Spring and Fall Parent Interviews

Parent Interview
Early Childhood Longitudinal Study, Kindergarten Class of 2010–11
Spring-Kindergarten

INTRODUCTION - INQ
BOX 1
IF FALL K NON-RESPONDENT (THE CASE DID NOT HAVE A PARENT INTERVIEW IN THE FALL), GO TO INQ040.
OTHERWISE, GO TO INQ050.
INQ.040

(As I mentioned earlier), you and {CHILD} have been selected to take part in the Early Childhood
Longitudinal Study, Kindergarten Class of 2010-2011, which is sponsored by the U.S. Department of
Education, National Center for Education Statistics. I have some questions for you that ask about {CHILD}'s
school and home experiences.

The information I collect in this interview will be extremely valuable in

understanding the development of young children and how their early school experiences can be improved.

All responses that relate to or describe identifiable characteristics of individuals may be used only for
statistical purposes and may not be disclosed, or used, in identifiable form for any other purpose, unless
otherwise compelled by law.

This call will be recorded for quality control purposes.

CONTINUE WITH RECORDING…………..1
CONTINUE WITHOUT RECORDING……..2

BOX 2
IF INQ.040 HAS BEEN ASKED TWICE, GO TO INQ.060. ELSE, GO TO INQ.041.
INQ.041

Are you the parent or guardian in this household who knows the most about {CHILD}'s care, education,
and health?
NOTE: TO ANSWER “1” FOR “YES, THE PARENT OR GUARDIAN SHOULD LIVE IN THE SAME
HOUSEHOLD AS THE CHILD FOR THE MAJORITY OF THE YEAR, HAVE JOINT CUSTODY OF THE
CHILD, OR BE THE ADULT WHO SPENDS THE MOST TIME WITH THE CHILD WHEN THE CHILD IS
NOT IN A GROUP HOME. IF YOU ARE NOT SPEAKING TO THIS PERSON NOW, CODE “2” FOR
“NO.” IF THE CHILD DOES NOT LIVE THERE NOW, CODE “3” FOR “CHILD LIVES ELSEWHERE.”

YES ............................................................
NO ..............................................................
CHILD LIVES ELSEWHERE ........................
REFUSED ..................................................
DON'T KNOW ............................................

1
2
3
8
9

(INQ.060)
(INQ.042)
(CMQ.701)
(INQ.042)
(INQ.042)

INQ.042

May I please speak with the parent or guardian in the household who knows the most about {CHILD}'s
care, education, and health?

NOTE: THE PARENT OR GUARDIAN SHOULD LIVE IN THE SAME HOUSEHOLD AS THE
CHILD FOR THE MAJORITY OF THE YEAR, HAVE JOINT CUSTODY OF THE CHILD, OR BE
THE ADULT WHO SPENDS THE MOST TIME WITH THE CHILD WHEN THE CHILD IS NOT IN
A GROUP HOME. IF THIS PERSON IS AVAILABLE AND YOU CAN SPEAK TO HIM/HER
NOW, CODE “1”. IF YOU NEED TO CALL BACK AND THE PARENT OR GUARDIAN WILL BE
AVAILABLE IN THE FIELD PERIOD, CODE “2”. IF THE PARENT OR GUARDIAN IS NOT
AVAILABLE IN THE FIELD PERIOD, CODE “3” TO ASK FOR SOMEONE ELSE. IF THERE IS
NOT A PARENT OR GUARDIAN IN THE HOUSEHOLD WHO KNOWS THE MOST ABOUT THE
CHILD’S CARE, EDUCATION, AND HEALTH, CODE “4”. IF THE CHILD DOES NOT LIVE
THERE NOW, CODE “5” FOR “CHILD LIVES ELSEWHERE.”
AVAILABLE........................................................................... .................. 1 (INQ.040)
NOT AVAILABLE BUT WILL BE BEFORE END
OF FIELD PERIOD (CALLBACK APPT.) .............................................. 2 (CMQ.702)
NOT AVAILABLE IN FIELD PERIOD.................................................... 3 (INQ.043)
NO PARENT OR GUARDIAN IN HH KNOWS
ABOUT CHILD ................................................................... ............... 4 (INQ.043)
CHILD LIVES ELSEWHERE ................................................ ......... ..... 5 (CMQ.701)
REFUSED .......................................................................... ......... ..... 8 (INQ.043)
DON'T KNOW ................................................................... ......... ..... 9 (INQ.043)

INQ.043

May I please speak with a household member who is 18 or older and knows about {CHILD}'s care,
education, and health?
NOTE: THE RESPONDENT SHOULD LIVE IN THE SAME HOUSEHOLD AS THE CHILD FOR THE
MAJORITY OF THE YEAR, HAVE JOINT CUSTODY OF THE CHILD, OR BE THE ADULT WHO
SPENDS THE MOST TIME WITH THE CHILD WHEN THE CHILD IS NOT IN A GROUP HOME. IF
THIS PERSON IS ON THE PHONE, CODE “1”. IF YOU NEED TO CALL BACK AND THIS PERSON
WILL BE AVAILABLE IN THE FIELD PERIOD, CODE “2”. IF THIS PERSON IS NOT AVAILABLE IN
THE FIELD PERIOD, CODE “3”. IF THERE IS NOT AN ADULT IN THE HOUSEHOLD WHO KNOWS
ABOUT THE CHILD’S CARE, EDUCATION, AND HEALTH, CODE “4”. IF THE CHILD DOES NOT
LIVE THERE NOW, CODE “5” FOR “CHILD LIVES ELSEWHERE.”

PERSON ON PHONE.......................................................................... 1 (INQ.060)
NOT AVAILABLE BUT WILL BE BEFORE END
OF FIELD PERIOD (CALLBACK APPT) ............................................... 2 (CMQ.702)
NOT AVAILABLE IN FIELD PERIOD.................................................... .3 (CMQ.703)
NO PARENT OR GUARDIAN IN HH KNOWS
ABOUT CHILD. ................................................................... ............... 4 (CMQ.703)
CHILD LIVES ELSEWHERE ................................................ ............... 5 (CMQ.701)
REFUSED .......................................................................... ............... 8 (CMQ.703)
DON'T KNOW ................................................................... ............... 9 (CMQ.703)

INQ.050

Last fall, we spoke with {NAME OF FALL RESPONDENT} who took part in the Early Childhood
Longitudinal Study, Kindergarten Class of 2010-2011 on {DATE OF FALL INTERVIEW}. Am I talking to
the same person?
VERIFY NAME, AGE AND RELATIONSHIP WITH RESPONDENT:
NAME: {FIRST NAME} {LAST NAME}.
AGE: APPROXIMATELY {UPDATED AGE FROM FALL} YEARS OLD.
RELATIONSHIP TO CHILD: {RELATIONSHIP TO CHILD}.
ENTER “1” FOR YES EVEN IF THE AGE LISTED IS A YEAR OR TWO DIFFERENT FROM THE AGE
OF THE RESPONDENT IF YOU HAVE CONFIRMED IT IS THE SAME PERSON.
CAPI INSTRUCTION: FOR “NAME OF FALL RESPONDENT” DISPLAY FIRST AND LAST NAME OF
RESPONDENT FROM PRELOAD. USE THE NAME OF PERSONTYPE=R.
CAPI INSTRUCTION: FOR “FIRST NAME” AND “LAST NAME” DISPLAY FALL K RESPONDENT’S
FIRST AND LAST NAME FROM THE PRELOAD. FOR “UPDATED AGE FROM FALL” DISPLAY AGE
OF RESPONDENT FROM PRELOAD. FOR “RELATIONSHIP TO CHILD” DISPLAY RELATIONSHIP
OF RESPONDENT TO CHILD FROM PRELOAD.
CAPI INSTRUCTION: FLAG THE RESPONDENT IN THE HOUSEHOLD ROSTER AND SET A FLAG
CALLED "FLAGS.SAMERESP" THAT EQUALS 1 IF INQ.050 = 1.
CAPI INSTRUCTION: REFUSED AND DON'T KNOW DISALLOWED.
YES ....................................................... 1 (INQ.090)
NO .................................................. ...... 2 (INQ.051)
YES, SAME PERSON, BUT
CHILD LIVES ELSEWHERE NOW.... ..... 3 (CMQ.701)

INQ.051

May I please speak with {NAME OF PREVIOUS ROUND RESPONDENT}

CAPI INSTRUCTION: DISPLAY FIRST AND LAST NAME OF RESPONDENT FROM FALL
KINDERGARTEN.
AVAILABLE........................................................................... 1 (INQ.050)
NOT AVAILABLE BUT WILL BE BEFORE END
OF FIELD PERIOD (CALLBACK APPT.)........................ ...... 2 (CMQ.702)
NOT AVAILABLE IN FIELD PERIOD........................... ......... 3 (INQ.052)
CHILD LIVES ELSEWHERE ............................................... 4 (CMQ.701)
REFUSED ......................................................................... 8 (INQ.052)
DON'T KNOW .................................................................. 9 (INQ.052)

INQ.052

Are you the parent or guardian in this household who knows the most about {CHILD}'s care, education,
and health?

NOTE: TO ANSWER “1” FOR “YES, THE PARENT OR GUARDIAN SHOULD LIVE IN THE SAME
HOUSEHOLD AS THE CHILD FOR THE MAJORITY OF THE YEAR, HAVE JOINT CUSTODY OF THE
CHILD, OR BE THE ADULT WHO SPENDS THE MOST TIME WITH THE CHILD WHEN THE CHILD IS
NOT IN A GROUP HOME. IF YOU ARE NOT SPEAKING TO THIS PERSON NOW, CODE “2” FOR
“NO.” IF THE CHILD DOES NOT LIVE THERE NOW, CODE “3” FOR “CHILD LIVES ELSEWHERE.”

YES ............................................................
NO ..............................................................
CHILD LIVES ELSEWHERE ........................
REFUSED ..................................................
DON'T KNOW ............................................
INQ.053

1
2
3
8
9

(INQ.055)
(INQ.053)
(CMQ.701)
(INQ.053)
(INQ.053)

May I please speak with the parent or guardian in the household who knows the most about {CHILD}'s
care, education, and health?
NOTE: THE PARENT OR GUARDIAN SHOULD LIVE IN THE SAME HOUSEHOLD AS THE CHILD
FOR THE MAJORITY OF THE YEAR, HAVE JOINT CUSTODY OF THE CHILD, OR BE THE ADULT
WHO SPENDS THE MOST TIME WITH THE CHILD WHEN THE CHILD IS NOT IN A GROUP HOME.
IF THIS PERSON IS AVAILABLE AND YOU CAN SPEAK TO HIM/HER NOW, CODE “1”. IF YOU
NEED TO CALL BACK AND THE PARENT OR GUARDIAN WILL BE AVAILABLE IN THE FIELD
PERIOD, CODE “2”. IF THE PARENT OR GUARDIAN IS NOT AVAILABLE IN THE FIELD PERIOD,
CODE “3” TO ASK FOR SOMEONE ELSE. IF THERE IS NOT A PARENT OR GUARDIAN IN THE
HOUSEHOLD WHO KNOWS THE MOST ABOUT THE CHILD’S CARE, EDUCATION, AND HEALTH,
CODE “4”. IF THE CHILD DOES NOT LIVE THERE NOW, CODE “5” FOR “CHILD LIVES
ELSEWHERE.”

AVAILABLE ......................................................................................... 1 (INQ.055)
NOT AVAILABLE BUT WILL BE BEFORE END
OF FIELD PERIOD (CALLBACK APPT.) .............................................. 2 (CMQ.702)
NOT AVAILABLE IN FIELD PERIOD.................................................... .3 (INQ.054)
NO PARENT OR GUARDIAN IN HH KNOWS ABOUT CHILD .............. 4 (INQ.054)
CHILD LIVES ELSEWHERE ................................................ ......... ..... 5 (CMQ.701)
REFUSED .......................................................................... ......... ..... 8 (INQ.054)
DON'T KNOW ................................................................... ......... ..... 9 (INQ.054)

INQ.054

May I please speak with a household member who is 18 or older and knows about {CHILD}'s care,
education, and health?
NOTE: THE RESPONDENT SHOULD LIVE IN THE SAME HOUSEHOLD AS THE CHILD FOR THE
MAJORITY OF THE YEAR, HAVE JOINT CUSTODY OF THE CHILD, OR BE THE ADULT WHO
SPENDS THE MOST TIME WITH THE CHILD WHEN THE CHILD IS NOT IN A GROUP HOME. IF
THIS PERSON IS ON THE PHONE, CODE “1”. IF YOU NEED TO CALL BACK AND THIS PERSON
WILL BE AVAILABLE IN THE FIELD PERIOD, CODE “2”. IF THIS PERSON IS NOT AVAILABLE IN
THE FIELD PERIOD, CODE “3”. IF THERE IS NOT AN ADULT IN THE HOUSEHOLD WHO KNOWS
ABOUT THE CHILD’S CARE, EDUCATION, AND HEALTH, CODE “4”. IF THE CHILD DOES NOT
LIVE THERE NOW, CODE “5” FOR “CHILD LIVES ELSEWHERE.”
PERSON ON PHONE............................................................1 (INQ.055)
NOT AVAILABLE BUT WILL BE BEFORE END
OF FIELD PERIOD (CALLBACK APPT).............................. 2 (CMQ.702)
NOT AVAILABLE IN FIELD PERIOD....................................3 (CMQ.703)
NO ADULT IN HH KNOWS ABOUT CHILD..........................4 (CMQ.703)
CHILD LIVES ELSEWHERE............. ...................................5 (CMQ.701)
REFUSED ........................................................................ 8 (CMQ.703)
DON'T KNOW ................................................................. 9 (CMQ.703)

INQ.055

May I have your name please?

SELECT NAME FROM LIST BELOW.
IF THE NAME IS ON THE LIST OF HOUSEHOLD MEMBERS, ENTER THE NUMBER NEXT TO THE
PERSON ON THE HOUSEHOLD ROSTER WHO WILL BE THE CURRENT ROUND RESPONDENT.
SELECT THIS PERSON’S NAME EVEN IF THE AGE LISTED IS A YEAR OR TWO DIFFERENT FROM
THE AGE OF THE RESPONDENT.
VERIFY NAME, RELATIONSHIP, AND AGE WITH RESPONDENT.
IF NAME NOT LISTED, ENTER 0.
CAPI INSTRUCTIONS:
1.
DISPLAY THE UPDATED HOUSEHOLD ROSTER WITH AGE, GENDER, AND
RELATIONSHIP FROM THE PRELOAD. AT THE TOP OF THE ROSTER,
DISPLAY "0 NOT ON LIST."
NEXT TO AGE, DISPLAY THE WORD
“APPROXIMATELY”.
2.

DISPLAY HOUSEHOLD MEMBERS 15 YEARS OR OLDER AS RESPONSE
CATEGORIES (IN CASE OF RESPONDENT/INTERVIEWER ERROR EARLY IN
THE INTERVIEW, INCLUDE THE PREVIOUS ROUND RESPONDENT IN THIS
DISPLAY EVEN THOUGH HE/SHE SHOULD HAVE BEEN SELECTED AT
INQ.050).

3.

IF ZERO IS ENTERED, GO TO INQ.060. OTHERWISE, GO TO INQ.090.

4.

DISALLOW DK AND RF.

5.

FLAG THE RESPONDENT.

6.

IF THE PREVIOUS ROUND RESPONDENT IS SELECTED AT THIS SCREEN
(EVEN THOUGH HE/SHE SHOULD HAVE BEEN SELECTED AT INQ.050), SET
"FLAGS.SAMERESP" =1.

INQ.060

{[}May I have your name, please?{]}

ENTER THE RESPONDENT’FIRST NAME.
VERIFY SPELLING.
CAPI INSTRUCTION: DISPLAY “[“ AND “]” IF INQ.055 WAS ASKED. ELSE, USE A NULL DISPLAY.
CAPI INSTRUCTION: REFUSED AND DON'T KNOW DISALLOWED.

________________________________________________________
FIRST NAME
INQ.070

[May I have your name, please?]
ENTER LAST NAME.
VERIFY SPELLING.
CAPI INSTRUCTION: REFUSED AND DON'T KNOW DISALLOWED.
________________________________________________________
LAST NAME

BOX 3
IF NEW SPRING K RESPONDENT (THE HOUSEHOLD PARTICIPATED IN THE FALL, BUT WE DO NOT HAVE THE
SAME RESPONDENT IN THE SPRING AS WE DID IN THE FALL), GO TO INQ080.
IF FALL K NON-RESPONDENT, ASK INQ.072.

INQ.072

{Now, I would like to get}/I see that you have already given us} permission for {CHILD} to participate in
the study. {We would like for you to say that you have given us this permission.} For our records, please
state your name, your relationship to {CHILD}, {CHILD}’s name, and that you give us permission for
{CHILD} to participate in the ECLS-K 2011 study.
DID PARENT GIVE PERMISSION?
CAPI INSTRUCTIONS: IF THE PRELOAD SHOWS THAT PARENT ALREADY GAVE CONSENT
FOR THE CHILD TO PARTICIPATE IN THE STUDY, DISPLAY “I see…us” AND “We…permission.”
ELSE, DISPLAY “Now, …get” AND USE A NULL DISPLAY FOR “We…permission.”
CAPI INSTRUCTION: REFUSED AND DON’T KNOW ARE NOT ALLOWED.

YES………………………………….1
NO…………………………………...2
BOX 4
FOR FALL K NON-RESPONDENTS, GO TO INQ.130 AND ASK INQ130 THROUGH BOX 8.

INQ.080

(As I mentioned earlier), you and {CHILD} were selected to take part in the Early Childhood
Longitudinal Study Kindergarten Class of 2010-2011 last fall, which is sponsored by the U.S. Department
of Education, National Center for Education Statistics. I have some questions for you that ask about
{CHILD}’s school and home experiences. The information I collect in this interview will be extremely
valuable in understanding the development of young children and how their early school experiences can
be improved.
All responses that relate to or describe identifiable characteristics of individuals may be used only for
statistical purposes and may not be disclosed, or used, in identifiable form for any other purpose, unless
otherwise compelled by law.
This call will be recorded for quality control purposes.

CONTINUE WITH RECORDING……….1
CONTINUE WITHOUT RECORDING….2

BOX 5
FOR NEW SPRING K RESPONDENTS, GO TO INQ130.
INQ.090

Last fall, you and {CHILD} took part in the Early Childhood Longitudinal Study Kindergarten Class of
2010-2011, which is sponsored by the U.S. Department of Education, National Center for Education
Statistics. I have some questions for you that ask about {CHILD}’s school and home experiences since
our last interview. The information I collect in this interview will be extremely valuable in understanding
the development of young children and how their early school experiences can be improved.
All responses that relate to or describe identifiable characteristics of individuals may be used only for
statistical purposes and may not be disclosed, or used, in identifiable form for any other purpose, unless
otherwise compelled by law.
This call will be recorded for quality control purposes.

CONTINUE WITH RECORDING……….1
CONTINUE WITHOUT RECORDING….2

INQ.110

I would like to verify the spelling of your name for our records. Is your first name spelled {FIRST
NAME OF FALL RESPONDENT}?
CAPI INSTRUCTION: DISPLAY RESPONDENT'S FIRST NAME FROM FALL K.
YES…………………………………………….. 1
NO……………………………………………… 2

(INQ.115)
(INQ.112)

INQ.112

How do you spell your first name?
VERIFY SPELLING.

INQ.115

[I would like to verify the spelling of your name for our records. Is your last name spelled] {LAST NAME
OF FALL RESPONDENT}?
CAPI INSTRUCTION: DISPLAY RESPONDENT'S LAST NAME FROM FALL K.
YES…………………………………………….. 1
NO……………………………………………… 2

INQ.116

(INQ.130)
(INQ.116)

How do you spell your last name?
VERIFY SPELLING.

INQ.130

Before we begin the interview, I would like to verify some information.
I have recorded {CHILD's FIRST, MIDDLE, AND LAST NAME} as {CHILD}'s full name. Is this correct?
ALSO VERIFY SPELLING.
MAKE CORRECTIONS TO NAME BELOW OR PRESS ENTER TO ACCEPT FIRST/MIDDLE/LAST
NAME.
IF NO MIDDLE NAME OR INITIAL, ENTER 'NMN'.
CAPI INSTRUCTION: REFUSED AND DON'T KNOW ALLOWED AT ALL FIELDS.
CAPI INSTRUCTION: FOR CHILD'S FIRST, MIDDLE, AND LAST NAME, DISPLAY CHILD'S FULL
NAME FROM PRELOAD.
CAPI INSTRUCTION: USE PRELOAD LENGTH FOR CHILD'S NAME.
Current Info:

[CHILD'S FIRST NAME]
[CHILD'S MIDDLE NAME]
[CHILD'S LAST NAME]

FIRST NAME: [___________________]
MIDDLE NAME: [___________________]
LAST NAME: [___________________]

INQ.160

ASK IF NOT OBVIOUS: {I have {CHILD} recorded as {male/female}. Is that correct?}{/{Is {CHILD} male
or female?}
MAKE CORRECTIONS TO GENDER BELOW OR PRESS ENTER TO ACCEPT CURRENT GENDER.
CAPI INSTRUCTION: DISPLAY CORRECTED INFORMATION ABOUT CHILD'S GENDER FROM
PRELOAD. IF GENDER IS NONMISSING IN THE PRELOAD, DISPLAY “I have…{male/female}. Is that
correct?”, DISPLAY “male” IF THE PRELOAD SHOWS THAT THE CHILD IS MALE, DISPLAY “female”
IF THE PRELOAD SHOWS THAT THE CHILD IS FEMALE, AND NEXT TO “CURRENT INFO” BELOW,
DISPLAY “MALE” IF THE CHILD IS MALE ACCORDING TO THE PRELOAD AND DISPLAY “FEMALE”
IF THE CHILD IS FEMALE.
ELSE, IF GENDER IS MISSING IN THE PRELOAD, DISPLAY “Is {CHILD}…female?” AND USE A NULL
DISPLAY FOR “MALE/FEMALE” NEXT TO “CURRENT INFO”.

CAPI INSTRUCTION: REFUSED AND DON'T KNOW ALLOWED.
Current Info: [MALE/FEMALE]
MALE………………………………………………. 1
FEMALE……………………………………………2

INQ.170

{I have recorded that {CHILD} was born on {DATE OF BIRTH}. Is that correct?/What is {CHILD}'s date
of birth?}
{MAKE CORRECTIONS TO DATE OF BIRTH BELOW OR PRESS ENTER TO ACCEPT CURRENT
DATE OF BIRTH.}
CAPI INSTRUCTION: DISPLAY INFORMATION ABOUT CHILD'S DATE OF BIRTH FROM PRELOAD.
CAPI INSTRUCTION: IF DATE OF BIRTH IS NOT AVAILABLE IN THE PRELOAD, ENTRY FOR DATE
OF BIRTH IS REQUIRED.
CAPI INSTRUCTION: REFUSED AND DON'T KNOW ALLOWED.
CAPI INSTRUCTION: IF A DATE OF BIRTH IS AVAILABLE FOR THE FOCAL CHILD FROM THE
PRELOAD, DISPLAY "I have recorded that {CHILD} was born on {DATE OF BIRTH}. Is that correct?"
AND "MAKE CORRECTIONS … BIRTH.”‘ ALSO, IF DATE OF BIRTH IS AVAILABLE IN THE
PRELOAD, DISPLAY IT NEXT TO “CURRENT INFO” BELOW. OTHERWISE, IF DATE OF BIRTH IS
NOT AVAILABLE IN THE PRELOAD, DISPLAY "What is {child}'s date of birth?" AND USE A NULL
DISPLAY NEXT TO “CURRENT INFO”.
CAPI INSTRUCTION: RANGE CHECK: 1-12 FOR MONTH, 1-31 FOR DAY, 2003-2006 FOR YEAR.

Current Info: [DATE OF BIRTH]
|___|___| / |___|___| / |___|___||___|___|
ENTER DATE OF BIRTH (MONTH/DAY/YEAR)
REFUSED ……….………………………………… 88
DON’T KNOW …………………………………….. 99

BOX 6
CONTINUE WITH INQ.175.
IF ANY FIELD IN DATE OF BIRTH INQ.170 = REFUSED OR DK, GO TO INQ.176.
INQ.175

So {CHILD} is {AGE CALCULATED FROM DATE OF BIRTH AT INQ.170} years old. Is that correct?
IF AGE IS INCORRECT, GO BACK TO INQ170 AND CORRECT DATE OF BIRTH.
IF AGE IS STILL INCORRECT, ANSWER “NO” TO THIS QUESTION (INQ175).
YES .................................................................. 1 (INQ.180)
NO .................................................................... 2 (INQ.176)
REFUSED …………………………………………..8 (INQ.176)
DON’T KNOW ………………………………………9 (INQ.176)

INQ.176

How old is {CHILD}?
CAPI INSTRUCTION: RANGE CHECK 4-8.
IF DK OR RF, DISPLAY "YOU MUST ENTER AN AGE FOR THE CHILD IF DATE OF BIRTH IS
MISSING. IF THEIR RESPONDENT DOESN'T KNOW THE AGE, ASK FOR HIS/HER BEST GUESS.
IF THE RESPONDENT REFUSES TO PROVIDE AN AGE, ENTER YOUR BEST GUESS OR A '5' IF
YOU CAN'T GUESS AT THE CHILD'S AGE."
REFUSED ………………………………………….. 8
DON’T KNOW ……………………………………… 9

INQ.180

{HELP AVAILABLE}
{I have recorded that {CHILD}'s home address is:}/{What is {CHILD}'s home
address?}
{Is this still correct?}

STREET ADDRESS1:
STREET ADDRESS2:
CITY:
STATE:
ZIP CODE:

[___________________]
[___________________]
[___________________]
[___________________]
[___________________]

{TYPE ADDRESS AND ENTER 1 FOR "YES, CORRECT ADDRESS."}
CAPI INSTRUCTION: IN THE RESPONSE FIELD, DISPLAY CURRENT ADDRESS INFO FROM THE
PRELOAD.
CAPI INSTRUCTION: DISPLAY "I have …is” and "Is this still correct" IF DATA ARE AVAILABLE FROM
THE PRELOAD.
IF DATA ARE NOT AVAILABLE, display "What is …" and "TYPE ADDRESS…"
CAPI INSTRUCTION: IF PREVIOUS DATA ARE NOT AVAILABLE FOR ADDRESS, ALLOW REFUSED
AND DON'T KNOW IN ALL FIELDS.
CAPI INSTRUCTION: IF PREVIOUS DATA ARE NOT AVAILABLE FOR ADDRESS, DISPLAY 'HELP
AVAILABLE' WHEN ON STATE ENTRY FIELD. USE STATE ABBREVIATIONS AS HELP TEXT.
YES, CORRECT ADDRESS......................... …….….. 1(INQ.200)
YES, SAME ADDRESS – MINOR
CORRECTIONS …………………………………………2 (INQ.190)
NO. NEW ADDRESS …………………………………….. 3 (INQ.190)

{HELP AVAILABLE}
INQ.190
MAKE CORRECTIONS TO ADDRESS BELOW.
CAPI INSTRUCTION: REFUSED AND DON'T KNOW ALLOWED AT ALL FIELDS.
CAPI INSTRUCTION: DISPLAY 'HELP AVAILABLE' WHEN ON STATE ENTRY FIELD.
STATE ABBREVIATIONS AS HELP TEXT.

USE

CAPI INSTRUCTION: DISPLAY CURRENT ADDRESS INFO IN THE RESPONSE FIELD.
Current Info:

[STREET ADDRESS1]
[STREET ADDRESS2]
[CITY]
[STATE]
[ZIP CODE]

STREET ADDRESS1:
STREET ADDRESS2:
CITY:
STATE:
ZIP CODE:
INQ.200

[___________________]
[___________________]
[___________________]
[___________________]
[___________________]

{I have recorded that {PHONE NUMBER} is {CHILD}'s family's current home phone number. Is this
correct?/What is {CHILD}'s family's current home phone number?}
IF NO TELEPHONE, ENTER '000'.
MAKE CORRECTIONS TO PHONE NUMBER BELOW OR PRESS ENTER TO ACCEPT CURRENT
PHONE NUMBER.
CAPI INSTRUCTION: DISPLAY CURRENT PHONE NUMBER FROM PRELOAD.
CAPI INSTRUCTION: DISPLAY "I have recorded … correct?" IF A HOME PHONE NUMBER IS
AVAILABLE FOR THIS CASE. OTHERWISE, DISPLAY "What is … phone number?"
CAPI INSTRUCTION: IF CURRENT INFO IS NOT AVAILABLE, ENTRY IS REQUIRED FOR
TELEPHONE NUMBER.
REFUSED ………………………………………8
DON’T KNOW …………………………………. 9

INQ.300

Next, I have a few questions about {CHILD}'s background. Was {CHILD} born in this country, that is, in
any of the fifty states or the District of Columbia?
YES …………………………………………….. 1 (BOX 8)
NO …………………………………………….... 2 (INQ.310)
REFUSED ………………………………………8 (BOX 8)
DON’T KNOW …………………………………. 9 (BOX 8)

INQ.310

In what country or territory was {CHILD} born?
TO ACTIVATE LOOKUP, BEGIN TO TYPE COUNTRY OR TERRITORY. IF COUNTRY IS NOT ON
THE LIST, HIGHLIGHT "NOT ON LIST" IN THE LOOKUP FILE AND PRESS ENTER.
USE THE ARROW KEYS TO HELP YOU LOCATE A MATCH.
CAPI INSTRUCTION: DISPLAY COUNTRY LOOKUP FILE. ALLOW 3 SPACES IN THE RESPONSE
FIELD FOR ENTERING RESPONSE CODES.
REFUSED ………………………………………8
DON’T KNOW …………………………………. 9

BOX 7
IF INQ.310 = 0 (NOT ON LIST), CONTINUE WITH INQ.312OS. OTHERWISE, GO TO INQ.320.
INQ.312OS

What is {CHILD}'s country of birth?
SPECIFY COUNTRY

INQ.320

In what year did {CHILD} come to the United States to stay?
CAPI INSTRUCTION: RANGE CHECK: THE YEAR CHILD CAME TO U.S. CANNOT BE EARLIER
THAN CHILD'S YEAR OF BIRTH OR LATER THAN THE CURRENT YEAR.
REFUSED ………………………………………8
DON’T KNOW ……………………..………….. 9

INQ.330

Is {CHILD} a U.S. citizen?
YES ……………………………………………...1
NO …………………………………………….....2
REFUSED …………………………...………….8
DON’T KNOW …………………………………..9

BOX 8
IF FALL K NON-RESPONDENT, GO TO NEXT SECTION (SPQ).
OTHERWISE, GO TO SECTION PIQ (PARENT'S INVOLVEMENT WITH CHILD'S SCHOOL).

