Screener for NS-CSHCN

Attachment 1

Screener:

2009-2010 National Survey of Children with

Special Health Care Needs instrument (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 3 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

AGE & CSHCN SCREENER

The screening portions for the National Immunization Survey (NIS) have been removed since this survey does not need OMB clearance.

Section 1. SLAITS - AGE SCREENING

SL_TRANS I appreciate your answers about the immunizations of [NIS CHILD].

(1) CONTINUE [GO TO SC1_INTRO]

SL_TRANS2 I appreciate your answers about the immunizations of [NIS CHILD / CHILDREN]. Next I have some questions about health care needs of all of the children under 18 years old living in this household.

(1) CONTINUE [GO TO C2Q03_X]

Section 2. CSHCN SCREENING

Begin Loop

C2Q03_X [SKIP IF NIS_WHO NE 10 OR NIS_WHO NE BLANK, FILL IN THE DATA FOR THE CHILD FROM NIS – S3.4]

Is your [AGEID] male or female?

(1) MALE

(2) FEMALE

(77) DON’T KNOW

(99) REFUSED

End Loop

SC1_INTRO The next questions are about any kind of health problems, concerns, or conditions that may affect your (IF S_UNDR18 = 1, INSERT ‘child’/ IF S_UNDR18 > 1, INSERT ‘children’)'s physical health, behavior, learning, growth, or physical development. Some of these health problems may affect your (IF S_UNDR18 = 1, INSERT ‘child’/ IF S_UNDR18 = 1, INSERT ‘children’)'s abilities and activities at school or at play. Some of these problems affect the kind or amount of services your (IF S_UNDR18 = 1, INSERT ‘child’/ IF S_UNDR18 > 1, INSERT ‘children’) may need or use.

[TIMESTAMP_SECTION23]

CSHCN1 (IF S_UNDR18 = 1, INSERT ‘Does your child’/ IF S_UNDR18 > 1, INSERT ‘Do any of your children’) currently need or use medicine prescribed by a doctor, other than vitamins?

(1) YES

(2) NO [SKIP TO CSHCN2]

(77) DON’T KNOW [SKIP TO CSHCN2]

(99) REFUSED [SKIP TO CSHCN2]

READ IF NECESSARY: This applies to ANY medications prescribed by a doctor. Do not include over-the-counter medications such as cold or headache medications, or any vitamins, minerals, or supplements that can be purchased without a prescription.

THIS QUESTION REFERS ONLY TO CURRENT NEED FOR PRESCRIPTION MEDICINE. THE RESPONDENT SHOULD REPLY WITH “YES” IF THE CHILD CURRENTLY NEEDS OR USES PRESCRIPTION MEDICINE.

CSHCN1_ROS (FA1_ROSX01 through FA1_ROSX09)

[IF S_UNDR18 = 1, SKIP TO CSHCN1_A]

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

CATI: ALLOW A “CHOOSE ALL THAT APPLY” PICKLIST OF CHILDREN. FOR EACH CHILD CHOSEN, ASK CSHCN1_A AND CSHCN1_B.

FOR EXAMPLE, IF THERE ARE 2 CHILDREN, A 10 YEAR OLD AND A 12 YEAR OLD, AND BOTH ARE CHOSEN FROM THE PICKLIST, ASK CSHCN1_A AND CSHCN1_B ABOUT THE 10 YEAR OLD FIRST, AND THEN ASK THE SERIES ABOUT THE 12 YEAR OLD, USING APPROPRIATE FILL.

CSHCN1_A_X Is (AGEID)'s need for prescription medicine because of ANY medical, behavioral, or other health condition?

(1) YES

(2) NO [SKIP TO CSHCN1_C_X]

(77) DON’T KNOW [SKIP TO CSHCN1_C_X]

(99) REFUSED [SKIP TO CSHCN1_C_X]

CSHCN1_B_X Is this a condition that has lasted or is expected to last 12 months or longer?

(1) YES [SKIP TO CSHCN2]

(2) NO [SKIP TO CSHCN2]

(77) DON’T KNOW [SKIP TO CSHCN2]

(99) REFUSED [SKIP TO CSHCN2]

INTERVIEWER INSTRUCTION: IF THE CONDITION, NEED, OR PROBLEM LASTS FOR SHORT PERIODS OF TIME BUT IS EXPECTED TO KEEP COMING BACK FOR 12 MONTHS OR LONGER, THE ANSWER SHOULD BE “YES.”

