

(77777) Don’t know

(99999) Refused

C11Q22_CONF [IF C11Q22 FILLED FROM C19A or TIS_C19A, THEN "Earlier you told me your zip code is" / IF C11Q22 ASKED, THEN "I entered"] [FILL C11Q22], is that correct?

YES [GO TO LOC_STATE]
NO [GO TO C11Q22]

LOC_STATE What state do you live in?

______________(DROP DOWN MENU OF STATE NAMES) [THIS DOES NOT CHANGE ‘STATE’ FROM THE SAMPLE PRE-FILL TABLE]

CSHCN_END

FOR DATE/TIME STAMPS, USE ONE COMBINED VAR FOR DATE AND TIME AS FOLLOWS: YYYYMMDDHHMMSS

CP_ADDRESS

IF CASE QUALIFIED FOR CSHCN OR NIS INCENTIVE, GO TO CSHCN_ADDRESS_CONF

CSHCN_ADDRESS_CONF

Those are all the questions I have. Before I go, I'll need your mailing address

[IF CSHCN_INCENT = 1 AND CSHCN_INCENT_FLAG = 1
OR
IF CSHCN_INCENT = 1 OR 2 AND CSHCN_INCENT_FLAG = 2 AND CSHCN_LTR_FLAG = 1
OR
IF CSHCN_INCENT = 1 OR 2 AND CSHCN_PASSIVE = 1 OR 2 AND CSHCN_LTR_FLAG = 1 THEN OFFER MONEY_1

IF CSHCN_INCENT = 1 OR 2 AND CSHCN_INCENT_FLAG = 2 AND CSHCN_LTR_FLAG = 2
OR
IF CSHCN_INCENT = 1 OR 2 AND CSHCN_PASSIVE = 1 OR 2 AND CSHCN_LTR_FLAG = 2 THEN OFFER MONEY_2

IF CSHCN_INCENT = 3 THEN OFFER MONEY_1]

THEN READ: so we can send you [MONEY_1 / MONEY_2] as a token of our appreciation for taking the time to answer our questions.]

[FOR SECOND FILL: If INCENT_GRP=1 USE $10, IF INCENT_GRP = 2 USE $15]

[If INCENTIVE > 0 AND AC_NIS_INCENT_EXIT NOT PREVIOUSLY READ AND CASE DID NOT QUALIFY FOR CSHCN INCENTIVES, READ: so the National Immunization Study can send you $[10/15], which you may have already received in the mail.]

[If INCENTIVE > 0 AND AC_NIS_INCENT_EXIT NOT PREVIOUSLY READ AND QUALIFIED FOR CSHCN INCENTIVES, READ: In addition, the National Immunization Study will be sending you $[10/15], which you may have already received in the mail.]

CWEND

Those are all the questions I have. I’d like to thank you on behalf of the Centers for Disease Control and Prevention for the time and effort you’ve spent answering these questions. If you have any questions about this survey, you may call my supervisor toll-free at 1 - 8 6 6 - 9 9 9 - 3 3 4 0 . If you have questions about your rights as a survey participant, you may call the chairman of the Research Ethics Review Board at 1 - 8 0 0 - 2 2 3 - 8 1 1 8 . Thank you again.

Language

LANG1 THIS FIELD MUST BE FILLED IN. DO NOT ALLOW INTERVIEWER TO SKIP AHEAD OR CALLBACKS TO BE SET.

- APPEARS AFTER COMPLETED INTERVIEWS ONLY.

INTERVIEWER: WAS THIS INTERVIEW COMPLETED USING ENGLISH ONLY?

(1) YES [TERMINATE]

(2) NO [SKIP TO LANG2]

LANG2 INTERVIEWER: WHICH LANGUAGES WERE NEEDED TO COMPLETE THIS INTERVIEW?