SUPPLEMENTARY ITEMS FOR NON-RESPONSE HOUSEHOLDS - SPQ
HELP AVAILABLE
SPQ.010

I'd like to talk to you about child care {CHILD} received on a regular basis from someone other than you
or {his/her} parents or guardians the year before {he/she} started kindergarten. This does not include
occasional baby-sitting or backup care providers. Did {CHILD} receive care from a relative on a regular
basis the year before (he/she) started kindergarten? This may include grandparents, brothers and sisters,
or any relatives other than you or {CHILD}'s parents or guardians.
CAPI INSTRUCTIONS: DISPLAY 'regular basis the year before' IN UNDERLINED TEXT.
THIS MEANS ANYTIME IN THE YEAR BEFORE CHILD ENTERED KINDERGARTEN.
HELP TEXT:
Care from a relative: Record care or programs provided by a relative other than the child’s parents in a
private home. The private home may be the child’s home, the caregiver’s home, or another home. In all
cases, do not include care provided by a parent, even if they do not live in the household. (Do not include
visitation with a separated or divorced parent who does not have custody.)
If there is at least one parent in the household, any relative living in the household is eligible to be
counted as a care arrangement, if the care is provided on a regularly scheduled basis. Relatives outside
the household may also be regular care providers.
If neither parent lives in the household, do not include care provided by guardians who live with the
child (they are similar to parents).
Relative care arrangements may or may not have a charge or fee.
Regular Basis: An arrangement or program occurring on a routine schedule (i.e., occurring at least
weekly or on some other schedule). Do not include occasional babysitting or "back up" arrangements
that are just used once in a while.
YES …………………………………………….. 1
NO …………………………………………….... 2 (SPQ.020)
REFUSED ……………………………………… 8 (SPQ.020)
DON’T KNOW …………………………… …. 9 (SPQ.020)

SPQ.015

HELP AVAILABLE
Head Start is a federally sponsored preschool program primarily for children from low-income families.
Were any of the regular care arrangements that {CHILD} had with relatives in the year before
kindergarten Head Start?
CAPI INSTRUCTION: DISPLAY “the year before” IN UNDERLINED TEXT.

HELP TEXT:
Head Start: Head Start is a federally funded early childhood education program designed to improve the
school-readiness of disadvantaged children (i.e., children from low-income families). Children who
participate are usually 3 to 5 years old. Head Start may be offered in a variety of locations. For this
question, we are interested in Head Start services in a family child care program in a private home where
the child was cared for by someone who is related to the child but is not his or her parent.
Rarely, you may find a case in which a respondent reports that the child is in "home Head Start," that is,
he/she participates in Head Start in his/her own home. Generally, this involves the parent acting as the
child's teacher, supplemented by occasional home visits by a Head Start teacher and perhaps some
occasional group activities at a central location. Do not include child care by a parent in this question.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

1
2
8
9

SPQ.020

HELP AVAILABLE
{Now I'd like to ask you about any care {CHILD} received from nonrelatives in a private home, not
including child care centers.} Did {CHILD} receive care from a nonrelative on a regular basis the year
before (he/she) started kindergarten? This includes home child care providers, regular sitters or
neighbors. {It does not include child care centers.}
THIS MEANS ANYTIME IN THE YEAR BEFORE CHILD ENTERED KINDERGARTEN.
PROBE: This refers to care received from nonrelatives in a private home, including home child care
providers, regular sitters, or neighbors. However, this does not include child care centers.
CAPI INSTRUCTIONS: DISPLAY 'a regular basis the year before' IN UNDERLINED TEXT.
CAPI INSTRUCTION: DISPLAY "Now . . . centers" IF SPQ.010 = 1. OTHERWISE, USE A NULL
DISPLAY.
CAPI INSTRUCTION: DISPLAY “It does not include child care centers.” IF SPQ.010 NE 1.
OTHERWISE, USE A NULL DISPLAY.

HELP TEXT:
Care from a non-relative: Non-relative care is provided by someone not related to the child and is
located in a private home. The private home may be the child’s home, the caregiver’s home, or another
home.
If there is at least one parent in the household, any nonrelative living in the household is eligible to be
counted as a care arrangement, IF the care is given on a regularly scheduled basis.
If neither parent lives in the household, do not include care provided by guardians who live with the
child (they are treated the same as parents).
Non-relative care arrangements or programs may or may not have a charge or fee.
Regular Basis: An arrangement or program occurring on a routine schedule (i.e., occurring at least
weekly or on some other schedule). Do not include occasional babysitting or "back up" arrangements
that are just used once in a while.
YES…………………………………………….... 1
NO ..............................................................
2 (SPQ.040)
REFUSED ...................................................
8 (SPQ.040)
DON'T KNOW……………………….………….. 9 (SPQ.040)

SPQ.025

HELP AVAILABLE
{Head Start is a federally sponsored preschool program primarily for children from low-income
families.} Were any of the regular care arrangements that {CHILD} had with nonrelatives in the year
before kindergarten Head Start?

CAPI INSTRUCTIONS: DISPLAY “Head Start…families” IF SPQ.015 WAS NOT ASKED. ELSE, USE A
NULL DISPLAY.
HELP TEXT:
Head Start: Head Start is a federally funded early childhood education program designed to improve
the school-readiness of disadvantaged children (i.e., children from low-income families). Children
who participate are usually 3 to 5 years old. Head Start may be offered in a variety of locations. For
this question, we are interested in Head Start services in a family child care program in a private
home where the child is cared for by someone who is not his or her parent and is not related to the
child.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

SPQ.040

1
2
8
9

HELP AVAILABLE
Did {CHILD} attend a day care center, nursery school, preschool, or prekindergarten program on a
regular basis the year before {he/she} started kindergarten?

DISPLAY 'a regular basis the year before’ IN UNDERLINED TEXT.
THIS MEANS ANYTIME IN THE YEAR BEFORE CHILD ENTERED KINDERGARTEN.
HELP TEXT:
Day Care Center: Includes any type of formal program that provides care and supervision. It may be in
a child's school or in another location, such as a church or a free-standing building. Head Start
programs, nursery schools, preschools, and prekindergarten programs (some of which may be
sponsored by the state) are also included.
Regular Basis: An arrangement or program occurring on a routine schedule (i.e., occurring at least
weekly or on some other schedule). Do not include occasional babysitting or "back up" arrangements
that are just used once in a while.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

1
2
8
9

SPQ.041

HELP AVAILABLE
{Head Start is a federally sponsored preschool program primarily for children from low-income families.}
Were any of {CHILD}’s care arrangements in a day care center, nursery school, preschool, or
prekindergarten program in the year before kindergarten Head Start?
CAPI INSTRUCTIONS: DISPLAY “Head Start…families.” IF SPQ.015 AND SPQ.025 WERE NOT
ASKED. ELSE, USE A NULL DISPLAY.
CAPI INSTRUCTION: DISPLAY “the year before” IN UNDERLINED TEXT.
HELP TEXT:
Head Start: Head Start is a federally funded early childhood education program designed to improve the
school-readiness of disadvantaged children (i.e., children from low-income families). Children who
participate are usually 3 to 5 years old. Head Start may be offered in a variety of locations. For this
question, we are interested in Head Start services in a center setting.

YES ............................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW ............................................
SPQ.060

1
2
8
9

Now I have some questions about {CHILD}'s health. How much did {CHILD} weigh when (he/she) was
born?
ENTER UNIT
POUNDS (WITH OR WITHOUT OUNCES) .
GRAMS ......................................................
REFUSED ..................................................
DON'T KNOW ............................................

SPQ.065

1
2
8
9

(SPQ.065)
(SPQ.066)
(SPQ.070)
(SPQ.070)

[Now I have some questions about {CHILD}'s health. How much did {CHILD} weigh when (he/she) was
born?]

CAPI INSTRUCTION: RANGE CHECK: 1-13 FOR POUNDS, 0-15 FOR OUNCES.

|___|___|
ENTER POUNDS

AND |___|___|
ENTER OUNCES

REFUSED ..................................................
DON'T KNOW ............................................

8
9

BOX 1
IF BOTH POUNDS AND OUNCES ARE ENTERED IN SPQ.065 AND NEITHER ANSWER IS REFUSED OR DON’T
KNOW, GO TO SPQ.090.
ELSE, IF (SPQ.065 IS REFUSED OR DON’T KNOW FOR THE NUMBER OF POUNDS) OR (THE NUMBER OF
POUNDS IN SPQ.065 IS 5 AND REFUSED OR DON'T KNOW FOR THE NUMBER OF OUNCES), GO TO SPQ.070.
ELSE, IF THE NUMBER OF POUNDS IN SPQ.065 IS 3 AND REFUSED OR DON’T KNOW FOR THE NUMBER OF
OUNCES, GO TO SPQ.380. ELSE, IF THE NUMBER OF POUNDS IN SPQ.065 IS 10 AND REFUSED OR DON’T
KNOW FOR THE NUMBER OF OUNCES, GO TO SPQ.085.
SPQ.066

[Now I have some questions about {CHILD}'s health. How much did {CHILD} weigh when (he/she) was
born?]
CAPI INSTRUCTION: RANGE CHECK: 454 –6,322 GRAMS.

|___|___|___|___|
ENTER GRAMS
REFUSED ..................................................
DON'T KNOW ............................................

8
9

BOX 2
IF GRAMS ARE ENTERED IN SPQ.066, GO TO SPQ.090.
ELSE, IF CHQ.007 IS REFUSED OR DON’T KNOW, GO TO SPQ.070.
HELP AVAILABLE
SPQ.070

When (he/she) was born, did {CHILD} weigh more than 5 1/2 pounds (2,495 grams)?
HELP TEXT:
5 ½ pounds = 5 pounds, 8 ounces = 2,495 grams
YES ............................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW ............................................

1 (SPQ085)
2 (SPQ.080)
8 (SPQ.080)
9 (SPQ.080)

BOX 3
IF THE NUMBER OF POUNDS IN SPQ.065 WAS 5 AND REFUSED OR DON’T
KNOW FOR THE NUMBER OF OUNCES), GO TO SPQ.090. ELSE, GO TO
SPQ.080.

HELP AVAILABLE
SPQ.080

Did (he/she) weigh more than 3 pounds?
HELP TEXT:
3 pounds = 1,361 grams
YES ............................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW ............................................

1
2
8
9

BOX 4
IF (SPQ.080 = 1 OR 2) OR (SPQ.070 = 2 AND SPQ.080 = REF OR DK), GO TO
SPQ.090. ELSE, GO TO SPQ.085.

SPQ.085
NEW

Did {he/she} weigh more than 10 pounds?
HELP TEXT:
10 pounds = 4,536 grams
YES ...........................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW .............................................

SPQ.090

Was {CHILD} born more than two weeks before (he/she) was due?
YES ............................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW ............................................

SPQ.100

1
2
8
9

1 (SPQ.100)
2 (SPQ.106)
8 (SPQ.106)
9 (SPQ.106)

How many days or weeks early was (he/she)?
CAPI INSTRUCTION: RANGE CHECK : 1-31 IF DAYS IS THE UNIT; 1-20 IF WEEKS IS THE UNIT.
|___|___|
ENTER NUMBER
REFUSED ..................................................
DON'T KNOW ............................................

88 (SPQ.106)
99 (SPQ.106)

SPQ.105

[How many days or weeks early was (he/she)?]

|___|
ENTER UNIT
WEEKS .......................................................
DAYS ..........................................................
REFUSED ..................................................
DON'T KNOW ............................................

SPQ.106

1
2
8
9

Was {CHILD} a twin, triplet, or other child born as part of a multiple birth?
IF HIGHER-ORDER MULTIPLE BIRTH, CODE NUMBER OF CHILDREN BORN TOGETHER, EVEN IF
ONE OR MORE WAS STILL BORN OR DIED SHORTLY AFTER BIRTH.
NO ..............................................................
YES, A TWIN ..............................................
YES, A TRIPLET .........................................
YES, MULTIPLE BIRTH (4 OR MORE) ........
REFUSED ...................................................
DON’T KNOW .............................................

SPQ.150

When {CHILD} was born, were {his/her} biological mother and biological father married?
YES ............................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW ............................................

SPQ.155

1
2
3
4
8
9

1
2
8
9

HELP AVAILABLE
Is any language other than English regularly spoken in your home?
HELP TEXT:
Regularly: A language, other than English, that is spoken on regular basis (that is, occurring at least
weekly) by at least one household member.
YES ............................................................ 1
NO .............................................................. 2 (SPQ.210)
REFUSED .................................................. 8 (SPQ.210)
DON'T KNOW ............................................ 9 (SPQ.210)

SPQ.156

Is English also spoken in your home?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW ............................................

1
2
8
9

HELP AVAILABLE
SPQ.157

What is the primary language spoken in your home?
HELP TEXT:
Primary language: The language spoken the most of the time by most of the household members.
CAPI INSTRUCTION: DISPLAY 'primary' IN UNDERLINED TEXT
CODE '16' IF RESPONDENT CAN'T CHOOSE A PRIMARY LANGUAGE.
ENGLISH ...................................
ARABIC .....................................
CHINESE LANGUAGE/DIALECT
FILIPINO LANGUAGE ................
FRENCH ....................................
GERMAN ...................................
GREEK ......................................
ITALIAN .....................................
JAPANESE ................................

0
1
2
3
4
5
6
7
8

KOREAN ...................................... 9
POLISH ...................................... 10
PORTUGUESE ........................... 11
SPANISH.................................... 12
VIETNAMESE............................. 13
FARSI......................................... 14
HMONG...................................... 15
RESPONDENT CANNOT
CHOOSE A PRIMARY
LANGUAGE.................................16
SOME OTHER LANGUAGE
(SPECIFY)__________________ 91
REFUSED ...................................88
DON’T KNOW..............................99

.
BOX 5
IF SPQ.157 = 91, GO TO SPQ.157OS. ELSE, IF SPQ.157 = 0, GO TO SPQ.210. ELSE, GO TO SPQ.210.

SPQ.157OS

[What is the primary language spoken in your home?]
CAPI INSTRUCTION: DISPLAY 'primary' IN UNDERLINED TEXT.
SPECIFY LANGUAGE.
___________________________________________________________

SPQ.210

HELP AVAILABLE
When (you were/{CHILD}'s mother was) pregnant with {CHILD}, did (you/she) receive any benefits
from the Special Supplemental Food Program for Women, Infants, and Children, or WIC?
CAPI INSTRUCTION: IF R VOLUNTEERED THAT SHE IS CHILD'S MOTHER, SAY 'you' INSTEAD OF
‘{CHILD}'S mother was’.
HELP TEXT:
WIC: This program provides food assistance and nutritional education to low-income pregnant and
postpartum women and their infants, as well as to low-income children up to age 5. WIC is short for the
Special Supplemental Food Program for Women, Infants, and Children. WIC benefits can include food,
checks, vouchers, and/or a debit card called EBT (Electronic Benefit Transfer).

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON’T KNOW .............................................

1
2
8
9

HELP AVAILABLE
SPQ.220

Did {CHILD} receive any WIC benefits as an infant or child?

HELP TEXT:
WIC: This program provides food assistance and nutritional education to low-income pregnant and
postpartum women and their infants, as well as to low-income children up to age 5. WIC is short for the
Special Supplemental Food Program for Women, Infants, and Children. WIC benefits can include food,
checks, vouchers, and/or a debit card called EBT (Electronic Benefit Transfer).

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW ............................................

BOX 6
GO TO PIQ (PARENT'S INVOLVEMENT WITH CHILD'S SCHOOL).

1
2
8
9

PARENT’S INVOLVEMENT WITH CHILD’S SCHOOL - PIQ
PIQ.110

Now I'd like to ask you about your family's involvement with {CHILD}'s school.
During this school year, have you or another adult in your household taken it upon yourself to contact
{CHILD}'s teacher or school for any reason having to do with {CHILD}?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW ............................................

PIQ.127

1
2
8
9

Since the beginning of this school year, how many times have any of {CHILD}’s teachers or {his/her}
school contacted (you/any adult in your household) about any behavior problems {he/she} is having in
school?
ENTER NUMBER OF TIMES.
CAPI INSTRUCTION: DISPLAY “his” AND “he” IF THE CHILD IS A BOY. ELSE, DISPLAY “her” AND
“she”. IF GENDER IS MISSING, DISPLAY “he/she”.
CAPI INSTRUCTION: DISPLAY “behavior” IN UNDERLINED TEXT.
________________________________________________________
TIMES

REFUSED ...................................................
DON'T KNOW ............................................
PIQ.128

8
9

How about any problems {he/she} is having with school work?
ENTER NUMBER OF TIMES.
CAPI INSTRUCTION: DISPLAY “school work” IN UNDERLINED TEXT.
CAPI INSTRUCTION: DISPLAY “he” IF THE CHILD IS A BOY. ELSE, DISPLAY “she”. IF GENDER IS
MISSING, DISPLAY “he/she”.
________________________________________________________
TIMES
REFUSED ...................................................
DON'T KNOW ............................................

PIQ.129

8
9

How about anything {CHILD} is doing particularly well or better in school?
ENTER NUMBER OF TIMES.
________________________________________________________
TIMES
REFUSED ...................................................
DON'T KNOW ............................................

8
9

PIQ.130

Since the beginning of this school year, have you or the other adults in your household… Attended an
open house or a back-to-school night?

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW ............................................

PIQ.140

[Since the beginning of this school year, have you or the other adults in your household…] Attended a
meeting of a PTA, PTO, or Parent-Teacher Organization?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

PIQ.145

1
2
8
9

[Since the beginning of this school year, have you or the other adults in your household…] Gone to a
regularly-scheduled parent-teacher conference with {CHILD}'s teacher or meeting with {CHILD}'s
teacher?

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

PIQ.160

1
2
8
9

[Since the beginning of this school year, have you or the other adults in your household…] Gone to a
meeting of a parent advisory group or policy council?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW ............................................

PIQ.150

1
2
8
9

1
2
8
9

[Since the beginning of this school year, have you or the other adults in your household…] Attended a
school or class event, such as a play, sports event, or science fair?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

PIQ.170

[Since the beginning of this school year, have you or the other adults in your household…] Served as a
volunteer in (CHILD)’s classroom or elsewhere in the school?

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………
PIQ.174

[Since the beginning of this school year, have you or the other adults in your household…] Served on a
school committee?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

PIQ.175

1
2
8
9

[Since the beginning of this school year, have you or the other adults in your household…] Participated
in fundraising for {CHILD}'s school?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

PIQ.185

1
2
8
9

1
2
8
9

During this school year, how many times have you or other adults in your household gone to meetings or
participated in activities at {CHILD}'s school?
CAPI INSTRUCTIONS: RANGE: 1 TO 180.
|___|___|___|
TIMES
REFUSED ...................................................
DON'T KNOW .............................................

PIQ.190

8
9

For each of the following statements, please tell me how well {CHILD}'s school has done with each
activity during this school year. The school lets you know between report cards how {CHILD} is doing in
school. Would you say {CHILD}'s school…

Does this very well, .............................. 1
Just OK, or .......................................... 2
Doesn’t do this at all?........................... 3
REFUSED ........................................... 8
DON’T KNOW ..................................... 9

PIQ.200

[For each of the following statements, please tell me how well {CHILD}'s school has done with each
activity during this school year.] The school helps you understand what children at {CHILD}'s age are
like. Would you say {CHILD}'s school…
Does this very well, .............................. 1
Just OK, or .......................................... 2
Doesn’t do this at all?........................... 3
REFUSED ........................................... 8
DON’T KNOW ..................................... 9

PIQ.210

[For each of the following statements, please tell me how well {CHILD}'s school has done with each
activity during this school year.] The school makes you aware of chances to volunteer at the school.
Would you say {CHILD}'s school…
Does this very well, .............................. 1
Just OK, or .......................................... 2
Doesn’t do this at all?........................... 3
REFUSED ........................................... 8
DON’T KNOW ..................................... 9

PIQ.220

[For each of the following statements, please tell me how well {CHILD}'s school has done with each
activity during this school year.] The school provides workshops, materials, or advice about how to help
{CHILD} learn at home. Would you say {CHILD}'s school…
Does this very well, .............................. 1
Just OK, or .......................................... 2
Doesn’t do this at all?........................... 3
REFUSED ........................................... 8
DON’T KNOW ..................................... 9

PIQ.230

[For each of the following statements, please tell me how well {CHILD}'s school has done with each
activity during this school year.] The school provides information on community services to help
{CHILD} or your family. Would you say {CHILD}'s school…
Does this very well, .............................. 1
Just OK, or .......................................... 2
Doesn’t do this at all?........................... 3
REFUSED ........................................... 8
DON’T KNOW ..................................... 9

PIQ.290

How often in the past month has {CHILD}'s teacher sent home ideas for things to do with {CHILD} at
home? (THIS INCLUDES HOMEWORK.)Would you say…
Never, .............................................. 1
One or two times, or….……………… 2
Three or more times?........................ 3
REFUSED ........................................ 8
DON’T KNOW .................................. 9

PIQ.300

About how many parents of children in {CHILD}'s class do you talk with regularly, either in person, on
the phone, or by texting, e-mailing, or using a social networking site?
CAPI INSTRUCTION: RANGE: 0 to 40.

NUMBER
REFUSED………………………………. 88
DON’T KNOW………………………….. 99

PIQ.305

Does {CHILD} have any older brothers or sisters who attend or attended the same school?

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

PIQ.400

{Last time we spoke to you/Earlier}, you said that (ENGLISH/NON-ENGLISH LANGUAGE/a language
other than English) is spoken in your home. When {CHILD}'s teacher sends home notes or
newsletters, are these in (ENGLISH/NON-ENGLISH LANGUAGE/a language that you speak)?
CAPI INSTRUCTIONS:
FOR FALL K CONTINUING HOUSEHOLDS:
DISPLAY “The last time we spoke to you”.
IF PLQ.020=2 FROM FALL K (NO OTHER LANGUAGE REGULARLY SPOKEN AT HOME BESIDES
ENGLISH) OR IF PLQ.060=0 FROM FALL K (ENGLISH SPOKEN AS PRIMARY LANGUAGE),
DISPLAY 'English.'
OTHERWISE, DISPLAY THE LANGUAGE SPECIFIED IN PLQ.060 FROM FALL K.
IF FALL K PLQ.060=91, DISPLAY THE OTHER SPECIFY TEXT.
IF FALL K PLQ.060=16, DK, RF, DISPLAY "a language other than English" AND “a language that you
speak”.
FOR FALL K NON-RESPONDENTS:
DISPLAY “Earlier”.
IF SPQ.155=2 (NO OTHER LANGUAGE REGULARLY SPOKEN AT HOME BESIDES ENGLISH), DK,
RF, OR SPQ.157=0 (ENGLISH SPOKEN AS PRIMARY LANGUAGE), DISPLAY 'English.'
OTHERWISE, DISPLAY THE LANGUAGE SPECIFIED IN SPQ.157.
IF SPQ.157=91, DISPLAY TEXT FROM OTHER SPECIFY.
IF SPQ.157=16, DK, RF, DISPLAY "a language other than English" AND “a language that you speak”.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

PIQ.410This year, have the following reasons made it harder for you to participate in activities at {CHILD}'s school?
Inconvenient meeting times? Has that made it harder for you to participate in activities at {CHILD}'s school?

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………
PIQ.420

1
2
8
9

[This year, have the following reasons made it harder for you to participate in activities at {CHILD}'s
school?] No child care keeps your family from going to school meetings or events? Has that made it
harder for you to participate in activities at {CHILD}'s school?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

PIQ.430

[This year, have the following reasons made it harder for you to participate in activities at {CHILD}'s
school?] Family members can't get time off from work? (Has that made it harder for you to
participate in activities at {CHILD}'s school?)

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………
PIQ.440

1
2
8
9

[This year, have the following reasons made it harder for you to participate in activities at {CHILD}'s
school?] Problems with safety going to the school? (Has that made it harder for you to
participate in activities at {CHILD}'s school?)
YES ............................................................
NO ..............................................................
REFUSED ...................................................

1
2
8

DON'T KNOW…………………………………… 9
PIQ.450

[This year, have the following reasons made it harder for you to participate in activities at {CHILD}'s
school?] The school does not make your family feel welcome? (Has that made it harder for you to
participate in activities at {CHILD}'s school?)

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………
PIQ.460

1
2
8
9

[This year, have the following reasons made it harder for you to participate in activities at {CHILD}'s
school?] Problems with transportation to the school? (Has that made it harder for you to
participate in activities at {CHILD}'s school?)

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

BOX 1
IF IT IS A FALL-K CONTINUING HOUSEHOLD AND PLQ.020=1 FROM FALL K (OTHER LANGUAGE
REGULARLY SPOKEN AT HOME BESIDES ENGLISH) OR IF PLQ060 NE 0 FROM FALL K (ENGLISH
NOT SPOKEN AS PRIMARY LANGUAGE), GO TO PIQ.470.
IF IT IS A FALL K NON-RESPONDENTS AND SPQ.155=1 (OTHER LANGUAGE REGULARLY
SPOKEN AT HOME BESIDES ENGLISH), OR SPQ.157 NE 0 (ENGLISH NOT SPOKEN AS PRIMARY
LANGUAGE), GO TO PIQ.470.
ELSE, GO TO PIQ.480

PIQ.470

[This year, have the following reasons made it harder for you to participate in activities at {CHILD}'s
school?] Problems because you or members of your family speak a language other than English and
meetings are conducted only in English? (Has that made it harder for you to participate in activities at
{CHILD}'s school?)

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………
PIQ.480

[This year, have the following reasons made it harder for you to participate in activities at {CHILD}'s
school?] You don't hear about things going on at school that you might want to be involved in? (Has
that made it harder for you to participate in activities at {CHILD}'s school?)
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

PIQ.490

1
2
8
9

Would you say that you are very satisfied, somewhat satisfied, somewhat dissatisfied or very dissatisfied
with the school {CHILD} attends this year?
VERY SATISFIED .......................................
SOMEWHAT SATISFIED ............................
SOMEWHAT DISSATISFIED .......................
VERY DISSATISFIED..…………………………
REFUSED………………………………………..
DON’T KNOW……………………………………

PIQ.491

1
2
8
9

1
2
3
4
8
9

About how far would you say it is from your home to the school {CHILD} attends?
LESS THAN 1/8TH MILE (LESS THAN 3 BLOCKS)…………………..1
(PIQ.492)
1/8TH MILE TO 1/4 MILE (3-5 BLOCKS)…………………………...…...2 (PIQ.492)
MORE THAN 1/4 MILE, BUT LESS THAN 1/2 MILE (6-9 BLOCKS)...3 (PIQ.492)
1/2 MILE TO LESS THAN 1 MILE (10-19 BLOCKS)…………………...4 (PIQ.492)
ONE MILE TO 2.5 MILES (LESS THAN 5 MINUTE DRIVE)…………..5 (PIQ.492)
2.6 MILES TO 5 MILES (BETWEEN 5-10 MINUTE DRIVE)…………...6 (PIQ.492)
5.1 MILES TO 7.5 MILES (BETWEEN 11 AND 15 MINUTE DRIVE)…7 (PIQ.492)
7.6 MILES TO 10 MILES (BETWEEN 16 AND 20 MINUTE DRIVE)….8 (PIQ.492)
10.1 MILES OR MORE (MORE THAN 20 MINUTE DRIVE)……….…..9 (PIQ.492)
OTHER (SPECIFY)………………………………………………………….91 (PIQ.491OS)
REFUSED……………………………………………………………………88 (PIQ.492)
DON’T KNOW……………………………………….……………………….99 (PIQ.492)

PIQ.491OS

[About how far would you say it is from your home to the school {CHILD} attends?]

_______________________________________
SPECIFY DISTANCE

PIQ.492

How does {CHILD} usually get to school in the morning?
SCHOOL BUS……………………………………. 1 (PIQ.493)
PARENT DRIVES (HIM/HER)………………….. 2 (PIQ.493)
CARPOOL………………………………………… 3 (PIQ.493)
WALK………………………………………………. 4 (PIQ.493)
RIDES A BIKE OR SCOOTER………………….. 5 (PIQ.493)
OTHER (SPECIFY)………………………………..91 (PIQ.492S)
REFUSED………………………………………….. 8 (PIQ.493)
DON’T KNOW……………………………………… 9 (PIQ.493)

PIQ.492OS

[How does {CHILD} usually get to school in the morning?]

_______________________________________
SPECIFY

PIQ.493

How long does this take? Would you say…
Less than 15 minutes, ............................... 1
15-30 minutes, or...................................... 2
More than 30 minutes? ............................. 3
REFUSED ................................................ 8
DON’T KNOW .......................................... 9

PIQ.494

On school days, how much time does {CHILD} have between arriving at school and classes starting?
Would you say…

Less than 10 minutes, .................................
10-20 minutes, or ........................................
More than 20 minutes? ................................
REFUSED ...................................................
DON’T KNOW .............................................

BOX 2
GO TO SECTION FSQ (FAMILY STRUCTURE).

