Attachment 1: Questions to be cognitively tested
The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, 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 the 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).
Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).
OMB #0920-0222; Expiration Date: 03/31/2013
THIS SECTION IS TO BE ASKED ONLY ABOUT CHILDREN 2 YEARS OF AGE OR OLDER.
1. 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 [SC] had the condition, even if [he/she] does not have the condition now.
1A. Attention Deficit Disorder or Attention Deficit Hyperactive Disorder, that is, ADD or ADHD?
1B. Depression?
1C. Anxiety problems?
1D. Behavioral or conduct problems, such as oppositional defiant disorder or conduct disorder?
1E. Autism, Asperger's Disorder, pervasive developmental disorder, or other autism spectrum disorder?
1F. Any developmental delay that affects [his/her] ability to learn?
1G. Intellectual disability or mental retardation?
IF NO CONDITIONS REPORTED, SKIP TO NEXT SECTION.
THE NEXT QUESTIONS SHOULD BE ASKED FOR ONE CONDITION IDENTIFIED BY PARENT. PICK THE CONDITION HIGHEST UP IN THIS LIST. USE THE FOLLOWING TEXT FOR CONDITION FILLS:
[Autism or ASD]
[Developmental delay]
[Intellectual disability]
[ADD or ADHD]
[Depression]
[Anxiety problems]
[Behavioral or conduct problems]
2. How old was [SC] when you were first told by a doctor or other health care provider that (he/she) had [CONDITION]?
RECORD AGE IN MONTHS FOR 0 TO 23 MONTHS. IF 2 YEARS OR OLDER AND MONTHS NOT GIVEN, RECORD AGE IN YEARS.
3. What type of doctor or other health care provider first told you that [SC] had [CONDITION]?
(1) Pediatrician or other general pediatric health care provider (such as nurse practitioner or physician’s assistant in pediatric clinic)
(2) Another type of general health care provider (such as family practice doctor or nurse practitioner or physician’s assistant in general practice)
(3) A specialist pediatrician such as a developmental pediatrician
(4) School psychologist / counselor
(5) Other psychologist (non-school)
(6) Psychiatrist (medical doctor)
(7) Neurologist
(8) School nurse
(9) Physical, occupational, speech, or other therapist
(10) A specialist doctor (other than a developmental pediatrician, psychiatrist, or neurologist)
(11) Other [RECORD VERBATIM RESPONSE]
(12) Wasn’t told by a doctor or other health care professional
4. Does [SC] currently have [CONDITION]?
YES/NO/DK/RF [GO TO NEXT SECTION IF YES/DK/RF]
5. To the best of your knowledge, did [SC] ever have [CONDITION]?
YES/NO/DK/RF [SKIP TO #8 IF NO. GO TO NEXT SECTION IF DK/RF]
6. I am going to read a list of reasons why [SC] may no longer have [CONDITION]. For each reason, please tell me if it applies to [SC].
a. Treatment helped the condition go away
b. The condition seemed to go away on its own
c. The behaviors or symptoms changed
d. A doctor or health care provider changed the diagnosis
YES/NO/DK/RF FOR EACH ITEM
7. Are there any other reasons why you think [SC] may no longer have [CONDITION]?
RECORD VERBATIM RESPONSE IF YES, THEN GO TO NEXT SECTION.
8. I am going to read a list of reasons why a doctor, health care provider, or school professional may have told you that [SC] had a condition that (he/she) never had. For each reason, please tell me if it applies to [SC].
a. With more information, the diagnosis was changed
b. The diagnosis was given so that [SC] could receive needed services
c. You disagree with the doctor or other health provider about his or her opinion that [SC] had [CONDITION].
YES/NO/DK/RF FOR EACH ITEM
9. Are there any other reasons why a doctor or other health care provider may have told you that [SC] had a condition that (he/she) never had?
RECORD VERBATIM RESPONSE IF YES, THEN GO TO NEXT SECTION.
ASK THESE THREE QUESTIONS ONLY IF CHILD WAS EVER DIAGNOSED WITH AUTISM/ASD OR WITH DEVELOPMENTAL DELAY.
Note to reviewers: Respondents will receive either the Alternate A or the Alternate B version of the following questions.
1. Alternative A: You told me that you had been told by a doctor or other health care provider that [SC] had a condition that affected [his/her] learning or development. Has [SC] ever received therapy services to meet his developmental needs, such as Early Intervention, occupational therapy, speech therapy, or behavioral therapy?
Alternative B: Children with learning and developmental conditions receive many different services to meet their needs, such as Early Intervention, occupational therapy, speech therapy, or behavioral therapy. Has [SC] ever used therapy services to meet (his/her) developmental needs?
YES / NO / DK / RF [SKIP TO NEXT SECTION IF NO/DK/RF]
2. Alternative A: How old was [SC] when [he/she] began receiving services?
Alternative B: How old was [SC] when [he/she] first started using these services?