(1) ENGLISH [SKIP TO LANG3]

(2) SPANISH [SKIP TO LANG3]

(4) CANTONESE [SKIP TO LANG3]

(8) KOREAN [SKIP TO LANG3]

(9) MANDARIN [SKIP TO LANG3]

(13) VIETNAMESE [SKIP TO LANG3]

(14) ANOTHER LANGUAGE [SKIP TO LANG2_OTHER]

LANG2_ ________ OTHER LANGUAGE

OTHER

[IF LANG2X01 AND ANY LANG2X02-LANGX14 SELECTED > GO TO LANG3 / ELSE TERMINATE INTERVIEW, GO TO COMMENTS]

LANG3 THIS INTERVIEW COMPLETED “MOSTLY IN ENGLISH” OR “MOSTLY IN OTHER LANGUAGE”?

(1) MOSTLY IN ENGLISH

(2) MOSTLY IN OTHER LANGUAGE

(3) ABOUT HALF AND HALF

[TERMINATE INTERVIEW. GO TO COMMENTS]

Callback/Refusal Conversion Script

INTRO_1 (FOR ANY CALLBACKS IN LCS 5 WHERE S_UNDR18 IS > 0 AND CSHCN IS NOT YET FINALIZED AND CSHCN_INCENT = 0 or is <null>)

Hello, my name is ____. I’m calling on behalf of the Centers for Disease Control and Prevention. Earlier, we contacted your household to participate in a survey about health services used by children and teenagers. I’m calling back to continue the interview.

(IF NAME WAS GIVEN FOR APPOINTMENT, ASK FOR THAT PERSON.)

INTRO_1A (FOR ANY CALLBACKS (IN LCS 5 or SUC 3, 5, 6) WHERE S_UNDR18 IS <null>)

Hello, my name is ____. I’m calling on behalf of the Centers for Disease Control and Prevention. Earlier we contacted your household to participate in a survey about health services used by children and teenagers. After just a few questions I can determine if your household is eligible to participate.

(IF NAME WAS GIVEN FOR APPOINTMENT, ASK FOR THAT PERSON.)

INTRO_1B (FOR CALLBACKS IN LCS 5 WHERE S_UNDR18 IS > 0 AND CSHCN_INCENT > 0)

IF CSHCN_INCENT = 3 THEN OFFER MONEY_1]

Hello, my name is ____. I’m calling on behalf of the Centers for Disease Control and Prevention. Earlier, someone in your household started a survey about health services used by children and teenagers, and we began talking about one child in your household. I’m calling back now to continue the interview. In appreciation for your time, we will send you $[MONEY_1 / MONEY_2].

(IF NAME WAS GIVEN FOR APPOINTMENT, ASK FOR THAT PERSON.)

S1 Am I speaking to someone who lives in this household who is over 17 years old?

(1) YES, I AM THAT PERSON > IF SUC =2 or 3 and [S.C.] IS SELECTED, GO TO REMIND1/ ELSE CONTINUE WITH INTERVIEW

(2) THIS IS A BUSINESS > GO TO SALZ

(3) NEW PERSON COMES TO PHONE > GO BACK TO INTRO_1

(8) DOES NOT LIVE IN HOUSEHOLD > GO TO INSTRUCTION: [ASK FORANOTHER PERSON OR SCHEDULE APPOINTMENT ON THE NEXT SCREEN]

(9) NO PERSON AT HOME WHO IS OVER 17 > GO TO S2_B

(99) REFUSED > GO TO REFUSAL CONVERSION, SET DISP AND TERMINATE

REMIND1 (CONTINUE WITH INTERVIEW AT POINT OF BREAKOFF)

I want to remind you that we will be asking questions about [S.C.] for the rest of this interview.

Answering Machine Messages

MSG_AUG

(PLEASE READ SLOWLY AND CLEARLY.) Hello. The Centers for Disease Control and Prevention is conducting a survey about health services used by children and teenagers. Your telephone number has been selected at random to participate in this survey. For most people, it will take only a few minutes. We’re sorry we missed you and will try back at another time. Or, you can call us at 1 - 8 8 8 - 9 9 0 - 9 9 8 6. Thank you.