1
2
3
7
9

FAMILY STRUCTURE - FSQ

BOX 1
FALL K CONTINUING RESPONDENTS (THIS INCLUDES (1) FALL K RESPONDENTS WHO PARTICIPATED IN
THE FALL AND THE RESPONDENT IS THE SAME IN THE FALL AND SPRING, AND (2) NEW SPRING K
RESPONDENTS WHOSE HOUSEHOLDS PARTICIPATED IN THE FALL, BUT THERE IS A NEW RESPONDENT IN
THE SPRING), GO TO FSQ010.
FALL K NON-RESPONDENTS: GO TO FSQ020.
FSQ.010

Now I have a few questions about your household. We have listed that (READ NAMES FROM
MATRIX) lived in this household at the time of our last interview.
As I read each person's name again, please tell me if he or she still lives in this household.
Does {NAME} still live in this household?
CAPI MATRIX INSTRUCTIONS:
1. DISPLAY 'still' IN UNDERLINED TEXT..
2. DISPLAY THE COMPLETED HOUSEHOLD MATRIX FROM THE ROUND 1 INTERVIEW. THIS
INCLUDES THE PERSON TYPE, FIRST NAME, LAST NAME, AGE, AND GENDER COLUMNS.
THESE COLUMNS SHOULD BE PROTECTED, THAT IS, INFORMATION CANNOT BE CHANGED.
CHANGES MADE AT INQ.130 AND INQ.170 SHOULD SHOW UP ON THE MATRIX AT FSQ.010. FOR
CONTINUING HOUSEHOLDS, CHANGES MADE AT INQ.112 AND INQ.116 SHOULD BE REFLECTED
IN THE FSQ.010 MATRIX.
3. ADD AS THE 6TH COLUMN TO THE MATRIX, 'STILL HERE'. DISPLAY 'Y' IF PERSON STILL
LIVES IN THE HOUSEHOLD AND 'N' IF THE PERSON DOES NOT (BASED ON HOW FSQ010 IS
CODED).
4. THE CURSOR SHOULD START AT THE 'STILL HERE' COLUMN FOR THE FIRST PERSON
LISTED IN THE MATRIX.
5. DISPLAY BRACKETS [ ] AROUND THE FIRST TWO PARAGRAPHS WHENEVER IN THE 'STILL
HERE' COLUMN FOR SOMEONE OTHER THAN THE FIRST PERSON LISTED ON THE MATRIX.
(THE FIRST TWO PARAGRAPHS SHOULD BE DISPLAYED WITHOUT THE BRACKETS WHEN YOU
FIRST ARRIVE AT THIS QUESTION.)
6. ADD AS THE 7TH COLUMN TO THE MATRIX, 'REASON LEFT’(FSQ.015).
7. IF THE 'STILL IN HH' COLUMN IS CODED 'NO', THE CURSOR SHOULD MOVE RIGHT TO THE
'REASON LEFT' COLUMN. IF THE 'STILL IN HH' IS CODED 'YES', THE CURSOR SHOULD MOVE TO
THE 'STILL HERE' COLUMN FOR THE NEXT PERSON ON THE MATRIX (THE 'REASON LEFT'
COLUMN DOES NOT NEED TO BE COMPLETED IN THIS INSTANCE).
8. ADD AS THE 8TH COLUMN TO THE MATRIX, 'REASON LEFT OTHER' (FSQ.015OS).
9. THE MATRIX CANNOT HAVE MORE THAN 25 ROW ENTRIES.
10. IF QUESTION IS ABOUT THE RESPONDENT AND INQ.055 NE 0 (RESPONDENT IS NOT A NEW
HOUSEHOLD MEMBER) AND FSQ.010 = 2 (NOT IN HH), DISPLAY ERROR MESSAGE: 'THIS
PERSON CANNOT BE THE RESPONDENT AND NOT BE IN THE HOUSEHOLD.'
YES…………… 1 (GO TO 'STILL HERE' COLUMN FOR THE NEXT PERSON IN THE MATRIX)
NO……………..2 (FSQ.015)

FSQ.015

Why is {NAME} no longer living in this household?
CODE ALL THAT APPLY
CAPI MATRIX INSTRUCTIONS:
1. DISPLAY THIS QUESTION WHENEVER IN THE 'REASON LEFT' COLUMN.
2. ONCE THIS ITEM IS CODED, THE CURSOR SHOULD MOVE TO THE 'STILL HERE' COLUMN
FOR THE NEXT PERSON ON THE MATRIX.
3. HOWEVER, IF SOME OTHER REASON IS CODED, THEN FSQ015OS MUST FIRST BE
COMPLETED BEFORE MOVING TO THE NEXT PERSON ON THE MATRIX.
SEPARATION OR DIVORCE……………………………………………1
ATTENDING COLLEGE OR BOARDING SCHOOL…………………..2
LIVING ELSEWHERE FOR EMPLOYMENT- RELATED REASONS 3
DECEASED…………………………………………………………...…...4
MOVED ON/MOVED
ELSEWHERE……………………………………………………...……5
ROSTER ERROR……………………………………………………….6
MOVED BACK WITH PARENTS………………………………...……7
SOME OTHER REASON (SPECIFY)…………………………………91
REFUSED………………………………………………………………..88
DON’T KNOW………………………………………………….………...99

FSQ.015OS

[Why is {NAME} no longer living in this household?]
CAPI MATRIX INSTRUCTIONS.
1. DISPLAY 'REASON LEFT OTHER' AS THE 8TH COLUMN IN THE MATRIX.
2. DISPLAY THIS QUESTION WHENEVER IN THE 'REASON LEFT OTHER' COLUMN.
3. THIS COLUMN ONLY NEEDS TO BE COMPLETED IF CODE 91 IS SELECTED AS A REASON IN
THE 'WHY REASON LEFT' COLUMN.

_______________________________________
ENTER OTHER REASON
FSQ.017

Other than the people I just asked about, is there anyone else currently living in this household? For
example, anyone who has moved in or any babies born since our last interview? Please do not include
anyone staying here temporarily who usually lives somewhere else.
YES ............................................................ 1 (FSQ.020)
NO .............................................................. 2 (FSQ.060)
REFUSED ................................................... 8 (FSQ.060)
DON'T KNOW…………………………………...9 (FSQ.060)

FSQ.020

{Now I have a few questions about your household. We have noted that you and {CHILD} currently
live in this household.} {Please tell me the names and ages of all the other people who normally live
here. Please do not include anyone staying here temporarily who usually lives somewhere else.}

{PROBE: Anyone else (living in this household)?}
{ENTER FIRST NAME OF {NEW} HOUSEHOLD MEMBER OR PRESS ENTER IF MATRIX IS
COMPLETE.}
{YOU WILL NEED TO ENTER THE NAME, AGE, AND GENDER OF EACH HOUSEHOLD MEMBER
NAMED BEFORE LEAVING THE MATRIX.}
{PRESS ENTER TO RECORD THE AGE AND GENDER OF THE RESPONDENT OR PRESS THE
DOWN ARROW KEY TO ADD A HOUSEHOLD MEMBER.}

CAPI MATRIX INSTRUCTIONS:
1. DISPLAY THE HOUSEHOLD MATRIX (PERSON TYPE, FIRST NAME, LAST NAME, AGE, AND
GENDER COLUMNS.)
2. THE INTERVIEWER CAN ADD UP TO 25 ROW ENTRIES.
3. THE INTERVIEWER CAN MOVE ALL AROUND THE MATRIX USING THE ARROW KEYS
(EXCEPT ON PROTECTED FIELDS).
4. IF A FALL-K CONTINUING HOUSEHOLD:
a. DISPLAY ALL HOUSEHOLD MEMBERS AND ASSOCIATED INFORMATION AS COLLECTED IN
THE FALL. HOWEVER, DO NOT DISPLAY THE NAMES OF THOSE HH MEMBERS THAT WERE
CODED '2' AT FSQ010 (NOT IN HH ANYMORE).
b. ALL PREVIOUS HH MEMBER ROWS SHOULD BE PROTECTED. THE CURSOR SHOULD
APPEAR ON THE FIRST BLANK FIRST NAME COLUMN.
c. WHEN ON THE FIRST BLANK FIRST NAME COLUMN DISPLAY "Please tell…somewhere else.",
"PROBE: … household", "ENTER FIRST …COMPLETE", AND THE "NEW" IN THAT SCREEN
INSTRUCTION.
d. WHEN ON THE SECOND BLANK FIRST NAME COLUMN, DISPLAY THE "PLEASE
TELL…SOMEWHERE ELSE." IN BRACKETS [ ]. THE PROBE AND SCREEN INSTRUCTION CITED
ABOVE SHOULD ALSO CONTINUE TO BE DISPLAYED.
5. IF A FALL-K NONRESPONSE HOUSEHOLD:
a. DISPLAY THE RESPONDENT'S FIRST AND LAST NAMES IN THE APPROPRIATE COLUMNS
(COLLECTED AT INQ060/070). DISPLAY 'R' IN THE FIRST COLUMN TO INDICATE THAT PERSON
IS THE RESPONDENT.
b. DISPLAY THE NAME OF THE FOCAL CHILD IN THE SECOND ROW OF THE FIRST AND LAST
NAME COLUMNS. DISPLAY 'C' IN THE FIRST COLUMN TO INDICATE THAT PERSON IS THE
FOCAL CHILD. DISPLAY THE AGE AND GENDER OF THE CHILD IN THE APPROPRATE COLUMNS
OF THE SECOND ROW.
THIS ROW IS PROTECTED.
c. DISPLAY THE FIRST PARAGRAPH "Now…somewhere else." WHEN YOU FIRST ARRIVE AT
FSQ020. ALSO DISPLAY THIS PARAGRAPH IN BRACKETS [ ] WHENEVER YOU ARE IN THE FIRST
NAME COLUMN FOR ANY PERSON OTHER THAN PERSON NUMBER 1 (THE RESPONDENT).
d. DISPLAY "YOU WILL NEED…THE MATRIX." AND "PRESS ENTER TO…A HOUSEHOLD
MEMBER" WHENEVER THE CURSOR IS POSITIONED IN THE FIRST NAME COLUMN FOR
PERSON NUMBER 1.
e. DISPLAY "ENTER FIRST NAME…IF MATRIX IS COMPLETE." WHENEVER THE CURSOR IS
POSITIONED IN THE FIRST NAME COLUMN FOR A ROW OTHER THAN PERSON NUMBER 1 (THE
FIRST BLANK ROW AFTER CHILD).
f. DISPLAY "PROBE:… household)?" WHENEVER THE CURSOR IS POSITIONED IN THE FIRST
NAME COLUMN FOR SOMEONE OTHER THAN PERSON NUMBER 1 OR THE FIRST HOUSEHOLD
MEMBER ADDED AFTER THE CHILD.

FSQ.025

ENTER LAST NAME OF {NAME}.
DISPLAY THIS QUESTION WHEN THE CURSOR IS POSITIONED IN THE LAST NAME COLUMN OF
THE HOUSEHOLD MATRIX.

FSQ.030

How old {are you/is {NAME}}?
ENTER AGE OF {NAME}.

CAPI INSTRUCTIONS: RANGE: 0 to 120.
DISPLAY THIS QUESTION WHEN THE CURSOR IS POSITIONED IN THE AGE COLUMN OF THE
HOUSEHOLD MATRIX.
DISPLAY "are you" WHEN THE CURSOR IS POSITIONED IN THE AGE COLUMN FOR THE
RESPONDENT'S ROW AND "is {NAME}" (DISPLAY THE APPROPRIATE FIRST NAME) WHEN THE
CURSOR IS POSITIONED IN THE AGE COLUMN FOR SOMEONE OTHER THAN THE
RESPONDENT'S ROW.
REFUSED ........................................... … 8
DON'T KNOW………………………………….9
FSQ.040

CODE IF OBVIOUS. OTHERWISE, ASK: {Are you/Is {NAME}} male or female?}

ENTER GENDER OF {NAME}.
CAPI INSTRUCTIONS: DISPLAY THIS QUESTION WHEN THE CURSOR IS POSITIONED IN THE
GENDER COLUMN.
CAPI INSTRUCTIONS: DISPLAY "Are you" WHEN THE CURSOR IS POSITIONED IN THE GENDER
COLUMN FOR THE RESPONDENT'S ROW AND "Is {NAME}" (DISPLAY THE APPROPRIATE FIRST
NAME) WHEN THE CURSOR IS POSITIONED IN THE GENDER COLUMN FOR SOMEONE OTHER
THAN THE RESPONDENT'S ROW.
MALE ..........................................................
FEMALE .....................................................
REFUSED ...................................................
DON'T KNOW………………………………….
FSQ.045

1
2
8
9

CHECK HOUSEHOLD MATRIX. IF ANY BLANK FIELDS, RETURN THE CURSOR TO THE BLANK
FIELD ON THE MATRIX AND DISPLAY THE APPROPRIATE ERROR MESSAGE. IF HOUSEHOLD
MATRIX IS COMPLETE, PRESS 1 AND ENTER TO CONTINUE.

FSQ.060

Have we missed anyone who usually lives here who is temporarily away from home or living in a dorm at
school, or any babies or small children?
{YOU WILL NEED TO ENTER THE NAME, AGE, AND GENDER OF EACH HOUSEHOLD MEMBER
NAMED BEFORE LEAVING THE MATRIX.}
{PRESS ENTER TO RECORD THE AGE AND GENDER OF THE RESPONDENT OR PRESS THE
DOWN ARROW KEY TO ADD A HOUSEHOLD MEMBER.}
{ENTER FIRST NAME OF {NEW} HOUSEHOLD MEMBER OR PRESS ENTER ON A BLANK FIELD IF
MATRIX IS COMPLETE.}
YES ............................................................ 1 (FSQ.020)
NO .............................................................. 2 (FSQ.070)
REFUSED ................................................... 8 (FSQ.070)
DON'T KNOW…………………………………...9 (FSQ.070)

FSQ.070

FLAG THE PERSON SELECTED AS THE RESPONDENT FOR THE SPRING-K ROUND. THE 'R' IN
THE PERSON TYPE COLUMN OF THE HOUSEHOLD MATRIX SHOULD ONLY SHOW UP FOR
THE PERSON SELECTED HERE.
ENTER THE NUMBER NEXT TO THE NAME OF THE PERSON WHO IS THE RESPONDENT.
CAPI INSTRUCTIONS: DISPLAY HOUSEHOLD MEMBERS OVER 16 YEARS OF AGE AS
RESPONSE CATEGORY CHOICES. (LINES FOR 8 HH MEMBERS ARE SHOWN BELOW, BUT UP TO
25 SHOULD BE DISPLAYED DEPENDING ON THE HOUSEHOLD). DO NOT DISPLAY THE NAMES
OF HOUSEHOLD MEMBERS CODED AS NO LONGER LIVING IN THE HOUSEHOLD AT FSQ.010.
CODE THE RESPONDENT.

{DISPLAY HH MEMBER NAME 1}……………….. 1
{DISPLAY HH MEMBER NAME 2}……………….. 2
{DISPLAY HH MEMBER NAME 3}……………….. 3
{DISPLAY HH MEMBER NAME 4}……………….. 4
{DISPLAY HH MEMBER NAME 5}………………...5
{DISPLAY HH MEMBER NAME 6}………………...6
{DISPLAY HH MEMBER NAME 7}………………...7
{DISPLAY HH MEMBER NAME 8}………………...8
FSQ.110

Do you have a spouse or partner who lives in this household?
YES ............................................................ 1 (FSQ.120)
NO .............................................................. 2 (BOX 2)
REFUSED ................................................... 8 (BOX 2)
DON'T KNOW…………………………………...9 (BOX 2)

FSQ.120

Who in the household is your spouse or partner?
ENTER THE NUMBER NEXT TO THE NAME OF THE PERSON WHO IS {RESPONDENT}'S
SPOUSE/PARTNER.
IF NAME NOT LISTED, BACK UP AND ADD PERSON (IF PART OF HOUSEHOLD).
CAPI INSTRUCTIONS: DISPLAY HOUSEHOLD MEMBERS OVER 16 YEARS OF AGE AS
RESPONSE CATEGORY CHOICES. (LINES FOR 8 HH MEMBERS ARE SHOWN BELOW, BUT UP
TO 25 SHOULD BE DISPLAYED DEPENDING ON THE HOUSEHOLD). DO NOT DISPLAY THE
NAMES OF HOUSEHOLD MEMBERS CODED AS NO LONGER LIVING IN THE HOUSEHOLD AT
FSQ.010.
CAPI INSTRUCTIONS: DO NOT DISPLAY THE RESPONDENT’S NAME.
CAPI INSTRUCTIONS: FLAG PERSON SELECTED AT FSQ.120 AS “RESPONDENT’S
SPOUSE/PARTNER”.
CAPI INSTRUCTIONS: DISPLAY THE RESPONDENT'S FIRST NAME FOR {RESPONDENT}.

{DISPLAY HH MEMBER NAME 1}……………….. 1
{DISPLAY HH MEMBER NAME 2}……………….. 2
{DISPLAY HH MEMBER NAME 3}……………….. 3
{DISPLAY HH MEMBER NAME 4}……………….. 4
{DISPLAY HH MEMBER NAME 5}………………...5
{DISPLAY HH MEMBER NAME 6}………………...6
{DISPLAY HH MEMBER NAME 7}………………...7
{DISPLAY HH MEMBER NAME 8}………………...8

BOX 2
IF FALL K NON RESPONSE HOUSEHOLD:
CONTINUE WITH BOX 3.
IF FALL K CONTINUING HOUSEHOLD (INCLUDES FALL K RESPONDENTS AND NEW SPRING RESPONDENTS):
IF FSQ.017=1, CONTINUE WITH BOX 3.
IF FSQ.017=2, RF, DK, GO TO FSQ.200.

BOX 3
LOOP 1
IF FALL K NON RESPONSE HOUSEHOLD, ASK FSQ.130 - FSQ.180 FOR EACH PERSON ENUMERATED ON THE
HOUSEHOLD MATRIX (AT FSQ.020) WHO IS NOT THE FOCAL CHILD.
ELSE, IF FALL K CONTINUING HOUSEHOLD (INCLUDES FALL K RESPONDENTS AND NEW SPRING
RESPONDENTS), ASK FSQ.130 - FSQ.180 FOR EACH NEW PERSON ENUMERATED ON THE HOUSEHOLD
MATRIX (AT FSQ.020) WHO IS NOT THE FOCAL CHILD.

HELP AVAILABLE
FSQ.130

What is {your/{NAME}'s} relationship to {CHILD}?
{CODE RELATIONSHIP OF NEW HOUSEHOLD MEMBERS ONLY.}
CAPI INSTRUCTION: REFUSED AND DON’T KNOW ARE DISALLOWED FOR FSQ.130.
CAPI INSTRUCTIONS: DISPLAY THE RELATIONSHIP MATRIX.
CAPI INSTRUCTIONS: DO NOT DISPLAY THE FOCAL CHILD'S ROW.
CAPI MATRIX INSTRUCTIONS:
1. IF FALL-K CONTINUING HOUSEHOLD:
a. DO NOT DISPLAY THE NAMES OF HH MEMBERS NOT LIVING IN THE HOUSEHOLD (CODED '2'
AT FSQ010).
b. THE NAMES AND RELATIONSHIPS OF HOUSEHOLD MEMBERS COLLECTED LAST ROUND
SHOULD BE PROTECTED.
c. THE CURSOR SHOULD START IN THE FIELD FOR THE FIRST NEW PERSON ADDED AT
FSQ020 THIS ROUND.
d. DISPLAY "CODE RELATIONSHIP…ONLY."
e. DISPLAY “your” IF LOOPING ON A NEW RESPONDENT. OTHERWISE, DISPLAY “{NAME}’s”
USING THE NAME OF THE NEW HOUSEHOLD MEMBER THAT IS BEING LOOPED ON.
2. IF FALL-K NONRESPONSE HOUSEHOLD:
a. DISPLAY ALL NAMES COLLECTED AT FSQ.020.
b. THE CURSOR SHOULD BEGIN IN THE COLUMN FOR THE RELATIONSHIP OF THE
RESPONDENT TO THE CHILD.
c. DISPLAY “your” IF LOOPING ON THE RESPONDENT. OTHERWISE, DISPLAY “{NAME}’s” USING
THE NAME OF THE HOUSEHOLD MEMBER THAT IS BEING LOOPED ON.
HELP TEXT:
Mother/Female Guardian: The female primarily responsible for the child. Includes birth or biological
mothers, adoptive, step, foster, and other mothers, as well as, legal female guardians.
Father/Male Guardian: The male primarily responsible for the child. Includes birth or biological fathers,
adoptive, step, foster, and other fathers, as well as, legal male guardians.
Sister: Include biological (full, half), adoptive, step, and foster sisters.
Brother: Include biological (full, half), adoptive, step, and foster brothers.
Girlfriend or Female Partner of CHILD's Parent/Guardian: The female who has a "partner-like"
relationship with one of the child's parents or guardians. "Living as married" is another way of describing
the relationship.
Boyfriend or Male Partner of CHILD's Parent/Guardian: The male who has a "partner-like"
relationship with one of the child's parents or guardians. "Living as married" is another way of describing
the relationship.
Grandmother: The female parent of the child's biological or adoptive mother or father .
Grandfather: The male parent of the child's biological or adoptive mother or father.
Aunt: The sister of the child's biological or adoptive mother or father or the wife of the child's uncle.
Uncle: The brother of the child's biological or adoptive mother or father or the husband of the child's
aunt.

Cousin: A child of the focal child's uncle, aunt, or cousin.
Other Relative: Refers to relationships that aren't specifically listed, such as great grandmother, niece,
or nephew.
Other Non-relative: Refers to the relationship between two people when there is no family relationship
through blood, marriage, adoption, or partnership (i.e., living together as married). It also refers to more
ambiguous relationships that exist where there are two people living together as married and they have
children. For example, the child's father and the father's girlfriend (who is not the child's mother) live
together as married and the girlfriend's daughter lives with them. The relationship of the girlfriend's
daughter to the child would be siblings if they were married, but since the father and the girlfriend are not
married, she is an "other non-relative." If the "other non-relative" is coded, you will receive a list of other
codes to use if they are more descriptive than "other non-relative."
MOTHER/FEMALE GUARDIAN………………………………..……………..….. 1 (FSQ.140)
FATHER/MALE GUARDIAN…………………………………………….…………..2 (FSQ.150)
SISTER……………………………………………………………………….…….….3 (FSQ.160)
BROTHER………………………………………….…………………………….……4 (FSQ.170)
GIRLFRIEND OR FEMALE PARTNER OF {CHILD}'S PARENT/GUARDIAN…5 (BOX 4)
BOYFRIEND OR MALE PARTNER OF {CHILD}'S PARENT/GUARDIAN……..6 (BOX 4)
GRANDMOTHER……………………………………………………………………..7 (BOX 4)
GRANDFATHER………………………………………………...……………………8 (BOX 4)
AUNT……………………………………………………………...…………………...9 (BOX 4)
UNCLE…………………………………………………………...………………..…10 (BOX 4)
COUSIN………………………………………………………...…………………….11 (BOX 4)
OTHER RELATIVE…………………………………………………………………..12 (BOX 4)
OTHER NON-RELATIVE……………………………………………………………13 (FSQ180)

HELP AVAILABLE
FSQ.140

{Are you/Is {NAME}} {CHILD}'s…
CAPI INSTRUCTION: DISPLAY “Are you” IF LOOPING ON THE RESPONDENT. OTHERWISE,
DISPLAY “Is {NAME}” USING THE NAME OF THE HOUSEHOLD MEMBER THAT IS BEING LOOPED
ON.
HELP TEXT:
Biological or Birth Mother: Child's female biological parent. This may be the birth mother, but could
also apply to a mother who used a surrogate mother to have her biological child.
Adoptive Mother: The female who has taken the child into her own family by legal process to raise as
her own child.
Step Mother: The female other than the child's mother who is married to the child's father.
Foster Mother: The female with whom the child is placed temporarily, usually through a social service
agency and/or a court.
Female Guardian: The female legally placed in charge of the affairs of the child.
Other Female Parent or Guardian: This person acts as the mother to the child, but does not fit into one
of the other categories. For example, in a household with two mothers, one of the mothers may not
classify herself as biologically related and she may not be legally in charge of the affairs of the child even
though she is another parent to the child. This category may also be used if a mother has a child through
a surrogate mother, or with a donated egg, and does not classify the child as biologically related or
adopted through a legal process.
Biological or birth mother, ............................
Adoptive mother, .........................................
Step mother, ...............................................
Foster mother or female guardian, or............
Other female parent or guardian...................
REFUSED ...................................................
DON’T KNOW .............................................

1
2
3
4
5
8
9

(BOX 4)
(BOX 4)
(BOX 4)
(BOX 4)
(BOX 4)
(BOX 4)
(BOX 4)

FSQ.150

HELP AVAILABLE
{Are you/Is {NAME}} {CHILD}'s…
CAPI INSTRUCTION: DISPLAY “Are you” IF LOOPING ON THE RESPONDENT. OTHERWISE,
DISPLAY “Is {NAME}” USING THE NAME OF THE HOUSEHOLD MEMBER THAT IS BEING LOOPED
ON.

HELP TEXT:
Biological or Birth Father: Child's male biological parent. This could also apply to a father who used a
surrogate mother to have his biological child.
Adoptive Father: The male who has taken the child into his own family by legal process to raise as his
own child.
Step Father: The male other than the child's father who is married to the child's mother.
Foster Father: The male with whom the child is placed temporarily, usually through a social service
agency and/or a court.
Male Guardian: The male legally placed in charge of the affairs of the child.
Other Type of Father: This person acts as the father to the child, but does not fit into one of the other
categories. For example, in a household with two fathers, one of the fathers may not classify himself as
biologically related and he may not be legally in charge of the affairs of the child even though he is
another parent to the child. This category may also be used if a father has a child through a surrogate
mother, or with donated sperm, and does not classify the child as biologically related or adopted through
a legal process.
Biological or birth father, ..............................
Adoptive father, ...........................................
Step father, or .............................................
Foster father or male guardian? ...................
Other male parent or guardian .....................
REFUSED ...................................................
DON’T KNOW .............................................

1
2
3
4
5
8
9

(BOX 4)
(BOX 4)
(BOX 4)
(BOX 4)
(BOX 4)
(BOX 4)
(BOX 4)

HELP AVAILABLE
FSQ.160

{Are you/Is {NAME}} {CHILD}'s…
CAPI INSTRUCTION: DISPLAY “Are you” IF LOOPING ON THE RESPONDENT. OTHERWISE,
DISPLAY “Is {NAME}” USING THE NAME OF THE HOUSEHOLD MEMBER THAT IS BEING LOOPED
ON.
HELP TEXT:
Full Sister: A female with whom the child shares the same biological parents.
Half Sister: A female with whom the child shares one biological parent.
Step Sister: A female to whom the child is unrelated except by the marriage of one biological parent.
Adoptive Sister: A female to whom the child is unrelated except that they are in the same family in
which she or the child has been legally adopted by the family.
Foster Sister: A female to whom the child is unrelated except that they are in the same family in which
she or the child have been taken into the home on a temporary basis and the parents have legal
responsibility for the child.
Full sister,.................................................... 1 (BOX 4)
Half sister, ................................................... 2 (BOX 4)
Step sister, .................................................. 3 (BOX 4)
Adoptive sister, or ........................................ 4 (BOX 4)
Foster sister? .............................................. 5 (BOX 4)
REFUSED ................................................... 8 (BOX 4)
DON’T KNOW ............................................. 9 (BOX 4)
HELP AVAILABLE

FSQ.170

{Are you/Is {NAME}} {CHILD}'s…

CAPI INSTRUCTION: DISPLAY “Are you” IF LOOPING ON THE RESPONDENT. OTHERWISE,
DISPLAY “Is {NAME}” USING THE NAME OF THE HOUSEHOLD MEMBER THAT IS BEING LOOPED
ON.
HELP TEXT:
Full Brother: A male with whom the child shares the same biological parents.
Half Brother: A male with whom the child shares one biological parent.
Step Brother: A male to whom the child is unrelated except by the marriage of one biological parent.
Adoptive Brother: A male to whom the child is unrelated except that they are in the same family in
which he or the child has been legally adopted by the family.
Foster Brother: A male to whom the child is unrelated except that they are in the same family in which
he or the child have been taken into the home on a temporary basis and the parents have legal
responsibility for the child.
Full brother, ................................................. 1 (BOX 4)
Half brother, ................................................ 2 (BOX 4)
Step brother, ............................................... 3 (BOX 4)
Adoptive brother, or ..................................... 4 (BOX 4)
Foster brother? ............................................ 5 (BOX 4)
REFUSED ................................................... 8 (BOX 4)
DON’T KNOW ............................................. 9 (BOX 4)

HELP AVAILABLE
FSQ.180

CODE NON-RELATIVE RELATIONSHIP BELOW IF MORE DESCRIPTIVE.

CAPI INSTRUCTIONS: IF FSQ.180 IS CODED 1 (GIRLFRIEND), FLAG RESPONSE TO FSQ.130 AS
CODE 5.
CAPI INSTRUCTIONS: IF FSQ.180 IS CODED 2 (BOYFRIEND), FLAG RESPONSE TO FSQ.130 AS
CODE 6.
CAPI INSTRUCTIONS: IF FSQ.180 IS CODED 3 (FEMALE GUARDIAN), FLAG RESPONSE TO
FSQ.130 AS CODE 1 AND RESPONSE TO FSQ.140 AS CODE 4.
CAPI INSTRUCTIONS: IF FSQ.180 IS CODED 4 (MALE GUARDIAN), FLAG RESPONSE TO FSQ.130
AS CODE 2 AND RESPONSE TO FSQ.150 AS CODE 4.
HELP TEXT:
Girlfriend or Female Partner of CHILD's Parent/Guardian: The female who has a "partner-like"
relationship with one of the child's parents or guardians. "Living as married" is another way of describing
the relationship.
Boyfriend or Male Partner of CHILD's Parent/Guardian: The male who has a "partner-like"
relationship with one of the child's parents or guardians. "Living as married" is another way of describing
the relationship.
Female Guardian: The female legally placed in charge of the affairs of the child.
Male Guardian: The male legally placed in charge of the affairs of the child.
Daughter/son of CHILD's Parent's Partner: The child of the person who has a "partner-like"
relationship with one of the child's parents or guardians.
Other Relative of CHILD's Parent's Partner: Some other relative of the person who has a "partner-like"
relationship with one of the child's parents or guardians.
Other Non-relative: If one of the codes for non-relative above does not better describe the relationship
of the person to the child, and there is no family relationship through blood, marriage, adoption, or
partnership (i.e., living together as married), use this code.

GIRLFRIEND OR FEMALE PARTNER OF {CHILD}'S PARENT/GUARDIAN…..1 (BOX 4)
BOYFRIEND OR MALE PARTNER OF {CHILD}'S PARENT/GUARDIAN………2 (BOX 4)
FEMALE GUARDIAN…………………………………………………………………..3 (BOX 4)
MALE GUARDIAN……………………………………………………………………...4 (BOX 4)
DAUGHTER/SON OF {CHILD}'S PARENT’S PARTNER………………………….5 (BOX 4)
OTHER RELATIVE OF {CHILD}'S PARENT’S PARTNER………………………...6 (FSQ.181)
OTHER NON-RELATIVE (SPECIFY)………………………………………………..91
REFUSED……………………………………………………………………………...88 (BOX 4)
DON’T KNOW……………………………………………………………………….…99 (BOX 4)

FSQ.181

_______________________________________
SPECIFY OTHER NON-RELATIVE.

BOX 4
END LOOP 1.
ASK FSQ130 - FSQ180 FOR NEXT PERSON ON THE HOUSEHOLD ROSTER WHO IS NOT THE FOCAL CHILD.
IF NO NEXT PERSON, CONTINUE WITH FSQ.190.
HELP AVAILABLE
FSQ.190

{Are you/Is {NAME}} Hispanic or Latino?

