Developmental Screener

Attachment 3A:

National Survey of Children with Special Health Care Needs

Pretest data collection instrument (developmental work)

Household screener

OMB

OMB Form Approved

OMB Control Number 0920-0406

Expiration Date November 30, 2007

State and Local Area Integrated Telephone Survey (SLAITS)

National Survey of Children with Special Health Care Needs

Pretest data collection instrument (developmental work)

Household screener

According to the Paperwork Reduction Act (PRA) of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 0920-0406. The time required to complete this information collection is estimated to average 3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments about the accuracy of the time estimate(s) or suggestions for improving this form please write to: CDC Reports Clearance Officer, 1600 Clifton Road, MS-D74, Atlanta, GA 30333; call 404-639-4794; or send an email to [email protected].

[The screener questions follow questions from the National Immunization Survey; so there is no direct lead in.]

S.C. = Sample Child

S3_INTRO/

S3_INTRO_

INCENT Before we continue, I'd like you to know that taking part in this research is voluntary. You may choose not to answer any questions you don’t wish to answer, or end the interview at any time. We are required by Federal law to develop and follow strict procedures to protect your information and use your answers only for statistical research. I can describe these laws if you wish. In order to review my work, my supervisor may record and listen as I ask the questions. I’d like to continue now unless you have any questions.

Continue 1 GO TO S3_EVAL_R

Respondent asks for description of law 2 GO TO S3_LAW

S3_EVAL_R/

S3_EVAL_R_

INCENT Yes, respondent agrees to recording/listening 1 GO TO S_UNDR18

No, the respondent does not agree to recording/listening 2 GO TO S_UNDR18 (THE TEXT OF S_UNDR18 IS NOT SHOWN TO ENHANCE CLARITY FOR THE READER; IT ASKS THE NUMBER OF CHILDREN WHO LIVE IN THE HOUSEHOLD WHO ARE UNDER THE AGE OF 18 YEARS)

S3_LAW/

S3_LAW_

INCENT The Public Health Service Act is Volume 42 of the US Code, Section 242k. The collection of information in this survey is authorized by Section 306 of this Act. The confidentiality of your responses is assured by Section 308d of this Act, and the Confidential Information Protection and Statistical Efficiency Act. Would you like me to read the Confidential Information Protection Provisions to you?

No GO TO S_UNDR18

Yes GO TO S3_CONF

S3_CONF The information you provide will be used for statistical purposes only. In accordance with the Confidential Information Protection Provisions of Title V, Subtitle A, Public Law 107-347 and other applicable Federal laws, your responses will be kept confidential and will not be disclosed in identifiable form to anyone other than employees or agents. By law, every employee of the National Center for Health Statistics, the National Center for Immunization and Respiratory Disease, and its agent, the National Opinion Research Center who works on this survey has taken an oath and is subject to a jail term of up to 5 years, a fine of up to $250,000, or both, if he or she willingly discloses ANY identifiable information about you or your household members. GO TO S_UNDR18

THE SAMPLED CHILD (OR CHILDREN) ARE RANDOMLY SELECTED HERE –THIS INFORMATION IS NOT SHOWN TO ENHANCE CLARITY FOR THE READER.

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

CSHCN1 (‘Does (S.C.)’/‘Does your child’/ ‘Do any of your children’) currently need or use medicine prescribed by a doctor, other than vitamins?

(1) YES

(0) NO [SKIP TO CSHCN2]

(6) DON’T KNOW [SKIP TO CSHCN2]

(7) 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.

THESE QUESTIONS REFER ONLY TO A CURRENT CONDITION. THE RESPONDENT SHOULD ONLY REPLY WITH “YES” IF THE CHILD CURRENTLY HAS A SPECIAL HEALTH CARE NEED.

CSHCN1_A Is (AGEID)'s need for prescription medicine because of ANY medical, behavioral, or other health condition?

(1) YES

(0) NO [SKIP TO CSHCN2]

(6) DON’T KNOW [SKIP TO CSHCN2]

(7) REFUSED [SKIP TO CSHCN2]

CSHCN1_B Is this a condition that has lasted or is expected to last 12 months or longer?