MSG_Y_APPT

[IF CSHCN_INCENT = 1 AND CSHCN_INCENT_FLAG = 1
OR
IF CSHCN_INCENT = 1 OR 2 AND CSHCN_INCENT_FLAG = 2 AND CSHCN_LTR_FLAG = 1
OR
IF CSHCN_INCENT = 1 OR 2 AND CSHCN_PASSIVE = 1 OR 2 AND CSHCN_LTR_FLAG = 1 THEN OFFER MONEY_1
OR
IF CSHCN_INCENT = 1 OR 2 AND CSHCN_INCENT_FLAG = 2 AND CSHCN_LTR_FLAG = 2
OR
IF CSHCN_INCENT = 1 OR 2 AND CSHCN_PASSIVE = 1 OR 2 AND CSHCN_LTR_FLAG = 2 THEN OFFER MONEY_2

IF CSHCN_INCENT = 3 THEN OFFER MONEY_1]

(PLEASE READ SLOWLY AND CLEARLY.) Hello. I am calling on behalf of the Centers for Disease Control and Prevention regarding a national study about the health services used by children and teenagers. I'm sorry that we've missed you. When we spoke previously about this important study, you requested that we call you back at this time. We'll try to contact you again soon but please feel free to return our call anytime at [IF SUC = 1, 2, 4 FILL 1 - 8 6 6 - 9 9 9 - 3 3 4 0 / IF SUC = 3, 5, 6 FIL 1 - 8 8 8 - 9 9 0 - 9 9 8 6 ]. [If INCENTIVE CASE, DISPLAY "In appreciation for your time, we will send you $[MONEY_1 / MONEY_2]."]. Thank you.

MSG_CSHCN

[IF CSHCN_INCENT = 1 AND CSHCN_INCENT_FLAG = 1
OR
IF CSHCN_INCENT = 1 OR 2 AND CSHCN_INCENT_FLAG = 2 AND CSHCN_LTR_FLAG = 1
OR
IF CSHCN_INCENT = 1 OR 2 AND CSHCN_PASSIVE = 1 OR 2 AND CSHCN_LTR_FLAG = 1 THEN OFFER MONEY_1
OR
IF CSHCN_INCENT = 1 OR 2 AND CSHCN_INCENT_FLAG = 2 AND CSHCN_LTR_FLAG = 2
OR
IF CSHCN_INCENT = 1 OR 2 AND CSHCN_PASSIVE = 1 OR 2 AND CSHCN_LTR_FLAG = 2 THEN OFFER MONEY_2

IF CSHCN_INCENT = 3 THEN OFFER MONEY_1]

(PLEASE READ SLOWLY AND CLEARLY.) Hello. I’m calling on behalf of the Centers for Disease Control and Prevention [IF CSHCN_INCENT = 1 OR 2 AND CSHCN_INCENT_FLAG = 2 AND CSHCN_LTR_FLAG = 2 OR IF CSHCN_INCENT = 1 OR 2 AND CSHCN_PASSIVE = 1 OR 2 AND CSHCN_LTR_FLAG = 2 THEN, “ to follow up on a letter that was sent to your home”/ ELSE NO FILL]. We recently contacted your household and began a children's health survey. I’m calling back to continue the survey. (If INCENTIVE CASE, DISPLAY: "In appreciation for your time, we will send you $[MONEY_1 / MONEY_2]."). If you would like to participate right away, please call our toll-free number, at [IF SUC = 1, 2, 4 FILL 1 - 8 6 6 - 9 9 9 - 3 3 4 0 / IF SUC = 3, 5, 6 FIL 1 - 8 8 8 - 9 9 0 - 9 9 8 6]. Thank you.

File Type	application/msword
File Title	Attachment 2
Author	kdo7
Last Modified By	kdo7
File Modified	2009-03-11
File Created	2009-03-11