{CODE HISPANIC OR LATINO FOR NEW HOUSEHOLD MEMBERS ONLY. IF NO NEW PERSONS,
PRESS ENTER TO CONTINUE.}
CAPI MATRIX INSTRUCTIONS:
DISPLAY IN COLUMN 1 EACH PERSON ENUMERATED ON THE HOUSEHOLD ROSTER (AT
FSQ.020) WHO IS THE FOCAL CHILD, RESPONDENT, MOTHER FIGURE (CODE ‘1’ AT FSQ.130),
OR FATHER FIGURE (CODE ‘2’ AT FSQ.130).
IF NO MOTHER OR FATHER FIGURES IN THE HOUSEHOLD (NO HOUSEHOLD MEMBERS WITH A
CODE ‘1’ OR ‘2’ AT FSQ.130), DISPLAY IN COLUMN 1 THE FOCAL CHILD, THE RESPONDENT, AND
THE RESPONDENT’S SPOUSE/PARTNER (HOUSEHOLD MEMBER SELECTED AT FSQ.120, IF
ANY).
NOTE: IF THE RESPONDENT IS A MOTHER OR FATHER FIGURE, ONLY DISPLAY HIS/HER NAME
ONCE.
NOTE: DO NOT DISPLAY HOUSEHOLD MEMBERS CODED AS NOT LIVING IN THE HOUSEHOLD
AT FSQ.010.
THE CURSOR SHOULD BE POSITIONED ON THE FIRST BLANK FIELD. IF NO BLANK FIELDS, THE
CURSOR SHOULD BE POSITIONED ON THE LAST COMPLETED FIELD IN THE MATRIX.
IF FALL K CONTINUING HOUSEHOLDS, ASK ABOUT HISPANIC OR LATINO ONLY IF NEW
HOUSEHOLD MEMBERS ARE THE FOCAL CHILD'S PARENTS OR THE RESPONDENT, OR IF
THERE ARE NO PARENTS, THEN ASK ABOUT THE RESPONDENT AND RESPONDENT'S
SPOUSE/PARTNER (IF THEY ARE NEW).
DISPLAY “Are you” IF LOOPING ON A NEW
RESPONDENT. OTHERWISE, DISPLAY “Is {NAME}” USING THE NAME OF THE NEW HOUSEHOLD
MEMBER THAT IS BEING LOOPED ON.
IF FALL K NON-RESPONSE HOUSEHOLDS, ASK ABOUT HISPANIC OR LATINO FOR THE FOCAL
CHILD, RESPONDENT, MOTHER AND FATHER FIGURES. IF NO MOTHER OR FATHER FIGURES,
THEN ASK ABOUT THE FOCAL CHILD, THE RESPONDENT AND RESPONDENT'S
SPOUSE/PARTNER (IF ANY). DISPLAY “Are you” IF LOOPING ON THE RESPONDENT.
OTHERWISE, DISPLAY “Is {NAME}” USING THE NAME OF THE HOUSEHOLD MEMBER THAT IS
BEING LOOPED ON.
HELP TEXT:
Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin, regardless of race.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

HELP AVAILABLE
FSQ.195

What is {your/{NAME}'s} race? You may name one or more races to indicate what {you/NAME}
{consider/considers} {yourself/himself/herself} to be.
CAPI MATRIX INSTRUCTIONS:
DISPLAY IN COLUMN 1 EACH PERSON ENUMERATED ON THE HOUSEHOLD ROSTER (AT
FSQ.020) WHO IS THE FOCAL CHILD, RESPONDENT, MOTHER FIGURE (CODE ‘1’ AT FSQ.130),
OR FATHER FIGURE (CODE ‘2’ AT FSQ.130).
IF NO MOTHER OR FATHER FIGURES IN THE HOUSEHOLD (NO HOUSEHOLD MEMBERS WITH A
CODE ‘1’ OR ‘2’ AT FSQ.130), DISPLAY IN COLUMN 1 THE FOCAL CHILD, THE RESPONDENT, AND
THE RESPONDENT’S SPOUSE/PARTNER (HOUSEHOLD MEMBER SELECTED AT FSQ.120, IF
ANY).
NOTE: IF THE RESPONDENT IS A MOTHER OR FATHER FIGURE, ONLY DISPLAY HIS/HER NAME
ONCE.
NOTE: DO NOT DISPLAY HOUSEHOLD MEMBERS CODED AS NOT LIVING IN THE HOUSEHOLD
AT FSQ.010.
IF FALL K CONTINUING HOUSEHOLDS, ASK ABOUT RACE ONLY IF NEW HOUSEHOLD
MEMBERS ARE THE FOCAL CHILD'S PARENTS OR THE RESPONDENT OR IF THER ARE NO
PARENTS, THEN ABOUT THE RESPONDENT AND RESPONDENT'S SPOUSE/PARTNER (IF THEY
ARE NEW). DISPLAY “your”, “you”, “consider”, AND “yourself” IF LOOPING ON THE RESPONDENT.
OTHERWISE, DISPLAY “{NAME}”, “{NAME}”, “considers” AND (“himself” OR “herself”) USING THE
NAME OF THE HOUSEHOLD MEMBER THAT IS BEING LOOPED ON. DISPLAY “himself” IF THE
PERSON IS MALE AND “herself” IF THE PERSON IS FEMALE. IF GENDER IS MISSING, DISPLAY
“himself/herself”.
IF FALL K NON-RESPONSE HOUSEHOLDS, ASK ABOUT RACE FOR THE FOCAL CHILD,
RESPONDENT, MOTHER AND FATHER FIGURES. IF NO MOTHER OR FATHER FIGURES, THEN
ASK ABOUT THE FOCAL CHILD, THE RESPONDENT AND RESPONDENT'S SPOUSE/PARTNER (IF
ANY). DISPLAY “your”, “you”, “consider”, AND “yourself” IF LOOPING ON THE RESPONDENT.
OTHERWISE, DISPLAY “{NAME}”, “{NAME}”, “considers” AND (“himself” OR “herself”) USING THE
NAME OF THE HOUSEHOLD MEMBER THAT IS BEING LOOPED ON. DISPLAY “himself” IF THE
PERSON IS MALE AND “herself” IF THE PERSON IS FEMALE. IF GENDER IS MISSING, DISPLAY
“himself/herself”.

{CODE RACE OF NEW HOUSEHOLD MEMBERS ONLY. IF NO NEW PERSONS, PRESS ENTER TO
CONTINUE.}
CODE ALL THAT APPLY.
HELP TEXT:
American Indian or Alaska Native: A person having origins in any of the original peoples of North and
South America (including Central America), and who maintains tribal affiliation or community attachment.
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,
the Philippine Islands, Thailand, and Vietnam.
Black or African American: A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of

Hawaii, Guam, Samoa, or other Pacific Islands.
White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
AMERICAN INDIAN OR ALASKA NATIVE…………..……1
ASIAN……………………………………………………….....2
BLACK OR AFRICAN AMERICAN..............................…...3
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER…4
WHITE………………………………………………………...5
REFUSED……………………………………………………8
DON’T KNOW………………………………………………..9

FSQ.200

{FILL 1}

{FILL 2}

ParentIsR

BioMoInHH

BioFaInHH

AdopMoInHH

AdopFaInHH

OtherinHH

The current
roster shows a
relationship of
biological/
adoptive mother
or biological/
adoptive father
for the person
flagged as the
respondent for
YES
YES

The current
roster shows the
relationship of
biological mother
for at
least one HH
member (not the
R)
for YES

The current
roster shows the
relationship of
biological father
for at
least one HH
member (not the
R)
for YES

The current
roster shows the
relationship of
adoptive mother
for at
least one HH
member (not the
R)
for YES

The current
roster shows
the
relationship of
adoptive
father for at
least one HH
member (not
the R)
for YES

The current
roster
shows there
is no
biological/a
doptive
mother/fath
er in the
household
for YES

Are you

have you

Are you

have you

Are CHILD's
biological parents
Are CHILD's
biological parents
Is CHILD's
biological mother
Is CHILD's
biological father
Is CHILD's
adoptive mother
Is CHILD's
adoptive father
Are CHILD's
adoptive parents

have they

NO

YES

YES

have they

NO

NO

NO

has she

NO

YES

NO

NO

has he

NO

NO

YES

NO

has she

NO

NO

NO

YES

NO

NO

has he

NO

NO

NO

NO

YES

NO

have they

NO

NO

NO

YES

YES

NO

YES
NO
NO

NO

{FILL 1} currently married, separated, divorced, widowed, or {FILL 2} never been married?
MARRIED……………………………………………..1
SEPARATED…………………………………………2
DIVORCED…………………………………………...3
WIDOWED……………………………………………4
NEVER MARRIED............................................... 5
CIVIL UNIONS/DOMESTIC PARTNERSHIP……...6
REFUSED……………………………………………..8
DON’T KNOW…………………………………………9

NO

BOX 5
IDENTIFY THE 2 “KEY” PARENT FIGURES IN THE HOUSEHOLD. THIS PERSON OR
PERSONS SHOULD BE CHOSEN AS FOLLOWS:

1) THE KEY PARENT FIGURES SHOULD BE CHOSEN ONLY FROM AMONG CURRENT
MEMBERS OF THE HOUSEHOLD;

2) IF A MOTHER (RELATION=1) IS IN THE HOUSEHOLD SHE SHOULD BE A KEY
PARENT FIGURE; IF A FATHER (RELATION =2) IS IN THE HOUSEHOLD HE SHOULD
BE A KEY PARENT FIGURE; IF THERE ARE TWO MOTHERS (RELATION=1) PICK THE
MOTHER WITH THE LOWER NUMBER RELATIONSHIP IN THE FOLLOWING SYSTEM:
BIRTH MOTHER =1, ADOPTIVE MOTHER=2, STEPMOTHER=3, FOSTER MOTHER OR
FEMALE GUARDIAN =4. OTHER TYPE OF MOTHER = 5. IF TWO MOTHERS HAVE
SAME NUMBER RELATIONSHIP, PICK ONE WITH LOWEST PERSON NUMBER. IF
THERE ARE TWO FATHERS (RELATION=2), PICK THE FATHER WITH THE LOWER
NUMBER RELATIONSHIP IN THE FOLLOWING SYSTEM: BIRTH FATHER =1,
ADOPTIVE FATHER=2, STEPFATHER=3, FOSTER FATHER OR MALE GUARDIAN =4,
AND OTHER TYPE OF FATHER = 5. IF TWO FATHERS HAVE SAME NUMBER
RELATIONSHIP, PICK ONE WITH LOWEST PERSON NUMBER;

3) IF THERE IS A MOTHER (RELATION =1) BUT NO FATHER (RELATION=2) AND THE
MOTHER HAS A SPOUSE/PARTNER, THE MOTHER SHOULD BE A KEY PARENT
FIGURE AND THE SPOUSE/PARTNER SHOULD BE A KEY PARENT FIGURE;

4) IF THERE IS A FATHER (RELATION=2) BUT NO MOTHER (RELATION=1) AND THE
FATHER HAS A SPOUSE/PARTNER, THE FATHER SHOULD BE A KEY PARENT
FIGURE AND THE SPOUSE/PARTNER SHOULD BE A KEY PARENT FIGURE;

5) OTHERWISE, IF THERE ARE NOT PARENTS IN THE HOUSEHOLD (RELATION NE
1 OR 2), THE RESPONDENT SHOULD BE A KEY PARENT FIGURE AND THE
RESPONDENT’S SPOUSE/PARTNER, IF ONE, SHOULD BE A KEY PARENT FIGURE.

BOX 6
ASK FSQ.212-FSQ.213 FOR 2 “KEY” PARENT FIGURES, AS DEFINED ABOVE.

FSQ.212

Now I have a few questions about {your/{NAME}'s} country of birth.
{you/{NAME}} born?

In what country {were/was}

TO ACTIVATE LOOKUP, BEGIN TO TYPE COUNTRY OR TERRITORY. IF COUNTRY IS NOT ON
THE LIST, HIGHLIGHT 'NOT ON LIST' IN THE LOOKUP FILE AND PRESS ENTER.
USE THE ARROW KEYS TO HELP YOU LOCATE A MATCH.
CAPI INSTRUCTIONS: DISPLAY "your",“were” AND “you” IF CURRENT CYCLE OF LOOP IS ASKING
ABOUT THE RESPONDENT. DISPLAY "{NAME}" (AND THAT PERSON'S FIRST NAME), “was” and
"{NAME}" (AND THAT PERSON'S FIRST NAME AGAIN), IF CURRENT CYCLE OF LOOP IS ASKING
ABOUT A HOUSEHOLD MEMBER WHO IS NOT THE RESPONDENT.
CAPI INSTRUCTION: DISPLAY COUNTRY LOOKUP FILE. ALLOW 3 SPACES IN THE RESPONSE
FIELD FOR ENTERING RESPONSE CODES.

BOX 7
IF FSQ.212 = 0 (NOT ON LIST), CONTINUE WITH FSQ.211OS.
IF FSQ.212 = 1, 5, 98, 152, 195, 217, 249 (UNITED STATES, AMERICAN SAMOA, GUAM, MARIANA ISLAND,
PUERTO RICO, SOLOMON ISLANDS, US VIRGIN ISLANDS), DK, OR RF, GO TO BOX 8.
OTHERWISE, CONTINUE WITH FSQ.213.

FSQ.212OS

[In what country {were/was} {you/{NAME}} born?}
CAPI INSTRUCTIONS: DISPLAY “were” AND “you” IF CURRENT CYCLE OF LOOP IS ASKING
ABOUT THE RESPONDENT. DISPLAY “was” and "{NAME}" (AND THAT PERSON'S FIRST NAME)
IF CURRENT CYCLE OF LOOP IS ASKING ABOUT A HOUSEHOLD MEMBER WHO IS NOT THE
RESPONDENT.
SPECIFY COUNTRY.
________________________________________________________

FSQ.213

How old {was/were} {you/{NAME}} when {you/{he/she}} first moved to the United States?
CAPI INSTRUCTIONS: DISPLAY “were”, “you”, AND “you” IF CURRENT CYCLE OF LOOP IS
ASKING ABOUT THE RESPONDENT. DISPLAY “was”, "{NAME}" (AND THAT PERSON'S FIRST
NAME), AND “he” FOR A MALE/”she” FOR A FEMALE/”he/she” IF GENDER IS MISSING IF
CURRENT CYCLE OF LOOP IS ASKING ABOUT A HOUSEHOLD MEMBER WHO IS NOT THE
RESPONDENT.
CAPI INSTRUCTION: RANGE CHECK: 0 – 75 YEARS OLD. UNLESS AGE IN HOUSEHOLD
ROSTER = DK OR RF, AGE ENTERED AT THIS ITEM CANNOT EXCEED THIS PERSON'S AGE IN
THE HOUSEHOLD ROSTER. OTHERWISE, DISPLAY ERROR MESSAGE: "This age cannot be
smaller than person’s age. Please correct one of the entries."
|___|___|
AGE
REFUSED ................................................... 88
DON'T KNOW ............................................. 99

BOX 8
ASK FSQ.212-FSQ.213 FOR THE NEXT KEY PARENT FIGURE. IF THERE IS NOT A KEY PARENT FIGURE LEFT
TO BE ASKED ABOUT, GO TO BOX 9.

BOX 9
IF FALL-K NON-RESPONDENT, ASK FSQ.221 AND FSQ.222 FOR 2 “KEY” PARENT FIGURES AS DEFINED IN BOX
5. (FSQ.221 AND FSQ.222 MAY BE ASKED IN A LOOP UP TO TWO TIMES). ELSE, FOR FALL CONTINUING
HOUSEHOLDS ( FALL K RESPONDENTS AND NEW SPRING K RESPONDENTS), GO TO SECTION HEQ (HOME
ENVIRONMENT, ACTIVITIES, AND COGNITIVE STIMULATION).

FSQ.221

HELP AVAILABLE
{Now I have a few questions about education and job training.} What is the highest grade or year of
school that {you/{NAME} {have/has} completed?
{[IF NECESSARY, SAY: Again, any information you can provide will be helpful.]}
CAPI INSTRUCTION: DISPLAY "Now … training." IF FIRST CYCLE OF LOOP. OTHERWISE, USE
A NULL DISPLAY.
CAPI INSTRUCTIONS: DISPLAY "you" AND “have” IF CURRENT CYCLE OF LOOP IS ASKING
ABOUT THE RESPONDENT. DISPLAY "{NAME}" (AND THAT PERSON'S FIRST NAME) and “has”
IF CURRENT CYCLE OF LOOP 1 IS ASKING ABOUT A HOUSEHOLD MEMBER WHO IS NOT THE
RESPONDENT.
CAPI INSTRUCTION: DISPLAY "[IF NECESSARY … be helpful.]" IF THERE ARE NO BIOLOGICAL
PARENTS IN THE HOUSEHOLD (NO HOUSEHOLD MEMBER WITH A CODE '1' AT FSQ.140 OR
FSQ.150). OTHERWISE, USE A NULL DISPLAY.
HELP TEXT:
Highest Grade or Year of School Completed: For grades 1-11, enter the exact grade level. If the
person you are asking about completed elementary school, find out the last grade completed. If the
respondent says the person finished 12th grade, ask whether the person received a diploma or got
the equivalent of a high school diploma.
Completing a given grade in school should be counted as the number of years it normally takes to
complete that grade level of education, regardless of how many years it actually took the person to
finish. This means that for persons who skipped or repeated grades in elementary school, you will
enter the highest grade completed regardless of the number of years they were in school. This rule is
true for elementary school through high school and is especially relevant to college.
12th grade but no diploma: The person completed the 12th grade, but did not earn a high school
diploma or GED.
High school equivalent: This means that the person has a GED. The GED is an exam certified
equivalent of a high school diploma received when the person has not actually received a degree
from attending high school, but has acquired his/her GED (high school equivalency based on passing
the GED exam).
High school diploma: A certificate that verifies that a person has successfully completed the
required courses of a high school curriculum and has actually graduated from high school rather than
having a GED.
Vocational/technical program after high school but no voc/tech diploma: The person attended
this type of program, but did not earn a degree/diploma/certificate of successful completion of the
program. Vocational/trade school after high school refers to work or trade-related education received
after completing high school, but does not include college. Examples include secretarial school,
mechanical or computer training school, etc. Some community colleges offer vocational training, but
this would be considered "1-2 years of college" or "associate's degree" and not vocational or trade
school.
Vocational/technical program after high school: The person attended this type of program and
DID earn a degree/diploma/certificate of successful completion of the program. Vocational/trade
school after high school refers to work or trade-related education received after completing high
school, but does not include college. Examples include secretarial school, mechanical or computer
training school, etc. Some community colleges offer vocational training, but this would be considered
"1-2 years of college" or "associate's degree" and not vocational or trade school.
Some college but no degree: The person does not have a 4-year college (bachelor's) degree but
has completed a class for credit at a college or university.

Associate's degree: A 2-year college degree typically earned at a community college (rather than a
trade school).
Bachelor's degree: A 4-year college degree earned at a university or 4-year college.
sometimes called an "undergraduate degree."

It is

Graduate or professional school but no degree: The person attended a graduate or professional
school that advanced him/her toward a degree beyond a Bachelor's degree (for example, a Master's,
Doctorate, or other professional degree). However, the person did not complete the program or earn
the degree.
Master's (MA, MS): Studies beyond a bachelor's degree, but not a Ph.D. or Ed.D.
Doctorate Degree (Ph.D., EDD):
degree.

Studies beyond a Master's degree that result in a doctorate

Professional degree after bachelor's degree (Medicine/MD; Dentistry/DDS, Law/JD/LLB): Any
other graduate degrees earned with academic studies beyond the bachelor's.
1ST GRADE.........................................................................................
2ND GRADE .......................................................................................
3RD GRADE ......................................................................................
4TH GRADE ........................................................................................
5TH GRADE ........................................................................................
6TH GRADE ........................................................................................
7TH GRADE ........................................................................................
8TH GRADE ........................................................................................
9TH GRADE ........................................................................................
10TH GRADE ......................................................................................
11TH GRADE ......................................................................................
12TH GRADE BUT NO DIPLOMA ........................................................
HIGH SCHOOL EQUIVALENT/GED .....................................................
HIGH SCHOOL DIPLOMA ....................................................................
VOC/TECH PROGRAM
AFTER HIGH SCHOOL BUT NO VOC/TECH DIPLOMA.....................
VOC/TECH PROGRAM AFTER HIGH SCHOOL, DIPLOMA..................
SOME COLLEGE BUT NO DEGREE ...................................................
ASSOCIATE'S DEGREE ......................................................................
BACHELOR'S DEGREE .......................................................................
GRADUATE OR PROFESSIONAL SCHOOL BUT NO DEGREE ...........
MASTER'S (MA, MS)............................................................................
DOCTORATE DEGREE (PHD, EDD) ....................................................
PROFESSIONAL DEGREE AFTER BACHELOR'S DEGREE
(MEDICINE/MD; DENTISTRY/DDS; LAW/JD/LLB; ETC.)....................
REFUSED ............................................................................................
DON'T KNOW ......................................................................................

1
2
3
4
5
6
7
8
9
10
11
12
13 (BOX 10)
14 (BOX 10)
15
16
17
18
19
20
21
22

(BOX 10)
(BOX 10)
(BOX 10)
(BOX 10)

23 (BOX 10)
88
99

FSQ.222

{Do/Does} {you/{NAME}} have a high school diploma, or its equivalent, such as a GED, or neither?
CAPI INSTRUCTIONS: DISPLAY “Do” AND "you" IF CURRENT CYCLE OF LOOP IS ASKING
ABOUT THE RESPONDENT. DISPLAY “Does” AND "{NAME}" (AND THAT PERSON'S FIRST
NAME) IF CURRENT CYCLE OF LOOP 1 IS ASKING ABOUT A HOUSEHOLD MEMBER WHO IS
NOT THE RESPONDENT.
HIGH SCHOOL DIPLOMA ..........................
HIGH SCHOOL EQUIVALENT (GED) ..........
NO HIGH SCHOOL DIPLOMA/EQUIVALENT
REFUSED ..................................................
DON’T KNOW ............................................

BOX 10
END LOOP.
ASK FSQ221 – FSQ222 FOR NEXT KEY PARENT FIGURE.
IF NO NEXT PERSON, CONTINUE WITH HEQ.

1
2
3
8
9

HOME ENVIRONMENT, ACTIVITIES, AND COGNITIVE STIMULATION - HEQ
HEQ.100

In the past month, that is, since {MONTH} {DAY}, has anyone in your family done the following things
with {CHILD}?
Visited a library?
CAPI INSTRUCTION: DISPLAY PREVIOUS MONTH FOR "MONTH" AND DATE OF INTERVIEW FOR
"DAY".
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.110

1
2
8
9

[In the past month, that is, since {MONTH} {DAY}, has anyone in your family done the following things
with {CHILD}?]
Visited a bookstore?
CAPI INSTRUCTION: DISPLAY PREVIOUS MONTH FOR "MONTH" AND DATE OF INTERVIEW FOR
"DAY".
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.130

1
2
8
9

[In the past month, that is, since {MONTH} {DAY}, has anyone in your family done the following things
with {CHILD}?]
Gone to a play, concert, or other live show?
CAPI INSTRUCTION: DISPLAY PREVIOUS MONTH FOR "MONTH" AND DATE OF INTERVIEW FOR
"DAY".
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.140

1
2
8
9

[In the past month, that is, since {MONTH} {DAY}, has anyone in your family done the following things
with {CHILD}?]
Visited an art gallery, museum, or historical site?
CAPI INSTRUCTION: DISPLAY PREVIOUS MONTH FOR "MONTH" AND DATE OF INTERVIEW FOR
"DAY".
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

HEQ.150

[In the past month, that is, since {MONTH} {DAY}, has anyone in your family done the following things
with {CHILD}?]
Visited a zoo, aquarium, or petting farm?

CAPI INSTRUCTION: DISPLAY PREVIOUS MONTH FOR "MONTH" AND DATE OF INTERVIEW FOR
"DAY".
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………
HEQ.180

1
2
8
9

[In the past month, that is, since {MONTH} {DAY}, has anyone in your family done the following things
with {CHILD}?]"
Attended an athletic or sporting event in which {CHILD} is not a player?
CAPI INSTRUCTION: DISPLAY PREVIOUS MONTH FOR "MONTH" AND DATE OF INTERVIEW FOR
"DAY".
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.200

1
2
8
9

In the past week, how often did {CHILD} look at picture books outside of school? Would you say …
CAPI INSTRUCTION: DISPLAY "past week" IN UNDERLINED TEXT.
Never, .........................................................
Once or twice a week,..................................
3 to 6 times a week, or…..……………………..
Every day?…………………….………… …….
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.210

1
2
3
4
8
9

In the past week, how often did {CHILD} read to (himself/herself) or to others outside of school?
Would you say …
CAPI INSTRUCTION: DISPLAY "past week" IN UNDERLINED TEXT.
Never, .........................................................
Once or twice a week,..................................
3 to 6 times a week, or..………………………..
Every day?..…………………………………….
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
3
4
8
9

HEQ.220

Do you have a home computer that {CHILD} uses?

YES ............................................................ 1 (HEQ.230)
NO .............................................................. 2 (HEQ.300)
REFUSED ................................................... 8 (HEQ.300)
DON'T KNOW…………………………………. 9 (HEQ.300)
HEQ.230

In an average week, how often does {CHILD} use the computer?
Would you say …
Never, .........................................................
Once or twice a week,..................................
3 to 6 times a week, or…..……………………..
Every day?…..………………………………….
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ240

Does {CHILD} use the computer … To play with programs that teach (him/her) something, like math or
reading skills?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.250

1
2
8
9

[Does {CHILD} use the computer …] To get on the Internet?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.270

1
2
8
9

[Does {CHILD} use the computer …] To play with drawing or art programs?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.260

1
2
3
4
8
9

1
2
8
9

Now, please think about the past week. How often did {CHILD} use a computer outside of school to
read stories or look at picture books in the past week? Would you say…
CAPI INSTRUCTION: DISPLAY “past week” IN UNDERLINED TEXT.
Never, .........................................................
Once or twice a week,..................................
3 to 6 times a week, or .................................
Every day? ..................................................
REFUSED ..................................................
DON'T KNOW ............................................

1
2
3
4
8
9

HEQ.300

Outside of school hours, has {CHILD} ever participated in:
Academic activities, like tutoring, or math lab?

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.301

1
2
8
9

[Outside of school hours, has {CHILD} ever participated in:]
Dance lessons?

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………
HEQ.310

1
2
8
9

[Outside of school hours, has {CHILD} ever participated in:]
Organized athletic activities, like basketball, soccer, baseball, or gymnastics?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.320

1
2
8
9

[Outside of school hours, has {CHILD} ever participated in:]
Organized clubs or recreational programs, like scouts?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.330

1
2
8
9

[Outside of school hours, has {CHILD} ever participated in:]
Music lessons, for example, piano, instrumental music or singing lessons?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.340

1
2
8
9

[Outside of school hours, has {CHILD} ever participated in:]
Drama classes?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

HEQ.350

[Outside of school hours, has {CHILD} ever participated in:]
Art classes or lessons, for example, painting, drawing, or sculpture?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.370

1
2
8
9

[Outside of school hours, has {CHILD} ever participated in:]
Organized performing arts programs, such as children's choirs, dance programs, or theater
performances?
YES ............................................................ 1
NO .............................................................. 2
REFUSED ................................................... 8
DON'T KNOW…………………………………… 9

HEQ.380

[Outside of school hours, has {CHILD} ever participated in:]
Crafts classes or lessons?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.390

1
2
8
9

[Outside of school hours, has {CHILD} ever participated in:]
Non-English language instruction?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.391

1
2
8
9

[Outside of school hours, has {CHILD} ever participated in:]
Religious activities or instruction?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.392

1
2
8
9

[Outside of school hours, has {CHILD} ever participated in:]
Volunteer work or community service?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

BOX 1
IF ANY OF THE ACTIVITY QUESTIONS HAS AN ANSWER OF 1 (HEQ.300 = 1 OR HEQ.301 = 1 OR HEQ.310 = 1
OR HEQ320 = 1 OR HEQ.330 = 1 OR HEQ.340 = 1 OR HEQ.350 = 1 OR HEQ.370 = 1 OR HEQ.380 = 1 OR HEQ.390
= 1 OR HEQ.391 = 1 OR HEQ.392 = 1), GO TO HEQ.393. ELSE, GO TO HEQ.400.
HEQ.393

Did {CHILD}’s participation in {this activity/any of these activities} help to cover the hours when you
needed adult supervision for {him/her}?
CAPI INSTRUCTIONS: IF ONLY ONE OF THE ACTIVITY QUESTIONS (HEQ.300 HEQ.301,
HEQ.310, HEQ320, HEQ.330, HEQ.340, HEQ.350, HEQ.370, HEQ.380, HEQ.390, HEQ.391,
HEQ.392) DISPLAY “this activity.” ELSE, DISPLAY “any of these activities”.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

HEQ.400

1
2
8
9

Now, I have some questions about your neighborhood. How safe is it for children to play outside during
the day in your neighborhood?
Would you say it's …
Not at all safe, ................................1
Somewhat safe, or..........................2
Very safe? ......................................3
REFUSED ......................................8
DON’T KNOW ................................9

HEQ.420

How much of a problem are the following in the block or area around your house or apartment? What
about … Selling or using drugs or excessive drinking in public?
Would you say they are a…
Big problem, ...................................1
Somewhat of a problem, or .............2
No problem?...................................3
REFUSED ......................................8
DON’T KNOW ................................9

HEQ.430

[How much of a problem are the following in the block or area around your house or apartment? What
about …] Burglary or robbery?
Would you say they are a…
Big problem, ...................................1
Somewhat of a problem, or .............2
No problem?...................................3
REFUSED ......................................8
DON’T KNOW ................................9

HEQ.460

During the last five days {CHILD} was in school, how many breakfasts did (he/she) eat that were NOT
school breakfasts. By breakfast we mean breakfasts eaten at home, at childcare, or at school, but not
part of a school breakfast program. Please count only one breakfast per day.
CAPI INSTRUCTIONS:
1.
2.
3.

DISPLAY "five days" IN UNDERLINED TEXT.
DISPLAY “NOT" IN UNDERLINED TEXT.
HARD RANGE CHECK: 0-5 BREAKFASTS
|___|
NUMBER OF BREAKFASTS
REFUSED…………………………………….8
DON’T KNOW………………………………...9

BOX 2
IF NUMBER OF BREAKFASTS IS ZERO REFUSED OR DON’T KNOW, GO TO HEQ.480.
ELSE, GO TO HEQ.470.
HEQ.470

Where did {CHILD} eat these breakfasts?