CSHCN1_C_X Has (AGEID)'s need for prescription medication lasted or is it expected to last 12 months or longer?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

INTERVIEWER INSTRUCTION: IF THE CONDITION, NEED, OR PROBLEM LASTS FOR SHORT PERIODS OF TIME BUT IS EXPECTED TO KEEP COMING BACK FOR 12 MONTHS OR LONGER, THE ANSWER SHOULD BE “YES.”

CSHCN2 (IF S_UNDR18 = 1, INSERT ‘Does your child’/ IF S_UNDR18 > 1, INSERT ‘Do any of your children’) need or use more medical care, mental health, or educational services than is usual for most children of the same age?

(1) YES

(2) NO [SKIP TO CSHCN3]

(77) DON’T KNOW [SKIP TO CSHCN3]

(99) REFUSED [SKIP TO CSHCN3]

READ IF NECESSARY: The child requires more medical care, the use of more mental health services, or the use of more educational services than most children the same age.

THIS QUESTION REFERS ONLY TO CURRENT NEED FOR SERVICES. THE RESPONDENT SHOULD REPLY WITH “YES” IF THE CHILD CURRENTLY NEEDS OR USES SERVICES

CSHCN2_ROS (FA2_ROSX01 through FA2_ROSX09)

[IF S_UNDR18 = 1, SKIP TO CSHCN2_A]

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

CATI: ALLOW A “CHOOSE ALL THAT APPLY” PICKLIST OF CHILDREN. FOR EACH CHILD CHOSEN, ASK CSHCN2_A AND CSHCN2_B.

CSHCN2_A_X Is (AGEID)'s need for medical care, mental health or educational services because of ANY medical, behavioral, or other health condition?

(1) YES

(2) NO [SKIP TO CSHCN2_C_X]

(77) DON’T KNOW [SKIP TO CSHCN2_C_X]

(99) REFUSED [SKIP TO CSHCN2_C_X]

CSHCN2_B_X Is this a condition that has lasted or is expected to last 12 months or longer?

(1) YES [SKIP TO CSHCN3]

(2) NO [SKIP TO CSHCN3]

(77) DON’T KNOW [SKIP TO CSHCN3]

(99) REFUSED [SKIP TO CSHCN3]

INTERVIEWER INSTRUCTION: IF THE CONDITION, NEED, OR PROBLEM LASTS FOR SHORT PERIODS OF TIME BUT IS EXPECTED TO KEEP COMING BACK FOR 12 MONTHS OR LONGER, THE ANSWER SHOULD BE “YES.”

CSHCN2_C_X Has (AGEID)'s need for medical care, mental health, or educational services lasted or is it expected to last 12 months or longer?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

INTERVIEWER INSTRUCTION: IF THE CONDITION, NEED, OR PROBLEM LASTS FOR SHORT PERIODS OF TIME BUT IS EXPECTED TO KEEP COMING BACK FOR 12 MONTHS OR LONGER, THE ANSWER SHOULD BE “YES.”

CSHCN3 (IF S_UNDR18 = 1, INSERT ‘Is your child’/ IF S_UNDR18 > 1, INSERT ‘Are any of your children’) limited or prevented in any way in (his/ her/their) ability to do the things most children of the same age can do?

(1) YES

(2) NO [SKIP TO CSHCN4]

(77) DON’T KNOW [SKIP TO CSHCN4]

(99) REFUSED [SKIP TO CSHCN4]

READ IF NECESSARY: A child is limited or prevented when there are things the child can’t do as much or can’t do at all that most children the same age can.

THIS QUESTION REFERS ONLY TO CURRENT LIMITATIONS. THE RESPONDENT SHOULD REPLY WITH “YES” IF THE CHILD IS CURRENTLY LIMITED.

CSHCN3_ROS (FA3_ROSX01 through FA3_ROSX09)

[IF S_UNDR18 = 1, SKIP TO CSHCN3_A]

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

CATI: ALLOW A “CHOOSE ALL THAT APPLY” PICKLIST OF CHILDREN. FOR EACH CHILD CHOSEN, ASK CSHCN3_A AND CSHCN3_B.

CSHCN3_A_X Is (AGEID)'s limitation in abilities because of ANY medical, behavioral, or other health condition?

(1) YES

(2) NO [SKIP TO CSHCN3_C_X]

(77) DON’T KNOW [SKIP TO CSHCN3_C_X]

(99) REFUSED [SKIP TO CSHCN3_C_X]

CSHCN3_B_X Is this a condition that has lasted or is expected to last 12 months or longer?