(1) YES

(0) NO

(6) DON’T KNOW

(7) REFUSED

CSHCN2 (‘Does (S.C.)’/ ‘Does your child’/ ‘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

(0) NO (SKIP TO CSHCN3)

(6) DON’T KNOW (SKIP TO CSHCN3)

(7) 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. THESE QUESTIONS REFER ONLY TO A CURRENT CONDITION. THE RESPONDENT SHOULD ONLY REPLY WITH “YES” IF THE CHILD CURRENTLY HAS A SPECIAL HEALTH CARE NEED.

CSHCN2_A Is (AGEID)'s need for medical care, mental health or educational services because of ANY medical, behavioral, or other health condition?

(1) YES

(0) NO [SKIP TO CSHCN3]

(6) DON’T KNOW [SKIP TO CSHCN3]

(7) REFUSED [SKIP TO CSHCN3]

CSHCN2_B Is this a condition that has lasted or is expected to last 12 months or longer?

(1) YES

(0) NO

(6) DON’T KNOW

(7) REFUSED

CSHCN3 (‘Is (S.C.)’/ ‘Is your child’/ ‘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

(0) NO [SKIP TO CSHCN4]

(6) DON’T KNOW [SKIP TO CSHCN4]

(7) 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. THESE QUESTIONS REFER ONLY TO A CURRENT CONDITION. THE RESPONDENT SHOULD ONLY REPLY WITH “YES” IF THE CHILD CURRENTLY HAS A SPECIAL HEALTH CARE NEED.

CSHCN3_A Is (AGEID)'s limitation in abilities because of ANY medical, behavioral, or other health condition?

(1) YES

(0) NO [SKIP TO CSHCN4]

(6) DON’T KNOW [SKIP TO CSHCN4]

(7) REFUSED [SKIP TO CSHCN4]

CSHCN3_B Is this a condition that has lasted or is expected to last 12 months or longer?

(1) YES

(0) NO

(6) DON’T KNOW

(7) REFUSED

CSHCN4 (‘Does (S.C.)’/ ‘Does your child’/ ‘Do any of your children’) need or get special therapy, such as physical, occupational, or speech therapy?

(1) YES

(0) NO [SKIP TO CSHCN5]

(6) DON’T KNOW [SKIP TO CSHCN5]

(7) 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. THESE QUESTIONS REFER ONLY TO A CURRENT CONDITION. THE RESPONDENT SHOULD ONLY REPLY WITH “YES” IF THE CHILD CURRENTLY HAS A SPECIAL HEALTH CARE NEED.

CSHCN4_A Is (AGEID)'s need for special therapy because of ANY medical, behavioral, or other health condition?

(1) YES

(0) NO [SKIP TO CSHCN5]

(6) DON’T KNOW [SKIP TO CSHCN5]

(7) REFUSED [SKIP TO CSHCN5]

CSHCN4_B Is this a condition that has lasted or is expected to last 12 months or longer?

(1) YES

(0) NO

(6) DON’T KNOW

(7) REFUSED

CSHCN5 (‘Does (S.C.)’/‘Does your child’/ ‘Do any of your children’) have any kind of emotional, developmental, or behavioral problem for which ('he/she needs'/ 'they need') treatment or counseling?

(1) YES

(0) NO [SKIP TO C2START1]

(6) DON’T KNOW [SKIP TO C2START1]

(7) REFUSED [SKIP TO C2START1]

READ IF NECESSARY: These are remedies, therapy, or guidance a child may receive for his/her emotional, developmental, or behavioral problem. THESE QUESTIONS REFER ONLY TO A CURRENT CONDITION. THE RESPONDENT SHOULD ONLY REPLY WITH “YES” IF THE CHILD CURRENTLY HAS A SPECIAL HEALTH CARE NEED.

CSHCN5_A Has (AGEID)'s emotional, developmental or behavioral problem lasted or is it expected to last 12

months or longer?

(1) YES

(0) NO

(6) DON’T KNOW

(7) REFUSED

THE NS-CSHCN SCREENER ENDS HERE.