CAPI INSTRUCTION: WHEN ON B-F, DISPLAY "Where…breakfasts?" IN SQUARE BRACKETS.
CAPI INSTRUCTION: RESPONSES: 1 = YES, 2 = NO

a. At home?
b. At a relative’s or friend’s home?
c. At a child care location?
d. At school, but not part of school breakfast?
e. At a restaurant, including food taken out from fast food
restaurants?
f. Somewhere else? (SPECIFY)

YES
1
1
1
1
1
1

NO
2
2
2
2
2
2

REF
8
8
8
8
8
8

BOX 3
IF HEQ470F = 1, GO TO HEQ470OS. ELSE, GO TO HEQ480.
HEQ.470OS

{Where did {CHILD} eat these breakfasts?}
___________________________________________________________
SPECIFY LOCATION.

DK
9
9
9
9
9
9

HEQ.480

During the last five days {CHILD} was in school, how many breakfasts did you eat? Please count only
one breakfast per day.
CAPI INSTRUCTIONS:
1.
2.

DISPLAY "five days" AND “you” IN UNDERLINED TEXT.
HARD RANGE CHECK: 0-5 BREAKFASTS
|___|
NUMBER OF BREAKFASTS
REFUSED…………………………………….8
DON’T KNOW………………………………...9
HELP AVAILABLE

HEQ.500

I'm going to read some statements about things that may occur in your family. In a typical week, please
tell me the number of days …
At least some of the family eats breakfast together.
HELP TEXT:
Family: By family, we mean at least one adult and one child.

CAPI INSTRUCTION: RANGE:0 TO 7.
CAPI INSTRUCTION: DISPLAY "typical week" IN UNDERLINED TEXT.
|___|
NUMBER OF DAYS
REFUSED…………………………………….8
DON’T KNOW………………………………...9
HEQ.510

[I'm going to read some statements about things that may occur in your family. In a typical week,
please tell me the number of days ... ]
{CHILD} has breakfast at a regular time.
IF RESPONDENT ASKS WHAT "REGULAR" MEANS, SAY THAT IT MEANS "GENERALLY AROUND
THE SAME TIME."
CAPI INSTRUCTION: RANGE: 0 TO 7.
CAPI INSTRUCTION: DISPLAY "typical week" IN UNDERLINED TEXT.
|___|
NUMBER OF DAYS
REFUSED…………………………………….8
DON’T KNOW………………………………...9

HELP AVAILABLE
HEQ.520

[I'm going to read some statements about things that may occur in your family. In a typical week, please
tell me the number of days ... ]
Your family eats the evening meal together.
HELP TEXT:
Family: By family, we mean at least one adult and one child.

CAPI INSTRUCTION: RANGE: 0 TO 7.
CAPI INSTRUCTION: DISPLAY "typical week" IN UNDERLINED TEXT.
|___|
NUMBER OF DAYS
REFUSED…………………………………….8
DON’T KNOW………………………………...9
HEQ.530

[I'm going to read some statements about things that may occur in your family. In a typical week, please
tell me the number of days ... ]
The evening meal is served at a regular time.
IF RESPONDENT ASKS WHAT "REGULAR" MEANS, SAY THAT IT MEANS "GENERALLY AROUND
THE SAME TIME."
CAPI INSTRUCTION: RANGE: 0 TO 7.
CAPI INSTRUCTION: DISPLAY "typical week" IN UNDERLINED TEXT.
|___|
NUMBER OF DAYS
REFUSED…………………………………….8
DON’T KNOW………………………………...9

HEQ.550

On weeknights during the school year, does {CHILD} usually go to bed at about the same time each
night, or does {his/her} bedtime vary a lot from night to night?

CAPI INSTRUCTIONS: DISPLAY “his” IF THE CHILD IS MALE. DISPLAY “her” IF THE CHILD IS
FEMALE. ELSE, IF THE CHILD’S GENDER IS MISSING, DISPLAY “his/her”.
HAS USUAL BEDTIME…………………….1 (HEQ.560)
BEDTIME VARIES………………………….2 (HEQ.570)
REFUSED…………………………………...8 (HEQ.570)
DON’T KNOW……………………………….9 (HEQ.570)

HEQ.560

About what time does {CHILD} usually go to bed?

CAPI INSTRUCTION: RANGE CHECK: LOWER RANGE: 1:00. UPPER RANGE: 12:59.
ENTER HOUR THEN MINUTE.
|___|___ |
HOUR

|___|___|
MINUTE

REFUSED…………………………………….8 (HEQ.570)
DON’T KNOW………………………………...9 (HEQ.570)
HEQ.565

[About what time does {CHILD} usually go to bed?]
SELECT A.M. OR P.M.

A.M. ............................................................
P.M. ............................................................
REFUSED ...................................................
DON'T KNOW……………………………………
HEQ.570

1
2
8
9

What is the latest time that {CHILD} goes to bed on weekdays?
CAPI INSTRUCTIONS: RANGE CHECK: LOWER RANGE: 1:00. UPPER RANGE: 12:59.
ENTER HOUR THEN MINUTE.
|___|___ |
HOUR

|___|___|
MINUTE

REFUSED…………………………………….8 (HEQ.580)
DON’T KNOW………………………………...9 (HEQ.580)
HEQ.575

[What is the latest time that {CHILD} goes to bed on weekdays?]

SELECT A.M. OR P.M.
A.M. ............................................................
P.M. ............................................................
REFUSED ...................................................
DON'T KNOW……………………………………
HEQ.580

1
2
8
9

How often does someone in your family talk with {CHILD} about {his/her} ethnic or racial heritage?
Would you say …
Never, ...................................................... 1
Almost never, ........................................... 2
Several times a year, ................................ 3
Several times a month, or ......................... 4
Several times a week or more? ................. 5
REFUSED ................................................ 8
DON’T KNOW .......................................... 9

HEQ.590

How often does someone in your family talk with {CHILD} about your family's religious beliefs or
traditions?
Would you say …
Never, ...................................................... 1
Almost never, ........................................... 2
Several times a year, ................................ 3
Several times a month, or ......................... 4
Several times a week or more? ................. 5
REFUSED ................................................ 8
DON’T KNOW .......................................... 9

BOX 4
GO TO SECTION SSQ (SOCIAL SKILLS, PROBLEM BEHAVIORS, AND APPROACHES TO LEARNING).

SOCIAL SKILLS, PROBLEM BEHAVIORS, AND APPROACHES TOWARD LEARNING - SSQ

SSQ.010

I am going to read you a list of statements describing things that children sometimes do. For each
statement, I want you to tell me how often {CHILD} acts in this way.
How often does {CHILD}:
RESPONSES: 1 = NEVER, 2 = SOMETIMES, 3 = OFTEN, 4 = VERY OFTEN, 8 = REFUSED,
9 = DON'T KNOW
a.

Easily join others in play? Would you say never, sometimes,
often, or very often? ...................................................................... ___
b. Respond appropriately to teasing? ................................................ ___
c. Make and keep friends? ................................................................ ___
d. Comfort or help others? ................................................................ ___
e. Worry about things? ...................................................................... ___
f. Listen carefully to others? ............................................................. ___
g. Act sad? ....................................................................................... ___
h. Control {his/her} temper? .............................................................. ___
i. Cooperate with family members? .................................................. ___
j. Keep working at something until {he/she} is finished? .................... ___
k. Argue with others? ........................................................................ ___
l. Fight with others? ......................................................................... ___
m. Show interest in a variety of things? .............................................. ___
n. Have a tantrum when {he/she} does not get {his/her} way? ............ ___
o. Concentrate on a task and ignore distractions? .............................. ___
p. Easily become angry? ................................................................... ___
q. Appear to be lonely? ..................................................................... ___
r. Help with chores? ......................................................................... ___
s. Have a problem being accepted and liked by others? ..................... ___
t. Act impulsively? ............................................................................ ___
u. Show low self-esteem? ................................................................. ___
How often is {CHILD}:
v. Eager to learn new things? ............................................................ ___
w. Hyperactive? ................................................................................ ___
x. Creative in work or in play? ........................................................... ___

BOX 1
GO TO SECTION CFQ (CRITICAL FAMILY PROCESSES).

CRITICAL FAMILY PROCESSES - CFQ
BOX 1
IF PERSON FLAGGED AS R SCORES '1' OR '2' AT FSQ.130
OR IF NO HOUSEHOLD MEMBER SCORES '1' OR '2' AT FSQ.130,
CONTINUE WITH BOX 2.
OTHERWISE, GO TO BOX 4.

BOX 2
IF FSQ110=1 (PARTNER CURRENTLY LIVING IN HOUSEHOLD), ASK CFQ100.
OTHERWISE, GO TO BOX 3.
CFQ.100

Now, I'd like to ask some questions about your relationship with {NAME OF CURRENT PARTNER}.
Would you say that your relationship is…
CAPI INSTRUCTION: DISPLAY NAME OF PARTNER FROM FSQ.120.
Very happy,. ................................................
Fairly happy, or............................................
Not too happy?.....……………………………...
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
3
8
9

BOX 3
IF FATHER FIGURE IN HOUSEHOLD (FSQ.130=2 FOR AT LEAST ONE MEMBER OF THE HOUSEHOLD),
CONTINUE WITH CFQ.300. OTHERWISE, GO TO BOX 4.
CFQ.300

How much time {do you/does {NAME} or another adult male in your home spend playing with {CHILD} on
a typical school day?
CAPI INSTRUCTION: DISPLAY 'do you' IF THE PERSON FLAGGED AS RESPONDENT IS A FATHER
FIGURE (FSQ.130=2).
OTHERWISE, DISPLAY 'does {NAME}'. FOR {NAME}, DISPLAY THE FIRST NAME OF THE PERSON
CODED '2' AT FSQ.130.
NO TIME…………………………………………………………..0
LESS THAN 5 MINUTES…………………………………….…1
5 - 9 MINUTES…………………………………………………...2
10 - 15 MINUTES………………………………………………..3
16 - 30 MINUTES………………………………………………..4
31 - 45 MINUTES………………………………………………..5
46 MINUTES TO ONE HOUR………………………………….6
MORE THAN ONE HOUR, BUT LESS THAN 2 HOURS…...7
TWO HOURS - BUT LESS THAN THREE HOURS…………8
THREE HOURS OR MORE…………………………………….9
REFUSED………………………………………………………88
DON’T KNOW………………………………………………….99

CFQ.310

How about on a typical weekend day?

NO TIME…………………………………………………………..0
LESS THAN 5 MINUTES…………………………………….…1
5 - 9 MINUTES…………………………………………………...2
10 - 15 MINUTES………………………………………………..3
16 - 30 MINUTES………………………………………………..4
31 - 45 MINUTES………………………………………………..5
46 MINUTES TO ONE HOUR………………………………….6
MORE THAN ONE HOUR, BUT LESS THAN 2 HOURS…...7
TWO HOURS - BUT LESS THAN THREE HOURS…………8
THREE HOURS OR MORE…………………………………….9
REFUSED………………………………………………………88
DON’T KNOW………………………………………………….99
BOX 4
GO TO SECTION NRQ (NON-RESIDENT PARENTS).

NON-RESIDENT PARENTS - NRQ
BOX 1
IF BOTH BIOLOGICAL PARENTS (CODED ‘1’ AT FSQ.140 FOR AT LEAST ONE HOUSEHOLD MEMBER AND
CODED ‘1’ AT FSQ.150 FOR AT LEAST ONE HOUSEHOLD MEMBER) ARE CURRENTLY LIVING TOGETHER IN
THE HOUSEHOLD, GO TO BOX 6.
OTHERWISE, CONTINUE WITH BOX 2.

BOX 2
LOOP 1
ASK NRQ.040 - NRQ.251 ONE TIME FOR EACH BIOLOGICAL MOTHER, ADOPTIVE MOTHER, BIOLOGICAL
FATHER, AND ADOPTIVE FATHER NOT LIVING IN THE HOUSEHOLD.
DETERMINING LOOPING ELIGIBILITY:
1. NO BIOLOGICAL/BIRTH MOTHER IN HH: IF NO HOUSEHOLD MEMBER WITH A CODE ‘1’ AT FSQ.140 AND
EITHER FALL K HRQ.030=1 (BIOLOGICAL
MOTHER LIVING) OR FALL K NON-RESPONDENT, THEN ASK ABOUT BIOLOGICAL MOTHER.
2. NO ADOPTIVE MOTHER IN HH: IF NO BIOLOGICAL OR ADOPTIVE MOTHER IN HOUSEHOLD, BUT ADOPTIVE
FATHER IS IN THE HOUSEHOLD
(THAT IS, THERE IS NO HOUSEHOLD MEMBER WITH A CODE '1' OR '2' AT FSQ.140, BUT AT LEAST ONE
HOUSEHOLD MEMBER WITH A CODE '2' AT FSQ.150), THEN ASK ABOUT ADOPTIVE MOTHER.
3. NO BIOLOGICAL/BIRTH FATHER IN HH: IF NO HOUSEHOLD MEMBER WITH A CODE ‘1’ AT FSQ.150 AND
EITHER FALL K HRQ.030=1 (BIOLOGICAL FATHER LIVING) OR FALL K NON-RESPONDENT, ASK ABOUT
BIOLOGICAL FATHER.
4. NO ADOPTIVE FATHER IN HH: IF NO BIOLOGICAL OR ADOPTIVE FATHER IN HOUSEHOLD, BUT ADOPTIVE
MOTHER IS IN THE HOUSEHOLD
(THAT IS, THERE IS NO HOUSEHOLD MEMBER WITH CODE '1' AT FSQ.150, BUT AT LEAST ONE HOUSEHOLD
MEMBER WITH A CODE '2' AT FSQ.140), THEN ASK ABOUT ADOPTIVE FATHER.
5. IF FALL-K ANSWERS WERE NRQ.040 = 5 (PARENT DECEASED), NRQ.040 = 6 (NO CONTACT SINCE
ADOPTION), NRQ.030 = 2 (NO ADOPTIVE NON-RESIDENT MOTHER/FATHER), NRQ.040 = 7 (NO ADOPTIVE
(MOTHER/FATHER), OR NRQ.040 = 8 (PARENT UNKNOWN /WAS ONLY A DONOR) FOR ANY OF THE NONRESIDENT PARENTS, DO NOT LOOP ON THIS PARENT.
IF THERE ARE ANY ELIGIBLE CASES ACCORDING TO THE LOOPING RULES ABOVE, GO TO NRQ.040 FOR
EACH ELIGIBLE CASE UNTIL ALL ELIGIBLES HAVE BEEN ASKED ABOUT IN THE QUESTIONS. ELSE, GO TO
BOX 6.

NRQ.040

The next questions are about {CHILD}'s contact with {his/her}{biological/adoptive}(father/mother).
[We understand that some of these questions may be difficult {for adoptive parents} to answer, however,
these are standard questions we ask when a child does not live with {his/her} biological parents. Any
information you can provide will be helpful.]
How long has it been since {CHILD} last had a visit, a phone call, or received a card or letter from
{his/her} {biological/adoptive} {father/mother}? Would you say …

CAPI INSTRUCTIONS:
DISPLAY “his” IF THE CHILD IS MALE. DISPLAY “her” IF THE CHILD IS FEMALE. ELSE, IF CHILD
GENDER IS MISSING, DISPLAY “his/her”.
IF FSQ.140 = 1, DISPLAY “biological” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 1, DISPLAY “biological” AND “father” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.140 =2, DISPLAY “adoptive” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 2, DISPLAY “adoptive” AND “father” FOR THE PARTICULAR LOOP R IS ON.
DISPLAY '[We…helpful]' IF THERE ARE NO BIOLOGICAL PARENTS IN THE HOUSEHOLD (NO
HOUSEHOLD MEMBER WITH A CODE '1' AT FSQ.140 OR FSQ.150). OTHERWISE, USE A NULL
DISPLAY.
DISPLAY 'for adoptive parents' IF THE RESPONDENT IS AN ADOPTIVE PARENT (FSQ.140 OR
FSQ.150 IS CODED '2' FOR THE PERSON FLAGGED AS THE RESPONDENT).
Less than one month……..…………………………………….1 (NRQ.050)
More than a month but less than a year……………………...2 (NRQ.124)
More than a year…….…………………………………………..3 (BOX 3)
No contact since birth?...........………………………………….4 (BOX 4)
PARENT IS DECEASED……………………………………….5 (BOX 4)
NO CONTACT SINCE ADOPTION……………………………6 (BOX 4)
NO ADOPTIVE {MOTHER/FATHER}………………………….7 (BOX 4)
PARENT UNKNOWN/WAS ONLY A DONOR……………….8 (BOX 4)
REFUSED………………………………………………………88 (BOX 4)
DON’T KNOW………………………………………………….99 (BOX 4)

NRQ.050

How many days has {CHILD} seen {his/her} {biological/adoptive}{father/mother} in the past 4 weeks?
CAPI INSTRUCTIONS:
DISPLAY “his” IF THE CHILD IS MALE. DISPLAY “her” IF THE CHILD IS FEMALE. ELSE, IF CHILD
GENDER IS MISSING, DISPLAY “his/her”.
IF FSQ.140 = 1, DISPLAY “biological” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 1, DISPLAY “biological” AND “father” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.140 =2, DISPLAY “adoptive” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 2, DISPLAY “adoptive” AND “father” FOR THE PARTICULAR LOOP R IS ON.
CAPI INSTRUCTIONS: RANGE: 0 TO 28

|___|___ |
NUMBER OF DAYS
REFUSED…………………………………….8
DON’T KNOW………………………………...9

NRQ.120 How many days was {CHILD} scheduled to see {his/her} {biological/adoptive} {father/mother}
in the past 4 weeks?
CAPI INSTRUCTIONS:
DISPLAY “his” IF THE CHILD IS MALE. DISPLAY “her” IF THE CHILD IS FEMALE. ELSE, IF CHILD
GENDER IS MISSING, DISPLAY “his/her”.
IF FSQ.140 = 1, DISPLAY “biological” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 1, DISPLAY “biological” AND “father” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.140 =2, DISPLAY “adoptive” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 2, DISPLAY “adoptive” AND “father” FOR THE PARTICULAR LOOP R IS ON.
CAPI INSTRUCTIONS: RANGE: 0 TO 28.

|___|___ |
NUMBER OF DAYS
REFUSED…………………………………….8
DON’T KNOW………………………………...9

NRQ.121

How many nights did {CHILD} and {his/her} {biological/adoptive} {father/mother} sleep in the same house
in the past four weeks?

CAPI INSTRUCTIONS:
DISPLAY “his” IF THE CHILD IS MALE. DISPLAY “her” IF THE CHILD IS FEMALE. ELSE, IF CHILD
GENDER IS MISSING, DISPLAY “his/her”.
IF FSQ.140 = 1, DISPLAY “biological” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 1, DISPLAY “biological” AND “father” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.140 =2, DISPLAY “adoptive” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 2, DISPLAY “adoptive” AND “father” FOR THE PARTICULAR LOOP R IS ON.
.
CAPI INSTRUCTIONS: RANGE: 0 TO 28.

|___|___ |
NUMBER OF DAYS
REFUSED…………………………………….8
DON’T KNOW………………………………...9
NRQ.122

Did {CHILD}'s {biological/adoptive} {father/mother} miss any scheduled visits with {CHILD} in the past
four weeks?
CAPI INSTRUCTIONS:
IF FSQ.140 = 1, DISPLAY “biological” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 1, DISPLAY “biological” AND “father” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.140 =2, DISPLAY “adoptive” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 2, DISPLAY “adoptive” AND “father” FOR THE PARTICULAR LOOP R IS ON.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

NRQ.123

How many times have {CHILD} and {his/her} {biological/adoptive} {father/ mother} talked on the
telephone to each other in the past 4 weeks?
CAPI INSTRUCTIONS:
DISPLAY “his” IF THE CHILD IS MALE. DISPLAY “her” IF THE CHILD IS FEMALE. ELSE, IF CHILD
GENDER IS MISSING, DISPLAY “his/her”.
IF FSQ.140 = 1, DISPLAY “biological” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 1, DISPLAY “biological” AND “father” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.140 =2, DISPLAY “adoptive” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 2, DISPLAY “adoptive” AND “father” FOR THE PARTICULAR LOOP R IS ON.

.

CAPI INSTRUCTIONS: RANGE: 0 TO 28.

|___|___ |
NUMBER OF DAYS
REFUSED…………………………………….8
DON’T KNOW………………………………...9
NRQ.124

Which of the following statements best describes your current relationship with {CHILD}’s
{biological/adoptive} {father/mother}?
CAPI INSTRUCTIONS:
IF FSQ.140 = 1, DISPLAY “biological” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 1, DISPLAY “biological” AND “father” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.140 =2, DISPLAY “adoptive” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 2, DISPLAY “adoptive” AND “father” FOR THE PARTICULAR LOOP R IS ON.

We generally get along pretty well, ............... 1
We don't get along too well, ......................... 2
We fight a lot and do not get along well, or ... 3
We avoid seeing each other? ....................... 4
REFUSED ................................................... 8
DON’T KNOW ............................................. 9

NRQ.130

Since the beginning of this school year, has {CHILD}'s {biological/adoptive} {mother/father}... Attended an
open house or a back-to-school night?
CAPI INSTRUCTIONS:
IF FSQ.140 = 1, DISPLAY “biological” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 1, DISPLAY “biological” AND “father” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.140 =2, DISPLAY “adoptive” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 2, DISPLAY “adoptive” AND “father” FOR THE PARTICULAR LOOP R IS ON.

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………
NRQ.135

1
2
8
9

[Since the beginning of this school year, has {CHILD}'s {biological/adoptive} {mother/father}…] Gone to a
regularly-scheduled parent-teacher conference with {CHILD}'s teacher or meeting with {CHILD}'s
teacher?
CAPI INSTRUCTIONS:
IF FSQ.140 = 1, DISPLAY “biological” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 1, DISPLAY “biological” AND “father” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.140 =2, DISPLAY “adoptive” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 2, DISPLAY “adoptive” AND “father” FOR THE PARTICULAR LOOP R IS ON.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

NRQ.140

[Since the beginning of this school year, has {CHILD}'s {biological/adoptive} {mother/father}…] Attended
a school or class event, such as a play or sports event or science fair?
CAPI INSTRUCTIONS:
IF FSQ.140 = 1, DISPLAY “biological” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 1, DISPLAY “biological” AND “father” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.140 =2, DISPLAY “adoptive” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 2, DISPLAY “adoptive” AND “father” FOR THE PARTICULAR LOOP R IS ON.

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………
NRQ.145

1
2
8
9

[Since the beginning of this school year, has {CHILD}'s {biological/adoptive} {mother/father}…]
Volunteered at the school or served on a committee?
CAPI INSTRUCTIONS:
IF FSQ.140 = 1, DISPLAY “biological” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 1, DISPLAY “biological” AND “father” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.140 =2, DISPLAY “adoptive” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 2, DISPLAY “adoptive” AND “father” FOR THE PARTICULAR LOOP R IS ON.

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

BOX 3
IF LOOPING ON NONRESIDENT BIOLOGICAL FATHER, CONTINUE WITH NRQ200.
OTHERWISE, GO TO NRQ.250.
NRQ.200

Did {CHILD}'s biological father ever sign the application for {CHILD}'s birth certificate or sign a statement
that legally says he is {CHILD}'s biological father?
YES ............................................................ 1 (NRQ.250)
NO .............................................................. 2 (NRQ.210)
REFUSED ................................................... 8 (NRQ.210)
DON'T KNOW…………………………………. 9 (NRQ.210)

NRQ.210

Did you or someone in your family go to court to establish that he was {CHILD}'s legal biological father?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

NRQ.250

1
2
8
9

How many minutes does {CHILD}'s {biological/adoptive} {mother/father} live from (him/her)?

CAPI INSTRUCTIONS:
DISPLAY “him” IF THE CHILD IS MALE. DISPLAY “her” IF THE CHILD IS FEMALE. ELSE, IF CHILD
GENDER IS MISSING, DISPLAY “him/her”.
IF FSQ.140 = 1, DISPLAY “biological” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 1, DISPLAY “biological” AND “father” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.140 =2, DISPLAY “adoptive” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 2, DISPLAY “adoptive” AND “father” FOR THE PARTICULAR LOOP R IS ON.
10 MINUTES OR LESS………………….1
11-30 MINUTES…………………………..2
31-59 MINUTES…………………………..3
1-2 HOURS………………………………..4
MORE THAN 2 HOURS………………….5
REFUSED…………………………………8
DON’T KNOW…………………………….9
NRQ.251

Does {CHILD}'s {biological/adoptive} {mother/father} live in the same state or a different state than
{CHILD}?
CAPI INSTRUCTIONS:
IF FSQ.140 = 1, DISPLAY “biological” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 1, DISPLAY “biological” AND “father” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.140 =2, DISPLAY “adoptive” AND “mother” FOR THE PARTICULAR LOOP R IS ON.
IF FSQ.150 = 2, DISPLAY “adoptive” AND “father” FOR THE PARTICULAR LOOP R IS ON.
SAME STATE .............................................
DIFFERENT STATE ....................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

BOX 4
ASK NRQ.040 TO NRQ.251 FOR THE NEXT NON-RESIDENTIAL PARENT. IF NO NEXT NON-RESIDENTIAL
PARENT, GO TO BOX 5.

BOX 5
IF NRQ.100 = 4 (NO CONTACT SINCE BIRTH), 5 (DECEASED), 6 (NO CONTACT SINCE ADOPTION), 7 (NO
ADOPTIVE PARENT), OR 8 (PARENT UNKNOWN/ONLY A DONOR) FOR ALL THE CHILD’S NON-RESIDENT
PARENT(S) , GO TO BOX 7. ELSE, GO TO NRQ.261.

NRQ.261

Next, I'd like to ask some questions about child support. Have child support payments for {CHILD} ever
been awarded by a court or a judge, agreed to in writing, agreed to informally, or do you not have an
agreement of any kind?
CODE ALL THAT APPLY. CODES 1 AND 4 CANNOT BE CODED TOGETHER. CODE 5 CANNOT BE
CODED WITH ANY OTHER.
YES, AWARDED BY A COURT…………………..1 (BOX 6)
YES, AGREED TO IN WRITING…………………..2 (BOX 6)
YES, AGREED TO INFORMALLY………………...3 (BOX 6)
YES, AWARD PENDING…………………………..4 (BOX 6)
NO AGREEMENT…………………………………..5 (BOX 7)
OTHER (SPECIFY)………………………………...91 (NRQ.262)
REFUSED…………………………………………..8 (BOX 7)
DON’T KNOW………………………………………9 (BOX 7)

NRQ.262

What kind of agreement do you have?
_____________________________
SPECIFY

BOX 6
IF MORE THAN 1 NONRESIDENT PARENT, CONTINUE WITH NRQ.264.
OTHERWISE, GO TO NRQ.265.
NRQ.264

What parent do you have this agreement with?
PROBE: Any other parent?
CODE ALL THAT APPLY
{CHILD}'s BIOLOGICAL FATHER……1
{CHILD}'S BIOLOGICAL MOTHER…..2
{CHILD}'S ADOPTIVE FATHER……...3
{CHILD}'S ADOPTIVE MOTHER……..4

NRQ.265

In the past year were you supposed to receive any child support payments for {CHILD}?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2 (BOX 7)
8 (BOX 7)
9 (BOX 7)

NRQ.266

During the last year, have you received this money regularly, so that you could almost always count on
getting the money?

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

BOX 7
GO TO SECTION DWQ (DISCIPLINE AND WARMTH).

1
2
8
9

DISCIPLINE, WARMTH, AND EMOTIONAL SUPPORTIVENESS - DWQ

BOX 1
IF PERSON FLAGGED AS R SCORES '1' OR '2' AT FSQ.130
OR IF NO HOUSEHOLD MEMBER SCORES '1' OR '2' AT FSQ.130,
CONTINUE WITH DWQ.010.
OTHERWISE, GO TO DWQ.080.
DWQ.010

Now, I'm going to read some statements. Please tell me whether each statement is completely true,
mostly true, somewhat true, or not at all true.
{CHILD} and I often have warm, close times together.
PROBE: Is it completely true, mostly true, somewhat true or not at all true?
COMPLETELY TRUE ..................................
MOSTLY TRUE ...........................................
SOMEWHAT TRUE .....................................
NOT AT ALL TRUE…..…………………………
REFUSED………………………………………..
DON’T KNOW……………………………………

DWQ.015

1
2
3
4
8
9

[Now, I'm going to read some statements. Please tell me whether each statement is completely true,
mostly true, somewhat true, or not at all true.]
Most of the time I feel that {CHILD} likes me and wants to be near me.
[PROBE: Is it completely true, mostly true, somewhat true or not at all true?]
COMPLETELY TRUE ..................................
MOSTLY TRUE ...........................................
SOMEWHAT TRUE .....................................
NOT AT ALL TRUE…..…………………………
REFUSED………………………………………..
DON’T KNOW……………………………………

DWQ.025

1
2
3
4
8
9

[Now, I'm going to read some statements. Please tell me whether each statement is completely true,
mostly true, somewhat true, or not at all true.]
Even when I'm in a bad mood, I show {CHILD} a lot of love.
[PROBE: Is it completely true, mostly true, somewhat true or not at all true?]
COMPLETELY TRUE ..................................
MOSTLY TRUE ...........................................
SOMEWHAT TRUE .....................................
NOT AT ALL TRUE…..…………………………
REFUSED………………………………………..
DON’T KNOW……………………………………

1
2
3
4
8
9

DWQ.035

[Now, I'm going to read some statements. Please tell me whether each statement is completely true,
mostly true, somewhat true, or not at all true.]
I express affection by hugging, kissing, and holding {CHILD}.
[PROBE: Is it completely true, mostly true, somewhat true or not at all true?]
COMPLETELY TRUE ..................................
MOSTLY TRUE ...........................................
SOMEWHAT TRUE .....................................
NOT AT ALL TRUE…..…………………………
REFUSED………………………………………..
DON’T KNOW……………………………………

DWQ.040

1
2
3
4
8
9

[Now, I'm going to read some statements. Please tell me whether each statement is completely true,
mostly true, somewhat true, or not at all true.]
Being a parent is harder than I thought it would be.
[PROBE: Is it completely true, mostly true, somewhat true or not at all true?]
COMPLETELY TRUE ..................................
MOSTLY TRUE ...........................................
SOMEWHAT TRUE .....................................
NOT AT ALL TRUE…..…………………………
REFUSED………………………………………..
DON’T KNOW……………………………………

DWQ.045

1
2
3
4
8
9

[Now, I'm going to read some statements. Please tell me whether each statement is completely true,
mostly true, somewhat true, or not at all true.]
{CHILD} does things that really bother me.
[PROBE: Is it completely true, mostly true, somewhat true or not at all true?]
COMPLETELY TRUE ..................................
MOSTLY TRUE ...........................................
SOMEWHAT TRUE .....................................
NOT AT ALL TRUE…..…………………………
REFUSED………………………………………..
DON’T KNOW……………………………………

1
2
3
4
8
9

DWQ.050

[Now, I'm going to read some statements. Please tell me whether each statement is completely true,
mostly true, somewhat true, or not at all true.]
I find myself giving up more of my life to meet {CHILD}'s needs than I ever expected.
[PROBE: Is it completely true, mostly true, somewhat true or not at all true?]
COMPLETELY TRUE ..................................
MOSTLY TRUE ...........................................
SOMEWHAT TRUE .....................................
NOT AT ALL TRUE…..…………………………
REFUSED………………………………………..
DON’T KNOW……………………………………

DWQ.060

1
2
3
4
8
9

[Now, I'm going to read some statements. Please tell me whether each statement is completely true,
mostly true, somewhat true, or not at all true.]
I often feel angry with {CHILD}.
[PROBE: Is it completely true, mostly true, somewhat true or not at all true?]
COMPLETELY TRUE ..................................
MOSTLY TRUE ...........................................
SOMEWHAT TRUE .....................................
NOT AT ALL TRUE…..…………………………
REFUSED………………………………………..
DON’T KNOW……………………………………

1
2
3
4
8
9

DWQ.080

Now I’d like to ask some questions about {CHILD}’s television viewing. We are interested in {his/her}
television viewing only in your home. We want you to include television shows, videotapes, and DVDs,
but not games played on gaming systems like Playstation, Wii, or XBox.
On any given weekday, how many hours of television, videotapes, or DVDs on average does {CHILD}
watch at home? How about…
ENTER “77” IF FAMILY DOES NOT HAVE A TV.

a.
b.
c.