(1) YES [SKIP TO CSHCN4]

(2) NO [SKIP TO CSHCN4]

(77) DON’T KNOW [SKIP TO CSHCN4]

(99) REFUSED [SKIP TO CSHCN4]

INTERVIEWER INSTRUCTION: IF THE CONDITION, NEED, OR PROBLEM LASTS FOR SHORT PERIODS OF TIME BUT IS EXPECTED TO KEEP COMING BACK FOR 12 MONTHS OR LONGER, THE ANSWER SHOULD BE “YES.”

CSHCN3_C_X Has (AGEID)'s limitation in abilities lasted or is it expected to last 12 months or longer?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

INTERVIEWER INSTRUCTION: IF THE CONDITION, NEED, OR PROBLEM LASTS FOR SHORT PERIODS OF TIME BUT IS EXPECTED TO KEEP COMING BACK FOR 12 MONTHS OR LONGER, THE ANSWER SHOULD BE “YES.”

CSHCN4 (IF S_UNDR18 = 1, INSERT ‘Does your child’/ IF S_UNDR18 > 1, INSERT ‘Do any of your children’) need or get special therapy, such as physical, occupational, or speech therapy?

(1) YES

(2) NO [SKIP TO CSHCN5]

(77) DON’T KNOW [SKIP TO CSHCN5]

(99) REFUSED [SKIP TO CSHCN5]

READ IF NECESSARY: Special therapy includes physical, occupational, or speech therapy. This is centered on physical needs, and things like psychological therapy are not included here.

THIS QUESTION REFERS ONLY TO CURRENT NEED FOR SPECIAL THERAPY. THE RESPONDENT SHOULD REPLY WITH “YES” IF THE CHILD CURRENTLY NEEDS OR USES SPECIAL THERAPY.

CSHCN4_ROS (FA4_ROSX01 through FA4_ROSX09)

[IF S_UNDR18 = 1, SKIP TO CSHCN4_A]

Is that (PICKLIST CONSISTING OF CHILDREN LISTED AS IN AGE_CONF)?

CATI: ALLOW A “CHOOSE ALL THAT APPLY” PICKLIST OF CHILDREN. FOR EACH CHILD CHOSEN, ASK CSHCN4_A AND CSHCN4_B.

CSHCN4_A_X Is (AGEID)'s need for special therapy because of ANY medical, behavioral, or other health condition?

(1) YES

(2) NO [SKIP TO CSHCN4_C_X]

(77) DON’T KNOW [SKIP TO CSHCN4_C_X]

(99) REFUSED [SKIP TO CSHCN4_C_X]

CSHCN4_B_X Is this a condition that has lasted or is expected to last 12 months or longer?

(1) YES [SKIP TO CSHCN5]

(2) NO [SKIP TO CSHCN5]

(77) DON’T KNOW [SKIP TO CSHCN5]

(99) REFUSED [SKIP TO CSHCN5]

INTERVIEWER INSTRUCTION: IF THE CONDITION, NEED, OR PROBLEM LASTS FOR SHORT PERIODS OF TIME BUT IS EXPECTED TO KEEP COMING BACK FOR 12 MONTHS OR LONGER, THE ANSWER SHOULD BE “YES.”

CSHCN4_C_X Has (AGEID)'s need for special therapy lasted or is it expected to last 12 months or longer?

(1) YES

(2) NO

(77) DON’T KNOW

(99) REFUSED

INTERVIEWER INSTRUCTION: IF THE CONDITION, NEED, OR PROBLEM LASTS FOR SHORT PERIODS OF TIME BUT IS EXPECTED TO KEEP COMING BACK FOR 12 MONTHS OR LONGER, THE ANSWER SHOULD BE “YES.”

CSHCN5 (IF S_UNDR18 = 1, INSERT ‘Does your child’/ IF S_UNDR18 > 1, INSERT ‘Do any of your children’) have any kind of emotional, developmental, or behavioral problem for which (IF S_UNDR18=1, INSERT 'he/she needs'/ IF S_UNDR18>1, INSERT 'they need') treatment or counseling?

(1) YES

(2) NO [SKIP TO CP_CWTYPE]

(77) DON’T KNOW [SKIP TO CP_CWTYPE]

(99) REFUSED [SKIP TO CP_CWTYPE]

READ IF NECESSARY: These are remedies, therapy, or guidance a child may receive for his/her emotional, developmental, or behavioral problem.

THIS QUESTION REFERS ONLY TO CURRENT NEED FOR TREATMENT OR COUNSELING. THE RESPONDENT SHOULD REPLY WITH “YES” IF THE CHILD CURRENTLY NEEDS OR USES TREATMENT OR COUNSELING.