RECORD AGE IN MONTHS FOR 0 TO 23 MONTHS. IF 2 YEARS OR OLDER AND MONTHS NOT GIVEN, RECORD AGE IN YEARS.
3. Alternative A: Is [SC] currently receiving therapy services?
Alternative B: Does [SC] currently use therapy services on a regular basis?
YES / NO / DK / RF
ASK THIS QUESTION ABOUT ALL CHILDREN 0 TO 17 YEARS OF AGE.
1. Has a doctor or other health care provider ever told you that [SC] had vision problems that could not be corrected with standard glasses or contact lenses?
YES / NO / DK / RF
2. AGE 0-5 YEARS: Has (SC) ever had (his/her) vision tested with pictures, shapes, or letters?
AGE 6-17 YEARS: During the past 2 years, that is, since (INTERVIEW DATE MINUS 48 MONTHS), has (SC) had (his/her) vision tested with pictures, shapes, or letters?
YES / NO / DK / RF [SKIP TO NEXT SECTION IF NO/DK/RF]
3. Who performed the vision test? [MARK ALL THAT APPLY]
PEDIATRICIAN OR OTHER GENERAL HEALTH CARE PROVIDER
EYE DOCTOR OR EYE SPECIALIST (OPHTHALMOLOGIST, OPTOMETRIST)
SCHOOL NURSE OR OTHER SCHOOL PROFESSIONAL
OTHER [RECORD VERBATIM RESPONSE]
(7) DK
(9) RF
ASK THESE QUESTIONS ABOUT CHILDREN 6 TO 17 YEARS OF AGE
1. During the past week, on how many days did (SC) spend at least 60 minutes doing physical activity that increased [his/her] heart rate and made [him/her] breathe hard?
____ ____ NUMBER OF DAYS
(96) DK
(97) RF
READ IF NECESSARY: Include active sports such as baseball, softball, basketball, swimming, soccer, tennis, or football; riding a bike or roller skating; walking or jogging; jumping rope; gymnastics; and active dance such as ballet.
2. During the past week, on how many days did (SC) do exercises to strengthen or tone [his/her] muscles, such as push-ups, sit-ups, or weight lifting?
____ ____ NUMBER OF DAYS
(96) DK
(97) RF
ASK ITEM 1 ABOUT CHILDREN 0 TO 5 YEARS OF AGE
1. On an average weekday, about how much time does (SC) usually spend in front of televisions, computers, smartphones, and handheld electronic devices?
___ ___ HOURS ___ ___ MINUTES DON’T KNOW REFUSED
(95) DON’T OWN ANY OF THESE DEVICES [SKIP TO NEXT SECTION]
ASK ITEMS 2 – 5 BELOW ABOUT CHILDREN 6 TO 17 YEARS OF AGE
2. On an average weekday, about how much time does (SC) usually spend in front of televisions, computers, smartphones, and handheld electronic devices, doing things other than schoolwork?
READ IF NECESSARY: Do not include time spent watching television shows, videos, or DVDs at school, or time spent playing computer or video games, or using the Internet at school.
___ ___ HOURS ___ ___ MINUTES DON’T KNOW REFUSED
(95) DON’T OWN ANY OF THESE DEVICES [SKIP TO NEXT SECTION]
3. Do you limit the amount of time [he/she] spends watching TV, playing on the computer, or using electronic devices?
YES / NO / DK / RF
4. Do you monitor the content on TV, on the computer, or on electronic devices?
YES / NO / DK / RF
IF RESPONDENT ASKS WHAT “MONITOR” MEANS: We want to know if you check or pre-screen media for topics you might not approve of, such as violence, drugs or alcohol, fighting, guns, or sexual content. If a respondent states that he/she uses media together with SC (such as watching TV shows or movies together) to explain the content to the child, code this as a “yes” response.
5. Does [he/she] have a TV, computer, or access to electronic devices in [his/her] bedroom?
YES / NO / DK / RF
ITEMS 1 THROUGH 4 SHOULD BE ASKED ABOUT CHILDREN 6 MONTHS TO 5 YEARS OF AGE
INTRO I am going to read a list of items that sometimes describe children. For each item, please tell me how often this was true for (SC) during the past month. Would you say never, rarely, sometimes, usually, or always?
1. [He/She] is affectionate and tender with you.
2. [He/She] shows interest and curiosity in learning new things.
3. [He/She] smiles and laughs a lot.
4. [He/She] bounces back quickly when things don’t go (his/her) way.
ITEMS 5 THROUGH 8 SHOULD BE ASKED ABOUT CHILDREN 6 YEARS TO 17 YEARS OF AGE
INTRO I am going to read a list of items that sometimes describe children. For each item, please tell me how often this was true for (SC) during the past month. Would you say never, rarely, sometimes, usually, or always?