Before 8:00 a.m.?
Between 8:00 a.m. and 6 p.m.?
After 6 p.m.?

CAPI INSTRUCTIONS:
1.
DISPLAY "in your home" AND "at home” IN UNDERLINED TEXT.
2.

DISPLAY THE FOLLOWING MATRIX IN THE RESPONSE FIELD:

HOURS

MINUTES

Before 8:00 a.m.?
Between 8:00 a.m. and 6 p.m.?
After 6 p.m.?
1.

WHEN CURSOR IS ON THE HOUR FIELDS, DISPLAY 'INTERVIEWER INSTRUCTION:
ENTER NUMBER OF HOURS. IF LESS THAN AN HOUR, ENTER '0.'

2.

WHEN CURSOR IS ON THE MINUTE FIELDS, DISPLAY 'INTERVIEWER INSTRUCTION:
ENTER NUMBER OF MINUTES.'

3.

WHEN CURSOR IS ON THE HOUR FIELDS OF DWQ.080B-C OR, OR ANY OF THE MINUTE
FIELDS, DISPLAY ’on any given….How about…' IN SQUARE BRACKETS.

4.

DK AND RF ALLOWED AT ALL FIELDS. EMPTY IS ALLOWED FOR MINUTES, BUT NOT FOR
HOURS.

5.

IF “77” IS ENTERED IN DWQ.080A, GO TO DWQ.100.

6.

USE THE FOLLOWING SKIP INSTRUCTIONS FOR DK OR RF AT HOUR FIELDS:
IF DK OR RF AT:
DWQ.080A HOUR FIELD
DWQ.080B HOUR FIELD
DWQ.080C HOUR FIELD

7.

SKIP TO
DWQ.080B
DWQ.080C
DWQ.082

ELSE
CONTINUE WITH MINUTE
CONTINUE WITH MINUTE
CONTINUE WITH MINUTE

HARD RANGE FOR DWQ.080A = 0 – 5 FOR HOURS; 0 – 59 FOR MINUTES. HARD RANGE
FOR DWQ.080B: 0 - 10 FOR HOURS; 0 - 59 FOR MINUTES. HARD RANGE FOR DWQ.080C
= 0 – 9 FOR HOURS; 0 – 59 FOR MINUTES. THE TOTAL OF THE THREE
TIME FRAMES SHOULD NOT EXCEED 24 HOURS. OTHERWISE, DISPLAY ERROR
MESSAGE: "The total number of hours exceeds 24! Please correct the entries."

DWQ.082

How about on Saturday and Sunday? How many hours does {CHILD} watch television, videotapes, or
DVDs at home on…

a.

Saturdays?

b.

Sundays?

CAPI INSTRUCTIONS:
1.

DISPLAY "at home" IN UNDERLINED TEXT.

2.

DISPLAY THE FOLLOWING MATRIX IN THE RESPONSE FIELD:
HOURS

MINUTES

Saturdays?
Sundays?
3.

WHEN CURSOR IS ON THE HOUR FIELDS, DISPLAY 'INTERVIEWER INSTRUCTION:
ENTER NUMBER OF HOURS. IF LESS THAN AN HOUR, ENTER '0.'

4.

WHEN CURSOR IS ON THE MINUTE FIELDS, DISPLAY 'INTERVIEWER INSTRUCTION:
ENTER NUMBER OF MINUTES.'

5.

WHEN CURSOR IS ON THE HOUR FIELD OF DWQ.082B OR ANY OF THE MINUTE
FIELDS, DISPLAY 'How about…at home on…' IN SQUARE BRACKETS.

6.

DK AND RF ALLOWED AT ALL FIELDS. EMPTY IS ALLOWED FOR MINUTES, BUT NOT
FOR HOURS.

7.

USE THE FOLLOWING SKIP INSTRUCTIONS FOR DK OR RF AT HOUR FIELDS:
IF DK OR RF AT:
DWQ.082A HOUR FIELD
DWQ.082BHOUR FIELD

8.

DWQ.084

SKIP TO
DWQ.082B
DWQ.084

ELSE
CONTINUE WITH MINUTE
CONTINUE WITH MINUTE

HARD RANGE: 0 - 24 HOUR FOR FIELDS; 0 - 59 FOR MINUTE FIELDS. IF HOURS = 24,
THEN MINUTES CANNOT EXCEED 0. OTHERWISE, DISPLAY ERROR MESSAGE: "The
total number of hours exceeds 24! Please correct the entries."

Are there family rules for {CHILD} about any of the following…
What programs {CHILD} can watch?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

DWQ.086

[Are there family rules for {CHILD} about any of the following…]
How many hours {CHILD} may watch television?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

DWQ.088

1
2
8
9

[Are there family rules for {CHILD} about any of the following…]
How early or late {CHILD} may watch television?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

DWQ.100

1
2
8
9

Sometimes kids mind pretty well and sometimes they don't. About how many times, if any, have you
spanked {CHILD} in the past week?
ENTER 95 IF RESPONDENT VOLUNTEERS THAT {CHILD} IS NEVER SPANKED.
CAPI INSTRUCTIONS: SOFT RANGE CHECK: 0 TO 15 SPANKINGS. HARD RANGE CHECK 0 to

95.
|__|__|
NUMBER
REFUSED ................................................... 8
DON'T KNOW…………………………………… 9
BOX 2
IF DWQ.100 = 0, GO TO DWQ.101. ELSE, GO TO DWQ.110.
DWQ.101

Do you ever spank {CHILD}?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

DWQ.110

Most children get angry with their parents from time to time. If {CHILD} got so angry that {he/she} hit you,
what would you do? Would you…
CODE ALL THAT APPLY
CAPI INSTRUCTIONS: IF DWQ.100 = 95 OR DWQ.101 = 2, USE A NULL DISPLAY FOR “Spank
{him/her}” IN THE FIRST CATEGORY. ELSE, DISPLAY “Spank {him/her}”.
{Spank {him/her}},…………………………………………………1
Have {him/her} take a time out……………………….………….2
Hit {him/her} back………………………………………...……….3
Talk to {him/her} about what {he/she} did wrong…………...…4
Ignore it………………………………………………………….…5
Make {him/her} do some work around the house…………..…6
Make fun of {him/her}…………………………………………….7
Make {him/her} apologize………………………………...……..8
Take away a privilege……………………………………………9
Give a warning……………………………………………….….10
Yell at {CHILD} or threaten {him/her}…………………………11
Something else……………………………………………….....91
REFUSED…………………………………………………..……88
DON’T KNOW…………………………………………...……….99

BOX 3
GO TO SECTION CHQ (CHILD HEALTH AND WELL-BEING).

CHILD’S HEALTH AND WELL-BEING – CHQ
CHQ.005

Now I have some questions about {CHILD}'s health and development. At what age did {CHILD} speak
{his/her} first words other than ma-ma or da-da?
PROBE- IF RESPONDENT DOES NOT REMEMBER OR DOES NOT ANSWER WITH A VALUE THAT
CAN BE CATEGORIZED, PROBE WITH THE FOLLOWING CATEGORIES.
BEFORE 6 MONTHS .................................................. 1
6 TO 9 MONTHS......................................................... 2
10 TO 12 MONTHS ..................................................... 3
13 TO 15 MONTHS ..................................................... 4
16 TO 18 MONTHS ..................................................... 5
19 TO 24 MONTHS ..................................................... 6
AFTER 24 MONTHS ................................................... 7
CHILD DOES NOT SPEAK………………………………..8
REFUSED………………………………………………….88
DON’T KNOW……………………………………………...99

CHQ.006

At what age did {CHILD} take {his/her} first steps without support?
PROBE- IF RESPONDENT DOES NOT REMEMBER OR DOES NOT ANSWER WITH A VALUE THAT
CAN BE CATEGORIZED, PROBE WITH THE FOLLOWING CATEGORIES.
BEFORE 6 MONTHS .................................................. 1
6 TO 9 MONTHS......................................................... 2
10 TO 12 MONTHS ..................................................... 3
13 TO 15 MONTHS ..................................................... 4
16 TO 18 MONTHS ..................................................... 5
19 TO 24 MONTHS ..................................................... 6
AFTER 24 MONTHS ................................................... 7
CHILD DOES NOT WALK…………………………………8
REFUSED………………………………………………….88
DON’T KNOW……………………………………………...99

CHQ.007

As an infant, did {CHILD} have difficulty sucking or swallowing?
YES .......................................................................... 1
NO........................................................................... 2
REFUSED ................................................................ 8
DON'T KNOW ........................................................... 9

CHQ.010

How long has it been since {CHILD}'s last visit to a dentist or dental hygienist for dental care?

1
2
3
4
5
DK Allowed
Refusal Allowed

NEVER BEEN TO DENTIST OR DENTAL HYGENIST FOR DENTAL CARE
LESS THAN 6 MONTHS
6 MONTHS TO LESS THAN 1 YEAR
1 YEAR TO 2 YEARS
MORE THAN 2 YEARS

CHQ.020

How long has it been since {CHILD}'s last visit to a clinic, health center, hospital, doctor's office, or
other place for routine health care?
PROBE: Routine health care may include check-ups, or immunization appointments.
1
2
3
4
5

NEVER HAD ROUTINE HEALTH CARE
LESS THAN 6 MONTHS
6 MONTHS TO LESS THAN 1 YEAR
1 YEAR TO 2 YEARS
MORE THAN 2 YEARS

DK Allowed
Refusal Allowed
CHQ.021

Has {CHILD} had an ear infection since entering kindergarten?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

CHQ.022

Has {CHILD} had an ear ache since entering kindergarten?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

CHQ.023

1 (CHQ.023)
2
8
9

1
2
8
9

(CHQ.024)
(CHQ.030)
(CHQ.030)
(CHQ.030)

Since entering kindergarten, how many times did a doctor, nurse, or other medical professional tell you
that {CHILD} had an ear infection?
RECORD NUMBER OF TIMES
CAPI INSTRUCTIONS: RANGE: 0 – 15.
|___|
NUMBER OF TIMES
REFUSED ..................................................
DON'T KNOW ............................................

8
9

BOX 1
IF CHQ.023 GE 1, GO TO CHQ.024. ELSE, GO TO CHQ.030.

CHQ.024

How have {CHILD}’s {ear infections/ear aches} been treated by your doctor, nurse, or other medical
professional since {she/he} entered kindergarten?
PROBE: Anything else?
CODE ALL THAT APPLY FOR 1-7.
CAPI INSTRUCTION: DISPLAY “ear infections” IF CHQ.021 = 1. ELSE, DISPLAY “ear aches”.

NO TREATMENT/WATCH AND WAIT ........................................................................ 1
DECONGESTANTS ................................................................................................... 2
ANTIBIOTICS ............................................................................................................ 3
WITH EAR TUBES ..................................................................................................... 4
ANALGESICS (E.G., FEVER REDUCER OR PAIN RELIEVER) .................................. 5
EAR DROPS ............................................................................................................ 6
DID NOT GO TO DOCTOR, NURSE, OR MEDICAL PROFESSIONAL ........................ 7 (CHQ.030)
OTHER (SPECIFY) .................................................................................................... 91
REFUSED
............................................................................................................ 8
DON’T KNOW ............................................................................................................ 9
BOX 2
IF ONE OF THE CODES IN CHQ.024 = 91, GO TO CHQ.024OS. ELSE, GO TO
BOX 3.

CHQ.024OS

[How have {CHILD}’s {ear infections/ear aches} been treated by your doctor, nurse, or other medical
professional since {she/he} entered kindergarten? ]
CAPI INSTRUCTION: DISPLAY “ear infections” IF CHQ.021 = 1. ELSE, DISPLAY “ear aches”.
SPECIFY TREATMENT.
________________________________________________________

BOX 3
IF ONE OF THE CODES IN CHQ.024 = 4, GO TO CHQ.025. ELSE, GO TO
CHQ.030.

CHQ.025

Have ear tubes been placed in the right ear, left ear, or both ears when your child has had surgery to
place tubes in his/her ears?
IF NEEDED: PLEASE CONSIDER ALL SURGERIES SINCE THE START OF KINDERGARTEN IF
{CHILD} HAD MORE THAN ONE TO PLACE EAR TUBES.
RIGHT EAR.................................................
LEFT EAR ...................................................
BOTH EARS ...............................................
REFUSED ..................................................
DON'T KNOW ............................................

CHQ.030

1
2
3
8
9

Is {CHILD} now covered by a health insurance plan which would pay any part of a hospital, doctor's, or
surgeon's bill?
PROBE: This includes {Medicaid/ {or STATE NAME FOR MEDICAID}}.
CAPI INSTRUCTIONS: FOR "or STATE MEDICAID PROGRAM NAME"; DISPLAY NAME FOR STATE
MEDICAID PROGRAM, IF ANY, FROM PRELOAD. ELSE, IF MISSING, DISPLAY “Medicaid.”
YES .......................................................................... 1
NO........................................................................... 2
REFUSED ................................................................ 8
DON'T KNOW ........................................................... 9

CHQ.060

In a typical week, on how many days does {CHILD} get exercise that causes rapid breathing,
perspiration, and a rapid heartbeat for 20 continuous minutes or more?
CAPI INSTRUCTION: RANGE CHECK 0-7.
|___|
ENTER # OF DAYS
REFUSED ................................................... 88
DON’T KNOW ............................................. 99

HELP AVAILABLE
CHQ.070

What types of exercise or physical activity does {CHILD} get? How about…..

HELP TEXT:
GROUP SPORTS: e.g. baseball, basketball, soccer, organized or unorganized games in the yard or neighborhood.
INDIVIDUAL SPORTS: e.g. tennis, swimming, gymnastics.
DANCE: e.g. tap, ballet, movement.
RECREATIONAL SPORTS/OUTDOOR ACTIVITIES: e.g. biking, hiking.
MARTIAL ARTS: e.g., Karate, Judo, Tae Kwan Do
PLAYGROUND ACTIVITIES: e.g. catch, jump-rope, tag; these do NOT need to occur necessarily in a “playground” but
could occur in a backyard or common area.
CALISTHENICS/GENERAL EXERCISING: e.g. jumping jacks, kid gyms.
a.
b.
c.
d.
e.
f.
g.
h.

Group sports?
Individual sports?
Dance?
Recreational sports or outdoor activities?
Martial Arts?
Playground activities?
Calisthenics or general exercising?
Anything else?

DISPLAY FOR EACH QUESTION:
1
YES
2
NO
Other Specify Allowed
DK Allowed
Refusal Allowed
BOX 4
IF CHQ.070h = 1, GO TO CHQ.070OS. ELSE, GO TO CHQ.095.
CHQ.070OS [What types of exercise or physical activity does {CHILD} get?]
SPECIFY ACTIVITY
________________________________________________________

CHQ.095

For the next set of questions, please base your answer on how {CHILD} compares to other children of the
same age.
{CHILD} is independent and takes care of {himself/herself} ...
DISPLAY ‘herself’ IF CHILD IS FEMALE ACCORDING TO THE PRELOAD.
ELSE, DISPLAY ‘himself’ '.
1.
2.
3.
4.

Better than other children {his/her} age,
As well as other children,
Slightly less well than other children, or
Much less well than other children?

DK Allowed
Refusal Allowed
CHQ.100

Does {CHILD} pay attention ....
1. Better than other children {his/her} age,
2. As well as other children,
3. Slightly less well than other children, or
4. Much less well than other children?
DK Allowed
Refusal Allowed

CHQ.105

Does {CHILD} learn, think, and solve problems ...
1.
2.
3.
4.

Better than other children {his/her} age,
As well as other children,
Slightly less well than other children, or
Much less well than other children?

DK Allowed
Refusal Allowed
CHQ.106

Does {CHILD} show good coordination in moving {his/her} arms and legs? Would you say {he/she} does
this ...
IF RESPONDENT REPORTS DIFFERENTIALLY FOR ARMS OR LEGS OR FOR SIDES OF THE BODY,
SAY: Answer for the part of the body your child has the most difficulty using.
IF CHILD HAS EPISODIC TROUBLE, SAY: Answer for what you consider a typical day.
1.
2.
3.
4.

......

Better than other children {his/her} age,
As well as other children,
Slightly less well than other children, or
Much less well than other children?

DK Allowed
Refusal Allowed

CHQ.107

Would you say {CHILD} behaves and relates to other children...
1.
2.
3.
4.

Better than other children {his/her} age,
As well as other children,
Slightly less well than other children, or
Much less well than other children?

......

DK Allowed
Refusal Allowed

CHQ.108

Would you say {CHILD} behaves and relates to adults ...
CAPI INSTRUCTION: DISPLAY “adults” IN UNDERLINED TEXT.
1
2
3
4

Better than other children {his/her} age,
As well as other children,
Slightly less well than other children, or
Much less well than other children?

......

DK Allowed
Refusal Allowed

CHQ.109

Thinking about {CHILD}'s overall activity level, would you say {he/she} is …
1.
2.
3.
4.

......

Less active than other children of {his/her} age,
About as active,
Slightly more active, or
A lot more active than other children of {his/her} age?

DK Allowed
Refusal Allowed

CHQ.110 Does {CHILD} have any emotional or psychological difficulties?
1.
2.

YES
NO (BOX 5)

DK Allowed (BOX 5)
Refusal Allowed (BOX 5)

CHQ.111 Do you think this is a mild problem, a moderate problem, or a severe problem?
a. MILD PROBLEM
b. MODERATE PROBLEM
c. SEVERE PROBLEM
DK Allowed
Refusal Allowed

BOX 5
IF (CHQ.095 = 3 OR 4) OR (CHQ.100 = 3 OR 4) OR (CHQ.105 = 3 OR 4) OR
(CHQ.106 = 3 OR 4), OR (CHQ.107 = 3 OR 4) OR (CHQ.108 = 3 OR 4) OR
(CHQ.109 = 4) OR (CHQ.110 = 1), GO TO CHQ.115. ELSE, GO TO CHQ.200.
HELP AVAILABLE
CHQ.115

Has {CHILD} ever been evaluated by a professional because of an issue with {independence and taking
care of {himself/herself} {or}/paying attention {or}/learning, thinking, and solving problems {or}/
coordination in moving {his/her} arms and legs {or}/behaving and relating to other children {or}/ behaving
and relating to adults {or}/{his/her} overall activity level {or}/{his/her} emotional or psychological
difficulties}?
HELP TEXT: Professional: This includes health professionals such as doctors, pediatricians, and other
licensed persons, including nurses or nurse practitioners, optometrists, ophthalmologists, ear-nose-throat
(ENT) doctors, audiologists, school or other psychologists, school or other psychiatrists, psychiatric social
workers, speech-language pathologists, etc. Do not include teachers or some other non-health
professional.
CAPI INSTRUCTIONS: DISPLAY ALL THE ISSUES THAT THE CHILD HAS ACCORDING TO THE
INSTRUCTIONS BELOW. IF THERE IS MORE THAN ONE ISSUE, DISPLAY THE “or” FOLLOWING
THE DISPLAY (E.G., IF A CHILD HAS PROBLEMS WITH BOTH PAYING ATTENTION AND BEHAVING
AND RELATING TO ADULTS, THE DISPLAY WOULD BE “paying attention or behaving and relating to
adults.”).
IF CHQ.095 = 1, DISPLAY “independence and taking care of {himself/herself}”. DISPLAY “herself” IF THE
CHILD IS FEMALE ACCORDING TO THE PRELOAD. ELSE, DISPLAY “himself”.
IF CHQ.100 = 1, DISPLAY “paying attention”.
IF CHQ.105 = 1, DISPLAY “learning, thinking, and solving problems”.
IF CHQ.106 = 1, DISPLAY “coordination in moving {his/her} arms and legs”.
IF CHQ.107 = 1, DISPLAY “behaving and relating to other children”.
IF CHQ.108 = 1, DISPLAY “behaving and relating to adults”.
IF CHQ.109 = 1, DISPLAY “overall activity level”.
IF CHQ.110 = 1, DISPLAY “{his/her} emotional or psychological difficulties”.

1.
2.

YES
NO (CHQ.200)

DK Allowed (CHQ.200)
Refusal Allowed (CHQ.200)

HELP AVAILABLE
CHQ.120

Did you obtain a diagnosis or diagnoses of a problem from a professional?
HELP TEXT: Professional: This includes health professionals such as doctors, pediatricians, and other
licensed persons, including nurses or nurse practitioners, optometrists, ophthalmologists, ear-nose-throat
(ENT) doctors, audiologists, school or other psychologists, school or other psychiatrists, psychiatric social
workers, speech-language pathologists, etc. Do not include teachers or some other non-health
professional.

1.
2.

YES
NO (CHQ.200)

DK Allowed (CHQ.200)
Refusal Allowed (CHQ.200)

HELP AVAILABLE
CHQ.125

What was the diagnosis or were the diagnoses?

HELP TEXT:
Learning disability: This is a disorder in one or more of the basic psychological processes involved in understanding or
in using language, spoken or written, which shows up as difficulty to listen, think, speak, read, write, spell, or do
mathematical calculations. In some cases the child can perform at grade level, but only with special help. Some names
of learning disabilities are dyslexia (CODE UNDER DYSLEXIA), dyscalculia (CODE UNDER DYSCALCULIA),
developmental aphasia, minimal brain dysfunction, brain injury, and perceptual disabilities. The term does not include
learning problems that are primarily the result of problems with seeing, hearing, or walking (or visual, hearing or motor
disabilities); mental retardation; emotional disturbance; or environmental, cultural, or economic disadvantage. A
commonly used acronym is "LD."
Attention Deficit Disorder (ADD): A childhood syndrome characterized by short attention span that is inappropriate for
his/her age group.
Attention Deficit Hyperactivity Disorder (ADHD): The child displays signs of inattention, impulsivity, and
hyperactivity that are inappropriate for his or her mental and chronological age. Adults in the child’s environment, such
as parents and teachers must report the signs. Inattention means difficulty concentrating, easily distracted, and not
finishing things started. Impulsivity means often acts before thinking, shifts excessively from one activity to another,
needs a lot of supervision. Hyperactivity means runs about or climbs on things excessively, has difficulty staying
seated, always on the go, as if driven by a motor. Onset is typically before age seven and condition lasts at least six
months.
Developmental delay: A condition in which a young child falls significantly behind his/her age-mates in physical,
mental (cognitive), speech (communication), social/emotional, adaptive (behavioral) development. It does not simply
mean that the child talked somewhat later than some children talked or was smaller than average. It is not to be
confused with autism or pervasive developmental delay. If the child's social behavior and relationships with other
people are generally consistent with his or her delayed cognitive development, then the classification of the condition as
developmental delay is probably appropriate. If this is not the case, see the definitions of autism and pervasive
developmental disorder or delay.
Autism is a developmental disability significantly affecting verbal and nonverbal communication as well as social
interaction, generally evident before age three. Other characteristics often associated with autism are a pervasive lack
of responsiveness to other people, and engagement in repetitive activities and stereotyped movements (such as handflapping or rocking). There is also often an insistence on sameness, as shown by stereotyped play, abnormal
preoccupations, or resistance to change. With autism, the impaired social development and delayed or deviant
language development are not merely predictable from the child's cognitive retardation. Some children with autism are
actually advanced in their reading skills, memory skills, or musical abilities. The term autism does not apply if the child’s
educational performance is negatively affected primarily because the child has an emotional disturbance. Asperger's
Disorder, Pervasive Developmental Disorder (PDD), or any other autism spectrum disorder may be coded here;
the subtype will be captured in the next question. Pervasive developmental disorder or delay is also characterized by
gross and sustained impairment in social relationships, but typically has an onset after 30 months of age. Other
characteristics are sudden excessive anxiety, inappropriate affect or emotions, resistance to change in the environment,
oddities of motor movement, abnormalities of speech, hypersensitivity to sensory stimuli, and self-mutilation. This
condition generally does not involve delusions, hallucinations, incoherence, or bizarre associations.
Dyslexia: A learning disability (see above definition) marked by impairment of the ability to recognize and comprehend
the written word.
Dyscalculia: A learning disability (see above definition) marked by impairment in the ability to perform and remember
calculations in mathematics.

Mental Retardation/Severe cognitive disability: The child's mental development is significantly and noticeably
behind what would ordinarily be expected for a child of his or her age. This significantly below average general
intellectual functioning exists at the same time as problems in adaptive behavior, and negatively affects the child’s
educational performance.
Orthopedic impairment: A bodily (or physical) impairment that is severe enough to negatively affect a child’s
educational performance. Disabling physical problems such as those resulting from poliomyelitis (often called polio or
infantile paralysis), bone tuberculosis, cerebral palsy, amputations, and fractures or contractures (shortening of tissue)
from burns would be considered as orthopedic impairments.
Serious Emotional Disturbance or SED: A condition that has one or more of the following characteristics over a long
period of time that negatively affect a child's educational performance: (a) an inability to learn that cannot be explained
by other factors; (b) an inability to build or maintain satisfactory interpersonal relationships with peers and teachers; (c)
inappropriate behavior or feelings; d) a general mood of unhappiness or depression; or (e) a tendency to develop
physical symptoms or fears associated with personal or school problems. The term includes schizophrenia but does not
apply to children who are socially maladjusted, unless it is determined that they have a serious emotional disturbance.
Traumatic Brain Injury: An acquired injury to the brain caused by an external force, resulting in total or partial
functional disability or psychosocial impairment, or both, that adversely affects a child's educational performance. The
term applies to open or closed head injuries resulting in impairments in one or more areas, such as cognition; language;
memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities;
psycho-social behavior; physical functions; information processing; and speech. The term does not apply to brain
injuries that are congenital (there at birth) or degenerative (problem that grows worse over time), or to brain injuries
brought on by birth trauma (injuries during birth). The term is used when an external force has caused the injury.
Panic Disorder: A disorder in which there is the sudden onset of several different physical signs, such as rapid heart
rate, shaking, sweating, nausea, dizziness, and difficulty breathing. A panic disorder may make a child think that
something horrible is about to happen.
Separation Anxiety Disorder: This is the fear a child has of being separated from his/her parents which is far more
than would be expected for the child’s developmental stage.
Obsessive Compulsive Disorder: A child must have obsessions or compulsions or both to have this disorder, and
these obsessions and/or compulsions must be disabling to the child. Obsessions are thoughts that aren’t visible to
others but cause the child distress. The thoughts occur over and over and the child spends so much time on them that
they have a hard time taking care of themselves or relating to others. Compulsions are mental acts that a child feels
driven to perform in response to an obsession.
Generalized Anxiety Disorder: Children who have this disorder worry all the time over nothing, themselves, other’s
safety, their health, and/or the world to a far greater extent than average. They often have many physical signs of
anxiety such as headache, abdominal pain, cramps, diarrhea, vomiting, and dizziness.
Other Anxiety Disorder: An anxiety disorder that is not one of the specific disorders in this list.
Bipolar Disorder: A child with bipolar disorder displays signs of major mood changes, sometimes sad, as in
depression, or the opposite, mania. All bipolar disorders are a combination of mania with or without depression. Some
signs of mania include inflated self-esteem, decreased need for sleep, distractibility and increased activity. Some signs
of depression are sleeping too much, poor appetite, feelings of severe worthlessness, hallucinations or strange beliefs
about the past.
Depression: Some signs of depression are frequent sadness, loss of interest or enjoyment of activities, low energy,
isolation from friends, sleeping too much, poor appetite, a severe sense of worthlessness, problems with concentration,
frequent complaints of physical illnesses, and thoughts of suicide or destructive behavior.

PROBE: Anything else?
CODE ALL THAT APPLY.

1. ... LEARNING DISABILITY
2. ... ATTENTION DEFICIT DISORDER (ADD)
3. ... ATTENTION DEFICIT HYPERACTIVE DISORDER (ADHD)
4. ... DEVELOPMENTAL DELAY
5. ... AUTISM
6. ... DYSLEXIA
7. ... DYSCALCULIA
8. ... MENTAL RETARDATION/SEVERE COGNITIVE DISABILITY
9. ... ORTHOPEDIC IMPAIRMENT
10... SERIOUS EMOTIONAL DISTURBANCE
11. .TRAUMATIC BRAIN INJURY
12. PANIC DISORDER
13. SEPARATION ANXIETY DISORDER
14. OBSESSIVE COMPULSIVE DISORDER
15. GENERALIZED ANXIETY DISORDER
16. OTHER ANXIETY DISORDER
17. BIPOLAR DISORDER
18. DEPRESSION
91. OTHER (SPECIFY)
Other Specify Allowed
DK Allowed
Refusal Allowed

BOX 6
IF CHQ.125 = 91, GO TO CHQ.125OS. ELSE, GO TO BOX 7.

CHQ.125OS
[What {was the diagnosis/were the diagnoses?}]
SPECIFY DIAGNOSIS/DIAGNOSES.
_____________________________________________________________
BOX 7
IF CHQ.125 HAS A CODE OF 5, GO TO CHQ.126. ELSE, GO TO BOX 8.