CSHCN5_ROS (FA5_ROSX01 through FA5_ROSX09)

[IF S_UNDR18 =1, SKIP TO CSHCN5_A]

Is that (PICKLIST CONSISTING OF CHILDREN LISTED AS IN AGE_CONF)?

CATI: ALLOW A “CHOOSE ALL THAT APPLY” PICKLIST OF CHILDREN. FOR EACH CHILD CHOSEN, ASK CSHCN5_A.

CSHCN5_A_X Has (AGEID)'s emotional, developmental or behavioral problem lasted or is it expected to last 12

months or longer?

(1) YES [SKIP TO CP_CWTYPE]

(2) NO [SKIP TO CP_CWTYPE]

(77) DON’T KNOW [SKIP TO CP_CWTYPE]

(99) REFUSED [SKIP TO CP_CWTYPE]

INTERVIEWER INSTRUCTION: IF THE CONDITION, NEED, OR PROBLEM LASTS FOR SHORT PERIODS OF TIME BUT IS EXPECTED TO KEEP COMING BACK FOR 12 MONTHS OR LONGER, THE ANSWER SHOULD BE “YES.”

[TIMESTAMP_SECTION24]

SCREENER DECISION INSTRUCTIONS

CREATE VARIABLE CWTYPE

IN CSHCN SCREENER, IF ANY OF THE FOLLOWING ARE TRUE FOR A PARTICULAR ROSTERED CHILD:

CSHCN1_B = 1;

CSHCN2_B = 1;

CSHCN3_B = 1;

CSHCN4_B = 1;

CSHCN5_A = 1;

THEN CWTYPE = S (SPECIAL)

IF NONE OF THE ABOVE ARE TRUE, THEN CWTYPE = N (NON-SPECIAL NEEDS)

IF ALL CHILDREN IN HOUSEHOLD HAVE CWTYPE = N, THEN SKIP TO C10START (IN SECTION 10).

IF ANY CHILDREN IN HOUSEHOLD HAVE CWTYPE = S, THEN AT THIS POINT, A FOCAL CHILD MUST BE SELECTED FOR THE REST OF THE INTERVIEW FROM ALL CHILDREN WITH A POSITIVE SPECIAL HEALTH CARE NEED SCREEN.

ONE CHILD:

IF ONLY ONE CHILD UNDER 18 YEARS OLD (S_UNDR18 = 1 CHILD) WITH A POSITIVE SPECIAL HEALTH CARE NEED SCREEN, THAT CHILD IS THE FOCAL CHILD [S.C.] FROM THIS POINT.

MORE THAN ONE CHILD:

IF THERE IS MORE THAN ONE CHILD UNDER THE AGE OF 18 (S_UNDR18 > 1 CHILD) WITH A POSITIVE SPECIAL HEALTH CARE NEED SCREEN, ONE OF THESE CHILDREN SHOULD BE RANDOMLY SAMPLED AND THAT CHILD IS THE FOCAL CHILD [S.C.] FROM THIS POINT.

GO TO SELECTION.

SELECTION IF S_UNDR18 > 1, SKIP TO SELECTION1;

ELSE DISPLAY, “This survey will continue to be about the health and health care of [S.C.]. Based on the answers you just gave, the rest of the survey will take about 25 minutes.”

IF RESPONDENT IS CONCERNED ABOUT THE LONGER 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

SELECTION1 IF S_UNDR18 = 1, SKIP TO SELECTION1_NAME;

ELSE DISPLAY, “The rest of the survey will be about the health and health care of [S.C.]. The computer randomly chose this child for the interview, and we will not be asking questions about any other child from this point forward. The rest of the survey will take about 25 minutes.”

IF RESPONDENT IS CONCERNED ABOUT THE LONGER 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

SELECTION1_

NAME [SKIP TO S3QINTRO IF NAME OF SELECTED CHILD ALREADY GATHERED BECAUSE FROM MULTIAGE, C2Q01N, NIS INTERVIEW, OR RESPONDENT REFUSED TO ANSWER NAME QUESTIONS.]

I can continue to refer to your child as (AGEID) for the rest of the interview, or if you prefer, you could give me a first name or initials.

(01) CONTINUE TO USE AGE REFERENCE > GO TO C3QINTRO

(02) USE NAME > GO TO SELECTION1_NAME_A

SELECTION1

_NAME_A ENTER NAME/INITIALS: ____________ > GO TO C3QINTRO

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

(77) DON’T KNOW > GO TO C3QINTRO

(99) REFUSED > GO TO C3QINTRO