5. [He/She] finishes the tasks [he/she] starts and follows through with what [he/she] says [he’ll/she’ll] do.
6. [He/She] stays calm and in control when faced with a challenge.
7. [He/She] shows interest and curiosity in learning new things.
THIS ITEM SHOULD BE ASKED ABOUT CHILDREN 6 YEARS TO 17 YEARS OF AGE
1. Other than adults in your home, is there at least one other adult in (SC)’s school, neighborhood, or community who knows (SC) well and who (he/she) can rely on for advice or guidance?
YES / NO / DK / RF
ASK ALL ITEMS BELOW ABOUT ALL CHILREN 0 TO 17 YEARS OF AGE
1. Was (SC) born premature?
YES / NO / DK /RF
READ IF NECESSARY: Most pregnancies last about 40 weeks. A premature birth is when a baby is born too early, that is, he/she is born more than three weeks before (his/her) due date.
INTRO I’d like to ask you some questions about things that may have happened during (SC)’s life. These things can happen to any family, but some people may feel uncomfortable with these questions. You can ask me to skip any question you do not want to answer.
2. Since [SC] was born, was it ever hard to get by on your family’s income, that is, was it ever hard to cover the basics like food or housing?
YES / NO / DK / RF [SKIP TO #4 IF NO/DK/RF]
3. Since [he/she] was born, how often would you say it has been hard to get by on your family’s income? Would you say very often, somewhat often, or rarely?
VERY OFTEN / SOMEWHAT OFTEN / RARELY / DK / RF
4. Did (SC) ever live with a parent or guardian who got divorced or separated after (SC) was born?
YES / NO / DK / RF
5. Did (SC) ever live with a parent or guardian who died?
YES / NO / DK / RF
6. Did (SC) ever live with a parent or guardian who served time in jail or prison after (SC) was born?
YES / NO / DK / RF
7. Did (SC) ever see or hear any parents or adults in (his/her) home slap, hit, kick, punch, or beat each other up?
YES / NO / DK / RF
8. Was (SC) ever the victim of violence or witness any violence in (his/her) neighborhood?
YES / NO / DK / RF
9. Did (SC) ever live with anyone who was severely depressed, mentally ill, or suicidal?
YES / NO / DK / RF
10. Did (SC) ever live with anyone who had a problem with alcohol or drugs?
YES / NO / DK / RF
11. How often do you worry that (SC) will be treated or judged unfairly because of his/her race or ethnic group? Would you say very often, somewhat often, rarely, or never?
VERY OFTEN / SOMEWHAT OFTEN / RARELY / NEVER / DK / RF
12. Was (SC) ever treated or judged unfairly because of [his/her] race or ethnic group?
YES / NO / DK / RF [SKIP TO NEXT SECTION IF NO/DK/RF]
13. During the past year, how often was (SC) treated or judged unfairly? Would you say very often, somewhat often, rarely, or never?
VERY OFTEN / SOMEWHAT OFTEN / RARELY / NEVER / DK / RF
ASK THE FIRST ITEM BELOW ABOUT ALL CHILREN 0 TO 17 YEARS OF AGE.
ASK THE REMAINING ITEMS IF CHILD IS UNINSURED OR IF PARENT DOES NOT KNOW.
1. Does [SC] have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicaid?
YES / NO / DK / RF [IF YES, SKIP TO NEXT SECTION.]
2. Has [SC] ever been covered by health insurance that was provided through an employer or union?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO #5.]
3. When was the last time that [SC] was covered by insurance that was provided through an employer or union?
RECORD LENGTH OF TIME IN MONTHS OR YEARS / DK / RF
4. What is the main reason that this coverage ended?
OBTAIN VERBATIM RESPONSE.
5. Has [SC] ever been enrolled in Medicaid or [STATE MEDICAID NAME]?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO #8.]
6. When was the last time that [SC] was enrolled in Medicaid or [STATE MEDICAID NAME]?
RECORD LENGTH OF TIME IN MONTHS OR YEARS / DK / RF
7. What is the main reason that [SC]’s enrollment ended?
OBTAIN VERBATIM RESPONSE.
8. Does [SC] live with anyone whose employer or union offers health insurance that could help pay for doctor visits and hospital stays for [SC]?
YES / NO / DK / RF [IF NO/DK/RF, SKIP TO NEXT SECTION.]
9. What is the main reason that [SC] is not covered by insurance provided through an employer or union?
OBTAIN VERBATIM RES
| File Type | application/msword |
| File Title | DEPARTMENT OF HEALTH & HUMAN SERVICES |
| Author | krs0 |
| Last Modified By | mxm3 |
| File Modified | 2010-10-15 |
| File Created | 2010-10-15 |