CHQ.126

What type of autistic spectrum disorder does {CHILD} have? Is it autism, Asperger's Disorder, Pervasive
Developmental Disorder, or something else?
1.
2.
3.
4.

DK Allowed
Refusal Allowed

AUTISM
ASPERGER'S DISORDER
PERVASIVE DEVELOPMENTAL DISORDER (PDD)
OTHER, SPECIFY

BOX 7B
IF CHQ.126 = 91, GO TO CHQ.126OS. ELSE, GO TO BOX 8.

CHQ.126OS
[What {was the diagnosis/were the diagnoses?}]
SPECIFY TYPE OF AUTISTIC SPECTRUM DISORDER.
_____________________________________________________________

BOX 8
LOOP 1
ASK CHQ.130, CHQ.131, CHQ.135, CHQ.140, CHQ.145, CHQ.150, CHQ.155,
AND CHQ.173 (IF APPLICABLE ACCORDING TO THE SKIPS BETWEEN THE
ITEMS) FOR EACH DIAGNOSIS IN CHQ.125, UP TO 19 TIMES. THE
DIAGNOSIS LISTED AS AN “OTHER SPECIFY” SHOULD ALSO BE PART OF
THIS LOOP.
LOOPING ELIGIBILITY:
IF CHQ.125 = 1, ASK ABOUT A LEARNING DISABILITY.
IF CHQ.125 = 2, ASK ABOUT ATTENTION DEFICIT DISORDER (ADD).
IF CHQ.125 = 3, ASK ABOUT ATTENTION DEFICIT HYPERACTIVE DISORDER
(ADHD).
IF CHQ.125 = 4, ASK ABOUT DEVELOPMENTAL DELAY.
IF CHQ.125 = 5, ASK ABOUT AUTISM.
IF CHQ.125 = 6, ASK ABOUT DYSLEXIA.
IF CHQ.125 = 7, ASK ABOUT DYSCALCULIA.
IF CHQ.125 = 8, ASK ABOUT MENTAL RETARDATION/SEVERE COGNITIVE
DISABILITY.
IF CHQ.125 = 9, ASK ABOUT ORTHOPEDIC IMPAIRMENT.
IF CHQ.125 = 10, ASK ABOUT SERIOUS EMOTIONAL DISTURBANCE.
IF CHQ.125 = 11, ASK ABOUT TRAUMATIC BRAIN INJURY.
IF CHQ.125 = 12, ASK ABOUT PANIC DISORDER.
IF CHQ.125 = 13, ASK ABOUT SEPARATION ANXIETY DISORDER.
IF CHQ.125 = 14, ASK ABOUT OBSESSIVE COMPULSIVE DISORDER.
IF CHQ.125 = 15, ASK ABOUT GENERALIZED ANXIETY DISORDER.
IF CHQ.125 = 16, ASK ABOUT OTHER ANXIETY DISORDER.
IF CHQ.125 = 17, ASK ABOUT BIPOLAR DISORDER.
IF CHQ.125 = 18, ASK ABOUT DEPRESSION.
IF CHQ.125 = 91, ASK ABOUT THE DIAGNOSIS AS LISTED IN THE OTHER
SPECIFY TEXT OF CHQ.125OS.

CHQ.130

How old was {CHILD} when the first diagnosis of a problem related to {a learning disability/Attention Deficit
Disorder (ADD)/Attention Deficit Hyperactive Disorder (ADHD)/developmental
delay/autism/dyslexia/dyscalculia/mental retardation or severe cognitive disability/orthopedic impairment/a
serious emotional disturbance/a traumatic brain injury/a panic disorder/separation anxiety
disorder/obsessive compulsive disorder/generalized anxiety disorder/an {other} anxiety disorder/bipolar
disorder/depression/{TEXT FROM OTHER SPECIFY}} was made?
CAPI INSTRUCTIONS: DISPLAY THE FOLLOWING FOR THE PARTICULAR LOOP THE R IS ON:
IF CHQ.125 = 1, DISPLAY “a learning disability”.
IF CHQ.125 = 2, DISPLAY “Attention Deficit Disorder (ADD)”.
IF CHQ.125 = 3, DISPLAY “Attention Deficit Hyperactive Disorder (ADHD)”.
IF CHQ.125 = 4, DISPLAY “developmental delay”.
IF CHQ.125 = 5, DISPLAY “autism”.
IF CHQ.125 = 6, DISPLAY “dyslexia”.
IF CHQ.125 = 7, DISPLAY “dyscalculia”.
IF CHQ.125 = 8, DISPLAY “mental retardation or severe cognitive disability“.
IF CHQ.125 = 9, DISPLAY “orthopedic impairment”.
IF CHQ.125 = 10, DISPLAY “a serious emotional disturbance”.
IF CHQ.125 = 11, DISPLAY “a traumatic brain injury”.
IF CHQ.125 = 12, DISPLAY “a panic disorder”.
IF CHQ.125 = 13, DISPLAY “separation anxiety disorder”.
IF CHQ.125 = 14, DISPLAY “obsessive compulsive disorder”.
IF CHQ.125 = 15, DISPLAY “generalized anxiety disorder”.
IF CHQ.125 = 16, DISPLAY “an {other} anxiety disorder” DISPLAY “other” IF (CHQ.125
= 12 OR CHQ.125 = 13 OR CHQ.125 = 14 OR CHQ.125 = 15). ELSE, USE A NULL
DISPLAY FOR “other”.
IF CHQ.125 = 17, DISPLAY “bipolar disorder”.
IF CHQ.125 = 18, DISPLAY “depression”.
IF CHQ.125 = 91, DISPLAY “{TEXT FROM OTHER SPECIFY}“ FROM CHQ.125OS.
CAPI INSTRUCTIONS: RANGE CHECK: 0-23.
|___|___|
ENTER AGE

......

DK Allowed (CHQ.135)
Refusal Allowed (CHQ.140)

CHQ.131

[How old was {CHILD} when the first diagnosis of a problem related to {a learning disability/Attention
Deficit Disorder (ADD)/Attention Deficit Hyperactive Disorder (ADHD)/developmental
delay/autism/dyslexia/dyscalculia/mental retardation or severe cognitive disability/orthopedic impairment/a
serious emotional disturbance/a traumatic brain injury/a panic disorder/separation anxiety
disorder/obsessive compulsive disorder/generalized anxiety disorder/an {other} anxiety disorder/bipolar
disorder/depression/{TEXT FROM OTHER SPECIFY} was made?]
IF CHQ.125 = 1, DISPLAY “a learning disability”.
IF CHQ.125 = 2, DISPLAY “Attention Deficit Disorder (ADD)”.
IF CHQ.125 = 3, DISPLAY “Attention Deficit Hyperactive Disorder (ADHD)”.
IF CHQ.125 = 4, DISPLAY “developmental delay”.
IF CHQ.125 = 5, DISPLAY “autism”.
IF CHQ.125 = 6, DISPLAY “dyslexia”.
IF CHQ.125 = 7, DISPLAY “dyscalculia”.
IF CHQ.125 = 8, DISPLAY “mental retardation or severe cognitive disability”.
IF CHQ.125 = 9, DISPLAY “orthopedic impairment”.
IF CHQ.125 = 10, DISPLAY “a serious emotional disturbance”.
IF CHQ.125 = 11, DISPLAY “a traumatic brain injury”.
IF CHQ.125 = 12, DISPLAY “a panic disorder”.
IF CHQ.125 = 13, DISPLAY “separation anxiety disorder”.
IF CHQ.125 = 14, DISPLAY “obsessive compulsive disorder”.
IF CHQ.125 = 15, DISPLAY “generalized anxiety disorder”.
IF CHQ.125 = 16, DISPLAY “an {other} anxiety disorder” DISPLAY “other” IF (CHQ.125
= 12 OR CHQ.125 = 13 OR CHQ.125 = 14 OR CHQ.125 = 15). ELSE, USE A NULL
DISPLAY FOR “other”.
IF CHQ.125 = 17, DISPLAY “bipolar disorder”.
IF CHQ.125 = 18, DISPLAY “depression”.
IF CHQ.125 = 91, DISPLAY “{TEXT FROM OTHER SPECIFY}“ FROM CHQ.125OS.
CAPI INSTRUCTIONS: RANGE CHECK: 0-23 IF MONTHS IS THE UNIT; 0-8 IF YEARS IS THE UNIT.
ENTER UNIT

1.
2.

MONTHS (CHQ.140)
YEARS (CHQ.140)

DK Allowed (CHQ.135)
Refusal Allowed (CHQ.140)
CHQ.135

What was the month and year when the diagnosis was made?
IF R DOESN'T KNOW MONTH, ASK: Do you remember the year?
IF THERE WAS MORE THAN ONE DIAGNOSIS, ASK FOR THE EARLIEST.
CAPI INSTRUCTIONS: RANGE CHECK: 1-12 FOR MONTH, 2003-2011 FOR YEAR.
CAPI INSTRUCTION: EDIT: YEAR ENTERED MUST BE EQUAL TO OR GREATER THAN CHILD'S
BIRTHDATE AND LESS THAN OR EQUAL TO INTERVIEW DATE.
|___|___|
ENTER MONTH
DK Allowed
Refusal Allowed

AND

|___|___|___|___|
ENTER YEAR

CHQ.140

Is {CHILD} now taking any prescription medicine for the condition related to {his/her] {learning
disability/Attention Deficit Disorder (ADD)/Attention Deficit Hyperactive Disorder (ADHD)/developmental
delay/autism/dyslexia/dyscalculia/mental retardation or severe cognitive disability/orthopedic impairment/a
serious emotional disturbance/a traumatic brain injury/a panic disorder/separation anxiety
disorder/obsessive compulsive disorder/generalized anxiety disorder/{other} anxiety disorder/bipolar
disorder/depression/{TEXT FROM OTHER SPECIFY}?
IF CHQ.125 = 1, DISPLAY “learning disability”.
IF CHQ.125 = 2, DISPLAY “Attention Deficit Disorder (ADD)”.
IF CHQ.125 = 3, DISPLAY “Attention Deficit Hyperactive Disorder (ADHD)”.
IF CHQ.125 = 4, DISPLAY “developmental delay”.
IF CHQ.125 = 5, DISPLAY “autism”.
IF CHQ.125 = 6, DISPLAY “dyslexia”.
IF CHQ.125 = 7, DISPLAY “dyscalculia”.
IF CHQ.125 = 8, DISPLAY “mental retardation or severe cognitive disability”.
IF CHQ.125 = 9, DISPLAY “orthopedic impairment”.
IF CHQ.125 = 10, DISPLAY “serious emotional disturbance”.
IF CHQ.125 = 11, DISPLAY “traumatic brain injury”.
IF CHQ.125 = 12, DISPLAY “panic disorder”.
IF CHQ.125 = 13, DISPLAY “separation anxiety disorder”.
IF CHQ.125 = 14, DISPLAY “obsessive compulsive disorder”.
IF CHQ.125 = 15, DISPLAY “generalized anxiety disorder”.
IF CHQ.125 = 16, DISPLAY “{other} anxiety disorder” DISPLAY “other” IF (CHQ.125 =
12 OR CHQ.125 = 13 OR CHQ.125 = 14 OR CHQ.125 = 15). ELSE, USE A NULL
DISPLAY FOR “other”.
IF CHQ.125 = 17, DISPLAY “bipolar disorder”.
IF CHQ.125 = 18, DISPLAY “depression”.
IF CHQ.125 = 91, DISPLAY “{TEXT FROM OTHER SPECIFY}“ FROM CHQ.125OS.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

BOX 9
IF CHQ.140 = 1 AND CHQ.125 = 2 OR 3, GO TO CHQ.145. ELSE, IF CHQ.140
=1, GO TO CHQ.173. ELSE, GO TO CHQ.200.

CHQ.145

What medication or medications is {CHILD} currently taking for ADD or ADHD? Does {he/she} take…
CAPI INSTRUCTION: DISPLAY “What…ADHD?” IN SQUARE BRACKETS FOR B-G.
RESPONSES: 1 = YES, 2 = NO
a.
b.
c.
d.
e.
f.
g.

Other Specify Allowed
DK Allowed
Refusal Allowed

Ritalin (METHYLPHENIDATE)?
Adderall (AMPHETAMINE)?
Dexedrine (DEXTRO-AMPHETAMINE)?
Metadate (METHYLPHENIDATE)?
Concerta (METHYLPHENIDATE)?
Straterra (ATOMOXETINE)?
Something else? (SPECIFY)

BOX 9b
IF CHQ.145g = 1, GO TO CHQ.145gOS. ELSE, GO TO BOX 10.
CHQ.145gOS
[What medications or medications is {CHILD} currently taking for ADD or ADHD?]
SPECIFY MEDICATION OR MEDICATIONS.
_____________________________________________________________

BOX 10
IF CHQ.145b = 1, GO TO CHQ.150. ELSE, IF ANY ANSWER IN CHQ.145 A - G
=1, GO TO CHQ.155. ELSE, IF CHQ.140 = 1, GO TO CHQ.173.

CHQ.150

Is {CHILD} taking Adderall (short acting) or Adderall XR (long acting/extended release)?
1. ADDERALL (SHORT ACTING)
2. ADDERALL XR (LONG ACTING/EXTENDED RELEASE)

DK Allowed
Refusal Allowed
CHQ.155

1.
2.
3.

Is {CHILD} medicated for ADD or ADHD at school, at home, or both?

AT SCHOOL
AT HOME
BOTH AT SCHOOL AND AT HOME

DK Allowed
Refusal Allowed

CHQ.173

1.
2.
3.
4.
5.

How long has {CHILD} taken such prescription medicine for {a learning disability/Attention Deficit Disorder
(ADD)/Attention Deficit Hyperactive Disorder (ADHD)/developmental
delay/autism/dyslexia/dyscalculia/mental retardation or severe cognitive disability/an orthopedic
impairment/a serious emotional disturbance/a traumatic brain injury/a panic disorder/separation anxiety
disorder/obsessive compulsive disorder/generalized anxiety disorder/an {other} anxiety disorder/bipolar
disorder/depression/{TEXT FROM OTHER SPECIFY}}, in total?
IF CHQ.125 = 1, DISPLAY “a learning disability”.
IF CHQ.125 = 2, DISPLAY "Attention Deficit Disorder (ADD)“.
IF CHQ.125 = 3, DISPLAY “Attention Deficit Hyperactive Disorder (ADHD) “.
IF CHQ.125 = 4, DISPLAY “developmental delay”.
IF CHQ.125 = 5, DISPLAY “autism”.
IF CHQ.125 = 6, DISPLAY “dyslexia”.
IF CHQ.125 = 7, DISPLAY “dyscalculia”.
IF CHQ.125 = 8, DISPLAY “mental retardation or severe cognitive disability”.
IF CHQ.125 = 9, DISPLAY “orthopedic impairment”.
IF CHQ.125 = 10, DISPLAY “a serious emotional disturbance”.
IF CHQ.125 = 11, DISPLAY “a traumatic brain injury”.
IF CHQ.125 = 12, DISPLAY “a panic disorder”.
IF CHQ.125 = 13, DISPLAY “separation anxiety disorder”.
IF CHQ.125 = 14, DISPLAY “obsessive compulsive disorder”.
IF CHQ.125 = 15, DISPLAY “generalized anxiety disorder”.
IF CHQ.125 = 16, DISPLAY “an {other} anxiety disorder” DISPLAY “other” IF (CHQ.125
= 12 OR CHQ.125 = 13 OR CHQ.125 = 14 OR CHQ.125 = 15). ELSE, USE A NULL
DISPLAY FOR “other”.
IF CHQ.125 = 17, DISPLAY “bipolar disorder”.
IF CHQ.125 = 18, DISPLAY “depression”.
IF CHQ.125 = 91, DISPLAY “{TEXT FROM OTHER SPECIFY}“ FROM CHQ.125OS.

Less than one month,
Less than a year,
1 to 2 years,
3 to 4 years, or
5 years or more?

DK Allowed
Refusal Allowed

BOX 11
END OF LOOP 1.
IF ALL CODES INDICATED IN CHQ.125 HAVE BEEN ASKED ABOUT IN LOOP 1
(ALL DIAGNOSES THE CHILD HAS HAVE BEEN ASKED ABOUT), GO TO
CHQ.200. ELSE, GO BACK UP TO BOX 8 AND ASK ABOUT THE NEXT
DIAGNOSIS.

CHQ.200

For the next question, please base your answer on how {CHILD} compares to other children of the same
age. Does {CHILD} pronounce words, communicate with and understand others...

IF RESPONDENT INDICATES CHILD DIFFERS ON ANY OF THE AREAS (E.G., CAN UNDERSTAND BUT NOT
PRONOUNCE), SAY: Answer for the area in which the child has the most difficulty.
CAPI INSTRUCTION: DISPLAY "IF … SAY: IN LIGHT BLUE "AND DISPLAY "Answer ….difficulty" IN BLACK.

1.
2.
3.
4.

Better than other children {his/her} age,
As well as other children,
Slightly less well than other children, (CHQ.206)
Much less well than other children? (CHQ.206)

DK Allowed
Refusal Allowed

CHQ.205

1.
2.

When {CHILD} was younger, did {he/she} ever have unusual difficulty pronouncing words, communicating
with, or understanding others, as compared to other children {his/her} age?

YES
NO

DK Allowed
Refusal Allowed
CHQ.206

Did or does {CHILD} have any of the following?

1.

Problem with talking too loudly

2.

Problem with talking too softly

3.

A problem chewing

4.

A problem swallowing

5.

A problem with stuttering

6.

A cleft lip and/or palate

7.

Abnormalities of the face or head

8.

Malformation of the ear
1.
2.

YES
NO

DK Allowed
Refusal Allowed
BOX 11B
IF (CHQ.200 = 3 OR 4) OR (CHQ.205 = 1), GO TO CHQ.210. ELSE, GO TO
CHQ.216.

CHQ.210

Has {CHILD} ever been evaluated by a professional because of {his/her} ability to communicate?
HELP TEXT: Professional: This includes health professionals such as doctors, pediatricians, and other
licensed persons, including nurses or nurse practitioners, optometrists, ophthalmologists, ear-nose-throat
(ENT) doctors, audiologists, school or other psychologists, school or other psychiatrists, psychiatric social
workers, speech-language pathologists, etc. Do not include teachers or some other non-health
professional.
YES
......................................................1
NO
......................................................2
REFUSED ..................................................8
DON'T KNOW .............................................9

CHQ.215

(CHQ.216)
(CHQ.216)
(CHQ.216)

Did you obtain a diagnosis or diagnoses of a problem related to {his/her} ability to communicate from a
professional?
YES
......................................................1
NO
......................................................2
REFUSED ..................................................8
DON'T KNOW .............................................9

CHQ.216

Which best describes {CHILD}’s hearing? If {CHILD} has a hearing aid or other assistive device, please
consider {his/her} hearing without the hearing aid or assistive device.
Excellent ................................................... 1
Good ........................................................ 2
A little trouble hearing................................. 3
Moderate trouble hearing............................ 4
A lot of trouble hearing ...............................5
Deaf........................................................... 6
REFUSED ................................................ 8
DON'T KNOW ........................................... 9

CHQ.217

(CHQ.221)
(CHQ.221)

(CHQ.221)
(CHQ.221)

Please indicate whether the following statement describes {CHILD}'s hearing. If {CHILD} has a hearing
aid or other assistive device, please consider {his/her} hearing without the hearing aid or assistive device.
{CHILD} can usually hear and understand what a person says without seeing his or her face if that person
whispers to {him/her} from across a quiet room.

CAPI INSTRUCTIONS: DISPLAY “hear and understand” AND ”whispers” IN UNDERLINED TEXT.
YES .......................................................................... 1
NO........................................................................... 2
REFUSED ................................................................ 8
DON'T KNOW ........................................................... 9

(CHQ.221)

CHQ.218

[Please indicate whether the following statement describes {CHILD}'s hearing. If {CHILD} has a hearing
aid or other assistive device, please consider {his/her} hearing without the hearing aid or assistive device.]
{CHILD} can usually hear and understand what a person says without seeing his or her face if that person
talks in a normal voice to {him/her} from across a quiet room.
CAPI INSTRUCTIONS: DISPLAY “hear and understand” AND ”talks in a normal voice” IN UNDERLINED
TEXT.
YES .......................................................................... 1
NO........................................................................... 2
REFUSED ................................................................ 8
DON'T KNOW ........................................................... 9

CHQ.219

(CHQ.221)

[Please indicate whether the following statement describes {CHILD}'s hearing. If {CHILD} has a hearing
aid or other assistive device, please consider {his/her} hearing without the hearing aid or assistive device.]
{CHILD} can usually hear and understand what a person says without seeing his or her face if that person
shouts to {him/her} from across a quiet room.
CAPI INSTRUCTIONS: DISPLAY “hear and understand” AND ”shouts” IN UNDERLINED TEXT.
YES .......................................................................... 1
NO........................................................................... 2
REFUSED ................................................................ 8
DON'T KNOW ........................................................... 9

CHQ.220

(CHQ.221)

[Please indicate whether the following statement describes {CHILD}'s hearing. If {CHILD} has a hearing
aid or other assistive device, please consider {his/her} hearing without the hearing aid or assistive device.]

{CHILD} can usually hear and understand what a person says without seeing his or her face if that person
speaks loudly into {his/her} ears or better ear.
CAPI INSTRUCTIONS: DISPLAY “hear and understand” AND ”speaks loudly” IN UNDERLINED TEXT.
YES .......................................................................... 1
NO........................................................................... 2
REFUSED ................................................................ 8
DON'T KNOW ........................................................... 9

(CHQ.221)

ALL HELP AVAILABLE
CHQ.221

Is {CHILD}’s hearing worse in one ear?

YES .......................................................................... 1
NO........................................................................... 2 (CHQ.235)
REFUSED ................................................................ 8 (CHQ.235)
DON'T KNOW ........................................................... 9 (CHQ.235)
CHQ.222

Which best describes {CHILD}'s hearing in {his/her} worse ear? If {CHILD} has a hearing aid or other
assistive device, please consider {his/her} hearing without the hearing aid or assistive device.
Is {CHILD}’s hearing…
CAPI INSTRUCTIONS: DISPLAY “worse” IN UNDERLINED TEXT.

1. Excellent ,
2. Good,
3. A little trouble hearing,
4. Moderate trouble hearing,
5. A lot of trouble hearing, or
6. Deaf?
DK Allowed
Refusal Allowed
CHQ.235

Has {CHILD}'s hearing ever been evaluated by a professional?
HELP TEXT: Professional: This includes health professionals such as doctors, pediatricians, and other
licensed persons, including nurses or nurse practitioners, optometrists, ophthalmologists, school or other
psychologists, school or other psychiatrists, psychiatric social workers, speech pathologists, etc. Do not
include teachers or some other non-health professional.
For the vision and hearing questions, having been evaluated at the school by a health professional
does count as being evaluated by a professional.

1.
2.

YES
NO

DK Allowed
Refusal Allowed
BOX 12
IF CHQ.235 = 1, GO TO CHQ.245. ELSE, IF CHQ215=1, GO TO BOX 13.
ELSE, GO TO CHQ.285.

CHQ.245
1.
2.

Did you obtain a diagnosis of a problem from a professional?

YES
NO (CHQ.285)

DK Allowed (CHQ.285)
Refusal Allowed (CHQ.285)
CHQ.246
What was the diagnosis?
PROBE: Anything else?
CODE ALL THAT APPLY?
1. DUE TO EAR WAX (EXTERNAL EAR CANAL EAR WAX)
2. DUE TO EAR CANAL DEFORMITY (“ATRESIA” (EAR CANAL NOT NORMALLY FORMED), CRANIAL-FACIAL
DISORDER, ETC.)
3. DUE TO EAR INFECTION (ACUTE OR RECURRENT EPISODES (INFECTION BEGINS AND PROGRESSES
QUICKLY OR KEEPS COMING BACK) OFTEN WITH BY EAR ACHE AND FEVER – ACUTE OTITIS MEDIA)
4. DUE TO FLUID IN THE EAR (FLUID BEHIND THE EARDRUM, RUNNY EARS, FLUID OR PUS DRAINING FROM
THE MIDDLE EAR SPACE, CHRONIC OTITIS MEDIA, GLUE EAR)
5. DUE TO EAR DRUM PROBLEM (INCLUDES PERFORATED/TORN/RUPTURED) EARDRUM)
6. DUE TO ILLNESS (MENINGITIS, MEASLES, MUMPS, RUBELLA, SCARLET FEVER, ETC.)
7. DUE TO CMV (CYTOMEGALOVIRUS, A TYPE OF HERPES VIRUS)
8. DUE TO OTOTOXIC EXPOSURE TO DRUGS/MEDICINES (DAMAGE TO THE EARS BY DRUGS OR
CHEMICALS. INCLUDES DAMAGE FROM MYCIN DRUGS, SUCH AS, STREPTOMYCIN, GENTAMYCIN, ETC.,
SALICYLATE, LASIX, CISPLATIN – MAY RESULT FROM TREATMENT OF RESPIRATORY PROBLEMS OF
PRETERM INFANTS, OR AS TREATMENTS DUE TO CHILDHOOD CANCER, ETC.)
9. DUE TO NOISE EXPOSURE (FROM GUNFIRE, FIRECRACKERS, etc.)
10. DUE TO GENETIC CAUSE (INCLUDES CONGENITAL (THERE AT BIRTH) HEARING LOSS, HEREDITARY
HEARING LOSS, SYNDROMAL HEARING LOSS – DOWN SYNDROME, USHER’S SYNDROME, ETC.)
11. DUE TO INJURY OR TRAUMA TO HEAD & NECK
12. DUE TO EAR OR FACIAL SURGERY
13. DUE TO NERVE DEAFNESS (NERVE HEARING LOSS OR SENSORI-NEURAL HEARING LOSS)
14. DUE TO CENTRAL AUDITORY PROCESSING DISORDER (PROBLEM WITH BEING ABLE TO RECOGNIZE,
TELL THE DIFFERENCE BETWEEN, OR UNDERSTAND SOUNDS)
15. DEAF
16. OTHER, SPECIFY:_____________________________________
DK Allowed
Refusal Allowed
CHQ.246OS [What was the diagnosis?]]
SPECIFY DIAGNOSIS
___________________________________________

BOX 13
ASK CHQ.250, CHQ.251, AND CHQ.255 (IF APPLICABLE) ONCE FOR ONE OF
THE FOLLOWING:
IF CHQ.215 = 1, ASK ABOUT ABILITY TO COMMUNICATE.
IF CHQ.215 NE 1 AND CHQ.245 = 1, ASK ABOUT HEARING.
IF CHQ.215 = 1 AND CHQ.245 = 1, ASK ABOUT BOTH ABILITY TO
COMMUNICATE AND HEARING.

CHQ.250

How old was {CHILD} when the first diagnosis of a problem related to {his/her} {ability to
communicate/hearing/ability to communicate or hearing} was made?
CAPI INSTRUCTIONS: IF CHQ.215 =1, DISPLAY “ability to communicate”. ELSE, IF CHQ.215 NE 1
AND CHQ.245 = 1, DISPLAY “hearing”. ELSE, IF CHQ.215 =1 AND CHQ.245 = 1, DISPLAY “ability to
communicate or hearing”.
CAPI INSTRUCTIONS: RANGE CHECK: 0-23.
|___|___|
ENTER AGE
Refusal Allowed
DK Allowed

BOX 14
IF CHQ.250 NE REF/DK, GO TO CHQ.251. ELSE, IF CHQ.250 = DK, GO TO
CHQ.255. ELSE, IF CHQ.250 = REF AND CHQ.245 = 1, GO TO CHQ.256. ELSE,
IF CHQ.250 = REF, GO TO CHQ.285.

CHQ.251

[How old was {CHILD} when the first diagnosis of a problem related to {his/her} {ability to
communicate/hearing/ability to communicate or hearing} was made?]

CAPI INSTRUCTIONS: RANGE CHECK: 0-23 IF MONTHS IS THE UNIT; 0-8 IF YEARS IS THE UNIT.
ENTER UNIT
1.
2.

MONTHS
YEARS

DK Allowed
Refusal Allowed
BOX 15
IF CHQ.251 = DK, GO TO CHQ.255. ELSE, IF CHQ.245 = 1, GO TO CHQ.256.
ELSE, GO TO CHQ.285.

CHQ.255

What was the month and year the problem with {CHILD}'s {ability to communicate /hearing/ability to
communicate or hearing} was diagnosed?

IF R DOESN'T KNOW MONTH, ASK: Do you remember the year?
IF THERE WAS MORE THAN ONE DIAGNOSIS, ASK FOR THE EARLIEST.
CAPI INSTRUCTIONS: RANGE CHECK: 1-12 FOR MONTH, 2003-2011 FOR YEAR.
CAPI INSTRUCTION: EDIT: YEAR ENTERED MUST BE EQUAL TO OR GREATER THAN CHILD'S BIRTHDATE
AND LESS THAN OR EQUAL TO INTERVIEW DATE.
|___|___|
ENTER MONTH

AND

|___|___|___|___|
ENTER YEAR

DK Allowed
Refusal Allowed

BOX 16
IF CHQ.245 =1, GO TO CHQ.256. ELSE, GO TO CHQ.285.

HELP AVAILABLE
CHQ.256

Has {CHILD} ever worn a hearing aid?

HELP TEXT: Hearing Aid: A small electronic sound amplifier worn in or behind the ear that compensates for impaired
hearing.

IF RESPONDENT SAYS “Yes” OR “CHILD USED TO WEAR ONE,” ASK “Does {CHILD} wear one now?”
1.
2.
3.

YES, CURRENTLY
YES, IN THE PAST
NO (CHQ.263)

DK Allowed (CHQ.263)
Refusal Allowed (CHQ.263)

CHQ.257

At what age was the recommendation that {CHILD} wear a hearing aid first made?

HELP TEXT: This question asks the age at which the recommendation to wear a hearing aid was first made, not the
age at which the child first started wearing a hearing aid. Some children may have started wearing a hearing aid right
after the recommendation was first made. For other children, there may have been a period of time between when the
recommendation was first made and when the child started wearing a hearing aid.
ALLOW RESPONSES IN MONTHS OR YEARS, BUT NOT BOTH.
CAPI INSTRUCTIONS: RANGE CHECK: 0-36 IF MONTHS IS THE UNIT; 0-8 IF YEARS IS THE UNIT.

|___|___|
ENTER AGE
REFUSED .................................................. 88
DON'T KNOW ............................................ 99
ENTER UNIT
MONTHS ...................................................
YEARS .......................................................
REFUSED ..................................................
DON'T KNOW ............................................
CHQ.258 How often does {CHILD} use the hearing aid(s) in school? Would you say…
1
2
3
4
5

All of the time,
Most of the time,
Sometimes,
Rarely, or
Never?

DK Allowed
Refusal

1
2
8
9

CHQ.259

Please indicate whether the following statement describes {CHILD}'s hearing when wearing {his/her}
hearing aid{s}.
{CHILD} can usually hear and understand what a person says without seeing his or her face if that person
whispers to {him/her} from across a quiet room.
CAPI INSTRUCTIONS: DISPLAY “hear and understand” AND ”whispers” IN UNDERLINED TEXT.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON’T KNOW .............................................

CHQ.260

1 (CHQ.270)
2
8
9

[Please indicate whether the following statement describes {CHILD}'s hearing when wearing {his/her}
hearing aid{s}.]
{CHILD} can usually hear and understand what a person says without seeing his or her face if that person
talks in a normal voice to {him/her} from across a quiet room.
CAPI INSTRUCTIONS: DISPLAY “hear and understand” AND ”talks in a normal voice” IN UNDERLINED
TEXT.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON’T KNOW .............................................

CHQ.261

1 (CHQ.270)
2
8
9

[Please indicate whether the following statement describes {CHILD}'s hearing when wearing {his/her}
hearing aid{s}.]
{CHILD} can usually hear and understand what a person says without seeing his or her face if that person
shouts to {him/her} from across a quiet room.
CAPI INSTRUCTIONS: DISPLAY “hear and understand” AND ”shouts” IN UNDERLINED TEXT.

YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON’T KNOW .............................................

1 (CHQ.270)
2
8
9

CHQ.262

[Please indicate whether the following statement describes {CHILD}'s hearing when wearing {his/her}
hearing aid{s}.]
{CHILD} can usually hear and understand what a person says without seeing his or her face if that person
speaks loudly into {his/her} {better} ear.
CAPI INSTRUCTIONS: DISPLAY “hear and understand” AND ”speaks loudly” IN UNDERLINED TEXT.
CAPI INSTRUCTION: DISPLAY “better” IF CHQ.221 = 1. ELSE, USE A NULL DISPLAY.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON’T KNOW .............................................

1
2
8
9

(CHQ.270)
(CHQ.270)
(CHQ.270)
(CHQ.270)

HELP AVAILABLE
CHQ.263 Has a doctor or other health care professional ever recommended that {CHILD} wear a hearing aid?
HELP TEXT: Hearing Aid: A small electronic sound amplifier worn in or behind the ear that compensates for impaired
hearing.
1.
2.

YES
NO (CHQ.270)

DK Allowed (CHQ.270)
Refusal Allowed (CHQ.270)
CHQ.264

At what age was the recommendation that {CHILD} wear a hearing aid first made?

CAPI INSTRUCTION: RANGE CHECK: 0-36 IF UNIT IS MONTHS; 0-8 IF UNIT IS YEARS.
|___|___|
ENTER NUMBER
REFUSED .................................................. 88
DON'T KNOW ............................................ 99
ENTER UNIT
MONTH ......................................................
YEAR .........................................................
REFUSED ..................................................
DON'T KNOW ............................................

1
2
8
9

CHQ.270

Does {CHILD} have a cochlear implant?

PROBE: IF RESPONDENT SAYS “YES,” BUT WHICH EAR IS NOT SPECIFIED, PROBE Is the cochlear implant in the
right or left ear or does {CHILD} have them in both ears?
HELP TEXT: Cochlear Implants: An electronic device that is surgically placed in the inner ear which is designed to
provide useful hearing and improved communication ability to individuals who are profoundly hearing impaired and
unable to understand speech with hearing aids.

1.
2.
3.
4.

YES, ONE EAR ONLY – RIGHT EAR (CHQ.271)
YES, ONE EAR ONLY – LEFT EAR (CHQ.271)
YES, IN BOTH EARS (CHQ.273)
NO (CHQ.285)

DK Allowed (CHQ.285)
Refusal Allowed (CHQ.285)
CHQ.271 In what year was it implanted?
CAPI INSTRUCTION: RANGE CHECK: 2003-2011.
CAPI INSTRUCTION: EDIT: YEAR ENTERED MUST BE EQUAL TO OR GREATER THAN CHILD'S
BIRTHDATE AND LESS THAN OR EQUAL TO INTERVIEW DATE.
|___|___|___|___| (CHQ.277)
ENTER YEAR
REFUSED .................................................. 88 (CHQ.272)
DON'T KNOW ............................................ 99 (CHQ.272)
CHQ.272

How old was {CHILD} when it was implanted?
CAPI INSTRUCTION: RANGE CHECK: 0-36 IF UNIT IS MONTHS; 0-8 IF UNIT IS YEARS.
|___|___| (CHQ.277)
ENTER NUMBER
REFUSED .................................................. 88 (CHQ.277)
DON'T KNOW ............................................ 99 (CHQ.277)
ENTER UNIT
MONTH ......................................................
YEAR .........................................................
REFUSED ..................................................
DON'T KNOW ............................................

1
2
8
9

(CHQ.277)
(CHQ.277)
(CHQ.277)
(CHQ.277)

CHQ.273 In what years were they implanted?
ENTER YEAR FOR LEFT EAR.
PROBE: When was it implanted in the left ear?
CAPI INSTRUCTION: RANGE CHECK: 2003-2011.
CAPI INSTRUCTION: EDIT: YEAR ENTERED MUST BE EQUAL TO OR GREATER THAN CHILD'S
BIRTHDATE AND LESS THAN OR EQUAL TO INTERVIEW DATE.
|___|___|___|___|
ENTER YEAR FOR LEFT EAR
REFUSED .................................................. 88
DON'T KNOW ............................................ 99

CHQ.274 [In what years were they implanted?]
ENTER YEAR FOR RIGHT EAR.
PROBE: When was it implanted in the right ear?
CAPI INSTRUCTION: RANGE CHECK: 2003-2011.
CAPI INSTRUCTION: EDIT: YEAR ENTERED MUST BE EQUAL TO OR GREATER THAN CHILD'S
BIRTHDATE AND LESS THAN OR EQUAL TO INTERVIEW DATE.

|___|___|___|___| (CHQ.277)
ENTER YEAR FOR RIGHT EAR
REFUSED .................................................. 88
DON'T KNOW ............................................ 99

CHQ.275

How old was {CHILD} when they were implanted?
ENTER AGE IN MONTHS OR YEARS FOR LEFT EAR.
PROBE: How old was {CHILD} when it was implanted in the left ear?
CAPI INSTRUCTION: RANGE CHECK: 0-36 IF UNIT IS MONTHS; 0-8 IF UNIT IS YEARS.
|___|___|
ENTER NUMBER FOR LEFT EAR
REFUSED .................................................. 88
DON'T KNOW ............................................ 99
ENTER UNIT
MONTH ......................................................
YEAR .........................................................
REFUSED ..................................................
DON'T KNOW ............................................

CHQ.276

1
2
8
9

[How old was {CHILD} when they were implanted?]
ENTER AGE IN MONTHS OR YEARS FOR RIGHT EAR.
PROBE: How old was {CHILD} when it was implanted in the right ear?
CAPI INSTRUCTION: RANGE CHECK: 0-36 IF UNIT IS MONTHS; 1-8 IF UNIT IS YEARS.
|___|___|
ENTER NUMBER FOR RIGHT EAR
REFUSED .................................................. 88
DON'T KNOW ............................................ 99
ENTER UNIT
MONTH ......................................................
YEAR .........................................................
REFUSED ..................................................
DON'T KNOW ............................................

1
2
8
9

CHQ.277

Please indicate whether the following statement describes {CHILD}'s hearing when wearing {his/her}
cochlear implant {s}.
{CHILD} can usually hear and understand what a person says without seeing his or her face if that person
whispers to {him/her} from across a quiet room.

CAPI INSTRUCTIONS: DISPLAY “hear and understand” AND ”whispers” IN UNDERLINED TEXT.
1 YES (CHQ.285)
2 NO
CHQ.278

[Please indicate whether the following statement describes {CHILD}'s hearing when wearing {his/her}
cochlear implant {s}.]
{CHILD} can usually hear and understand what a person says without seeing his or her face if that person
talks in a normal voice to {him/her} from across a quiet room.

CAPI INSTRUCTIONS: DISPLAY “hear and understand” AND ”talks in a normal voice” IN UNDERLINED
TEXT.

1 YES (CHQ.285)
2 NO

CHQ.279

[Please indicate whether the following statement describes {CHILD}'s hearing when wearing {his/her}
cochlear implant {s}.]
{CHILD} can usually hear and understand what a person says without seeing his or her face if that person
shouts to {him/her} from across a quiet room.
CAPI INSTRUCTIONS: DISPLAY “hear and understand” AND ”shouts” IN UNDERLINED TEXT.

1 YES (CHQ.285)
2 NO

CHQ.280

[Please indicate whether the following statement describes {CHILD}'s hearing when wearing {his/her}
cochlear implant {s}.]
{CHILD} can usually hear and understand what a person says without seeing his or her face if that person
speaks loudly into {his/her} {better} ear.

CAPI INSTRUCTIONS: DISPLAY “hear and understand” AND ”speaks loudly” IN UNDERLINED TEXT.
CAPI INSTRUCTION: DISPLAY “better” IF CHQ.221 = 1. ELSE, USE A NULL DISPLAY.
1 YES
2 NO

DK Allowed
Refusal Allowed
CHQ.285 Now I want to ask you about {CHILD}’s vision. Without the use of eyeglasses or contact lenses, does
{CHILD} have difficulty seeing objects in the distance or letters on paper?
1. YES (CHQ.286)
2. NO (CHQ.290)
DK Allowed
Refusal Allowed
CHQ.286
1.
2.
3.

Is {CHILD}’s difficulty with seeing objects in the distance, things up close, like letters on paper, or both?

SEEING THINGS UP CLOSE
SEEING THINGS IN THE DISTANCE
BOTH

DK Allowed
Refusal Allowed
CHQ.290

Has {CHILD}'s vision ever been evaluated by an eye care professional?

HELP TEXT: Eye Care Professional: This includes optometrists and ophthalmologists. Include a school nurse who
gives a vision test, but do not include teachers or some other non-health professional, or a doctor who simply looks in
the child’s eyes.

1. YES
2. NO (CHQ.330)
DK Allowed (CHQ.330)
Refusal Allowed (CHQ.330)

CHQ.300 Did you obtain a diagnosis of a vision-related problem from an eye care professional?
CAPI INSTRUCTION: DISPLAY "vision-related" IN UNDERLINED TEXT.
1.
2.

YES
NO (CHQ.330)

DK Allowed (CHQ.330)
Refusal Allowed (CHQ.330)
CHQ.301

What was the diagnosis?
PROBE: Anything else?
CODE ALL THAT APPLY
1.
2.
3.
4.
5.
6.
7.
8.
91.

NEARSIGHTEDNESS (MYOPIA) ........................................................
FARSIGHTED (HYPEROPIA) .............................................................
COLOR BLINDNESS OR DEFICIENCY ..............................................
ASTIGMATISM ...................................................................................
CROSSED OR WANDERING EYE (STRABISMUS)
AMBLYOPIA OR “LAZY EYE” ............................................................
RETINOPATHY
BLINDNESS .......................................................................................
OTHER (SPECIFY)______

Other Specify Allowed
DK Allowed
Refusal Allowed
BOX 17
IF CHQ.301 = 91, CONTINUE WITH CHQ.301OS. OTHERWISE, GO TO CHQ.305.

CHQ.301OS [What was the diagnosis?]
SPECIFY DIAGNOSIS.

CHQ.305

How old was {CHILD} when the first diagnosis of a problem was made?
ENTER AGE IN MONTHS OR YEARS.
CAPI INSTRUCTION: RANGE CHECK: 0-36 IF UNIT IS MONTHS; 0-8 IF UNIT IS YEARS.
|___|___|
ENTER NUMBER
REFUSED .................................................. 88
DON'T KNOW ............................................ 99
ENTER UNIT
MONTH ......................................................
YEAR .........................................................
REFUSED ..................................................
DON'T KNOW ............................................

CHQ.310

1
2
8
9

(CHQ.311)
(CHQ.311)
(CHQ.311)
(CHQ.310)

What was the month and year the diagnosis was made?
IF R DOESN'T KNOW MONTH, ASK: Do you remember the year?
IF THERE WAS MORE THAN ONE DIAGNOSIS, ASK FOR THE EARLIEST.
CAPI INSTRUCTIONS: RANGE CHECK: 1-12 FOR MONTH, 2003-2011 FOR YEAR.
CAPI INSTRUCTION: EDIT: YEAR ENTERED MUST BE EQUAL TO OR GREATER THAN CHILD'S
BIRTHDATE AND LESS THAN OR EQUAL TO INTERVIEW DATE.
|___|___|
ENTER MONTH

AND

|___|___|___|___|
ENTER YEAR

DK Allowed
Refusal Allowed

CHQ.311
1.
2.

Has {CHILD} been prescribed glasses or contact lenses to improve {his/her} vision?

YES
NO (CHQ.330)

DK Allowed (CHQ.330)
Refusal Allowed (CHQ.330)

CHQ.312

CHQ.313

How often does {CHILD} wear glasses or contact lenses?
All of the time, .............................................
Most of the time, ..........................................
Sometimes, .................................................
Rarely, or ....................................................
Never? ........................................................
CHILD DOES NOT HAVE GLASSES OR
CONTACTS ................................................
REFUSED ..................................................
DON'T KNOW ............................................

1
2
3
4
5

(CHQ.314)
(CHQ.330)
(CHQ.330)
(CHQ.330)
(CHQ.313)

6 (CHQ.330)
8 (CHQ.330)
9 (CHQ.330)

Does {CHILD} have glasses or contact lenses?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

1
2 (CHQ.330)
8 (CHQ.330)
9 (CHQ.330)

CHQ.314 Do {CHILD}’s glasses or contacts help {him/her} see things up close, see things in the distance, or both?
1.
2.
3.

SEE THINGS UP CLOSE
SEE THINGS IN THE DISTANCE
BOTH

DK Allowed
Refusal
CHQ.330 Would you say {CHILD}'s health is ...
4.
5.
6.
7.
8.

Excellent,
Very good,
Good,
Fair, or
Poor?

DK Allowed
Refusal Allowed

BOX 18
IF CHILD DOES NOT HAVE ANY DISABILITIES AND HIS OR HER HEALTH IS GOOD TO
EXCELLENT, THAT IS:
CHQ.095=1, 2, 8, 9 (INDEPENDENCE)
AND
CHQ.100=1, 2, 8, 9 (ATTENTION)
AND
CHQ.105=1, 2, 8, 9 (THINK/LEARN/SOLVE)
AND
CHQ.106=1, 2, 8, 9 (COORDINATION)
AND
CHQ.107=1, 2, 8, 9 (BEHAVIOR WITH OTHER CHILDREN)
AND
CHQ.108=1, 2, 8, 9 (BEHAVIOR WITH ADULTS)
AND
CHQ.109=1, 2, 3, 8, 9 (HYPERACTIVE)
AND
CHQ.110=2, 8, 9 (EMOTIONAL/PSYCHOLOGICAL DIFICULTIES)
AND
CHQ.200=1, 2, 8, 9 (COMMUNICATION)
AND
CHQ205=2, 8, 9 (COMMUNICATION PROBLEMS WHEN YOUNGER)
AND
CHQ.216=1, 2, 8, 9 (HEARING)
AND
CHQ.285=2, 8, 9 (VISION)
AND
CHQ.330=1, 2, 3, 8, 9 (HEALTH),
GO TO BOX 22.
OTHERWISE, CONTINUE WITH CHQ.340.
CHQ.340
Prior to this school year, did {CHILD} ever receive therapy services or take part in a program for children
with disabilities?
HELP TEXT: Children with disabilities include children with developmental delays, communication impairments, or
special health care needs.
1.
2.

YES
NO (BOX 22)

DK Allowed (BOX 22)
Refusal Allowed (BOX 22)

CHQ.345a
I'm going to read a list of services. For each service, please tell me if {CHILD} or your family ever received this service
before this school year to help with {CHILD}'s special needs.
RESPONSES: 1=YES, 2=NO
a.

Speech or language therapy?

DK Allowed
Refusal Allowed
HELP TEXT:
Speech or language therapy: Therapy involving the evaluation or treatment of the student’s speech or language
abilities. Impairments to speech can include one or more of the following: articulation errors (includes omitting
words, substituting words, or distorting sounds), inappropriate voice (including pitch, loudness, or voice quality), or
abnormal fluency (including abnormal rate of speaking, speech interruptions, repetitions of sounds, words, phrases
or sentences). Impairments to language can include improper use of phonemes, syntax, or semantics. Language
impairments can also stem from improper practical use of language. Therapy includes special techniques to
overcome speech or language limitations. Therapy should be provided only by a teacher of the speech or language
impaired who is certified by the state, or by a certified Speech and Language Therapist/Pathologist.
CHQ.345b
[I'm going to read a list of services. For each service, please tell me if {CHILD} or your family ever received this service
before this school year to help with {CHILD}'s special needs.]
RESPONSES: 1=YES, 2=NO
b.

Occupational therapy?

DK Allowed
Refusal Allowed
HELP TEXT
Occupational therapy: Therapy involving the evaluation or treatment of the student’s level of independence in daily
living activities. The goal of occupational therapy is to promote maximum independence in daily living. Therapy can
include the use of work, play, or self-care activities to improve functional ability, promote health, prevent injury or
further disability. Therapy should be provided only by a therapist who has been certified by the American
Occupational Therapy Association or by an occupational therapy assistant who provides therapy under the
supervision of a certified occupational therapist.

CHQ.345c
[I'm going to read a list of services. For each service, please tell me if {CHILD} or your family ever received this service
before this school year to help with {CHILD}'s special needs.]
RESPONSES: 1=YES, 2=NO
c.

Physical therapy?

DK Allowed
Refusal Allowed
HELP TEXT:
Physical therapy: Therapy involving the evaluation or treatment of health problems resulting from injury or disease. It
is also sometimes called physiotherapy. Physical therapists assess joint motion, muscle strength and endurance,
how well the heart and lungs work, and how well children can do activities required for daily living. Treatment
includes therapeutic exercise, cardiovascular endurance training, and training in activities of daily living, as well as
the use of massage, light, cold, heat, electricity, and mechanical devices to treat physical disorders. Physical
therapy does not include the use of X-Ray technology. Therapy should be provided only by a therapist who has
been state-certified to provide such services.
CHQ.345d
[I'm going to read a list of services. For each service, please tell me if {CHILD} or your family ever received this service
before this school year to help with {CHILD}'s special needs.]
RESPONSES: 1=YES, 2=NO
d.

Vision services?

DK Allowed
Refusal Allowed
HELP AVAILABLE
Vision services: Therapy combines health and education professions to improve the student’s independence in daily
living and access to educational materials. Health professionals include ophthalmologists and optometrists.
Ophthalmologists are medical doctors who specialize in medical and surgical care of the eyes and visual system.
Optometrists are health service providers who evaluate vision conditions such as nearsightedness, farsightedness,
astigmatism, and presbyopia. They test the student’s ability to focus and coordinate the eyes, judge depth, and see
colors accurately. They prescribe eyeglasses, contact lenses, low vision aids, and vision therapy. Teachers of the
visually impaired are state-certified to teach students who are visually impaired or blind.
CHQ.345e
[I'm going to read a list of services. For each service, please tell me if {CHILD} or your family ever received this service
before this school year to help with {CHILD}'s special needs.]
RESPONSES: 1=YES, 2=NO
e.
DK Allowed
Refusal Allowed

Hearing services?

CHQ.345f
[I'm going to read a list of services. For each service, please tell me if {CHILD} or your family ever received this service
before this school year to help with {CHILD}'s special needs.]
RESPONSES: 1=YES, 2=NO
f. Social work services?
DK Allowed
Refusal Allowed
HELP TEXT:
Social work services: Services that provide support to students and their families to meet individual human needs.
Particular attention is devoted to the needs and empowerment of students and their families who are disadvantaged,
vulnerable, or at risk. Social workers strive to focus on the well being of the student and his/her family in the context
of their school and community. Social workers attend to the environmental forces that create, contribute to, and
address problems of daily living. Services should be provided only by a social worker who has been certified by the
state to provide such services.
CHQ.345g
[I'm going to read a list of services. For each service, please tell me if {CHILD} or your family ever received this service
before this school year to help with {CHILD}'s special needs.]
RESPONSES: 1=YES, 2=NO
g.

Psychological services?

DK Allowed
Refusal Allowed
HELP TEXT:
Psychological services: Services that involve the assessment of academic skills and learning aptitudes, personality
and emotional development, social skills and school climates, and eligibility for special education. Treatment involves
one-on-one interaction with students or parents to resolve personal conflicts and problems in learning and
adjustment, psychological counseling for students and parents, social skills training, and assistance through
separation and loss. Within school systems, psychological services are typically provided by certified school
psychologists. However, assessment and treatment can be extended to the health community and include services
provided by clinical psychologists, psychiatric social workers, or psychiatrists (who are medical doctors).

CHQ.345h
[I'm going to read a list of services. For each service, please tell me if {CHILD} or your family ever received this service
before this school year to help with {CHILD}'s special needs.]
RESPONSES: 1=YES, 2=NO
h.

Home visits?

DK Allowed
Refusal Allowed
HELP TEXT:
Home visits: Refer to formal visits to the homes of students by a certified health or education professional. Home
visits can involve therapy or education services. Home visits are typically made by teachers of preschool or
kindergarten age students with disabilities, occupational or physical therapists, school social workers, school
psychologists, or regular classroom teachers.
CHQ.345i
[I'm going to read a list of services. For each service, please tell me if {CHILD} or your family ever received this service
before this school year to help with {CHILD}'s special needs.]
RESPONSES: 1=YES, 2=NO
i.

Parent support or training?

DK Allowed
Refusal Allowed
HELP TEXT:
Parent support or training: Refer to assistance provided by the schools or other organizations to parents who have
students with unique educational needs, such as the student with a disability. Parent support ranges from the provision
of information or referral to assistance in accessing community services for their child. Parent training can involve
learning to use special instructional techniques, assistive devices (such as low vision aids) or other equipment needed
by their child,
or general understanding of the unique educational needs of their child.

CHQ.345j
[I'm going to read a list of services. For each service, please tell me if {CHILD} or your family ever received this service
before this school year to help with {CHILD}'s special needs.]
RESPONSES: 1=YES, 2=NO
j.

Special class with other children some or all of whom also had
special needs?

DK Allowed
Refusal Allowed
HELP TEXT:
Special class with other children some or all of whom also had special needs: Refers to a classroom with a smaller
number of students than found in the regular classroom. Students in special classes have unique learning needs
often resulting from a disability or limited English proficiency. All students in such classrooms require individual
attention to their educational needs.
CHQ.345k
[I'm going to read a list of services. For each service, please tell me if {CHILD} or your family ever received this service
before this school year to help with {CHILD}'s special needs.]
RESPONSES: 1=YES, 2=NO
k.

Private tutoring or schooling for learning problems?

DK Allowed
Refusal Allowed
HELP TEXT:
Private tutoring or schooling for learning problems: Refer to education or training associated with a specific learning
problem or need. The term “private” suggests either that there is a cost associated with the service or education is
not provided by the public school system. Individuals, organizations, or businesses in school, home, or community
settings can provide private tutoring designed to improve the student’s educational achievement, typically in math or
reading. Special schools are available to students with particular needs such as emotional problems, learning
disabilities, blindness, or deafness. Such schools charge parents for their child’s education. However, the
education of students with disabilities may be subsidized by their home school district if the district cannot provide a
similar appropriate education.
BOX 19
IF CHILD DOES NOT HAVE DIFFICULTY SEEING (CHQ.285=2, 8, 9) , GO TO BOX 20.
OTHERWISE, CONTINUE WITH CHQ.345l.

CHQ.345l
[I'm going to read a list of services. For each service, please tell me if {CHILD} or your family ever received this service
before this school year to help with {CHILD}'s special needs.]
RESPONSES: 1=YES, 2=NO
l.

Instruction in Braille

DK Allowed
Refusal Allowed
HELP TEXT:
Instruction in Braille: Braille is a touch system of reading using as the basic graphic symbol a cell composed of six
dots, two dots wide and three dots high. The dots are “read” by running the hand over the paper rather than looking
at it. Sixty-three possible dot combinations of the cell form the basis of the Braille code, and numerous rules govern
the usage of the code. Learners who are totally blind, near-blind, and with profound low vision need mastery of
reading Braille since it is likely their only means of gaining access to educational information in print form. Reading in
Braille is a system of reading that differs in many significant ways from reading in print. Teachers receive special
training to teach Braille.
BOX 20
IF CHILD DOES NOT HAVE DIFFICULTY HEARING (CHQ.216=1, 2, 8, 9), GO TO CHQ.345n.
OTHERWISE, CONTINUE WITH CHQ.345m.
CHQ.345m
[I'm going to read a list of services. For each service, please tell me if {CHILD} or your family ever received this service
before this school year to help with {CHILD}'s special needs.]
RESPONSES: 1=YES, 2=NO
m. Instruction in sign language, Cued Speech, ASL, total communication
DK Allowed
Refusal Allowed
HELP TEXT:
Instruction in sign language, Cued speech, ASL, TOCO: Refers to various manual methods that replace the use of
speech only as a means of communication. Manual communication is a system of teaching individuals with hearing
impairments that makes use of sign language and fingerspelling. Sign language is a general term for using the hands
to form words and phrases. There are many forms of sign language, including American Sign Language (ASL),
Signed English, Sign Exact English (SEE), etc. Cued Speech uses hand signals to symbolize sounds. TOCO refers to
total communication. TOCO employs a combination of oral and manual approaches to communication and includes
speech, sign language, lip-reading, natural gestures, fingerspelling, residual hearing, reading and writing.

CHQ.345n
[I'm going to read a list of services. For each service, please tell me if {CHILD} or your family ever received this service
before this school year to help with {CHILD}'s special needs.]
RESPONSES: 1=YES, 2=NO
n.

Any other service? (SPECIFY)

Other Specify Allowed
DK Allowed
Refusal Allowed
BOX 21
IF CHQ.345n = 1, GO TO CHQ.345nOS. ELSE, GO TO CHQ.375.

CHQ.345nOS

[I’m going to read a list of services. For each service, please tell me if {CHILD} or your family ever
received this service before this school year to help with {CHILD}’s special needs.]

SPECIFY OTHER SERVICE
_____________________________________________________________
CHQ.375

How old was {CHILD} when {this service/the earliest of these services} began?

ENTER MONTHS OR YEARS.
CAPI INSTRUCTION: DISPLAY “this service” IF ONLY ONE ITEM CODED 1 (YES) FOR CHQ.345/LETTERS A-N).
OTHERWISE, DISPLAY “the earliest of these services.”

CAPI INSTRUCTION: RANGE CHECK: 0-36 IF UNIT IS MONTHS; 1-8 IF UNIT IS YEARS.
|___|___|
ENTER NUMBER
REFUSED .................................................. 88 (CHQ.385)
DON'T KNOW ............................................ 99 (CHQ.380)
ENTER UNIT
MONTH ......................................................
YEAR .........................................................
REFUSED ..................................................
DON'T KNOW ............................................

1
2
8
9

(CHQ.385)
(CHQ.385)
(CHQ.385)
(CHQ.380)

CHQ.380 What is the month and year when {{CHILD} first received {{NAME OF SINGLE SERVICE}/{this service}/{the
first of these services began}}?
IF R DOESN'T KNOW MONTH, ASK: Do you remember the year?
CAPI INSTRUCTION: DISPLAY "{{CHILD}} first received {NAME OF SINGLE SERVICE}}" IF ONLY ONE ITEM
CODED 1 (YES) FOR CHQ.345/LETTERS A-N). FOR “{NAME OF SINGLE SERVICE}” DISPLAY THE NAME OF
THE SERVICE CODED AT CHQ.345A-N. ELSE, IF CHQ.340 = 1 AND EVERY ITEM AT CHQ.345/ LETTERS A-N = 2,
8, OR 9. DISPLAY "{{CHILD} first received this service}." OTHERWISE, DISPLAY "the first of these services began."
CAPI”INSTRUCTIONS: RANGE CHECK: 1-12 FOR MONTH, 2003-2011 FOR YEAR.
CAPI INSTRUCTION: EDIT: YEAR ENTERED MUST BE EQUAL TO OR GREATER THAN CHILD'S BIRTHDATE IN
INQ.170 (OR YEAR OF BIRTH ESTIMATED FROM CHILD’S AGE IN INQ.175/INQ.176) AND LESS THAN OR EQUAL
TO INTERVIEW DATE.
|___|___|
ENTER MONTH

AND

|___|___|___|___|
ENTER YEAR

REFUSED ................................................... 888
DON’T KNOW ............................................. 999
CHQ.385

Is {CHILD} still receiving {this service/any of these services}?

CAPI INSTRUCTION: DISPLAY "this service" IF ONLY ONE ITEM CODED 1 (YES) FOR
CHQ.345/LETTERS A-N) OR IF CHQ.340 = 1 AND EVERY ITEM AT CHQ.345 = 2, 8, OR 9.
OTHERWISE, DISPLAY "any of these services."
1.
2.

YES (CHQ.420)
NO

DK Allowed (CHQ.420)
Refusal Allowed (CHQ.420)
CHQ.390
What is the month and year when {{CHILD} last received {NAME OF SINGLE SERVICE}/the last of these
services was received}?
CAPI INSTRUCTION: DISPLAY "{CHILD} last received {NAME OF SINGLE SERVICE}" IF ON”Y
ONE ITEM CODED 1 (YES) FOR CHQ.345/LETTERS A-N) OR IF CHQ.340 = 1 AND EVERY ITEM AT
CHQ.345 = 2, 8, OR 9. OTHERWISE, DISPLAY "the last of these services was received."
CAPI INSTRUCTION: DISPLAY "this service" FOR {NAME OF SINGLE SERVICE} IF CHQ.340 = 1
AND EVERY ITEM AT CHQ.345 = 2, 8, OR 9. OTHERWISE, DISPLAY THE NAME OF THE SERVICE CODED AT
CHQ.345.
CAPI INSTRUCTIONS: RANGE CHECK: 1-12 FOR MONTH, 2003-2011 FOR YEAR.
CAPI INSTRUCTION: EDIT: YEAR ENTERED MUST BE EQUAL TO OR GREATER THAN CHILD'S BIRTHDATE
AND LESS THAN OR EQUAL TO INTERVIEW DATE.
|___|___|
ENTER MONTH
DK Allowed
Refusal Allowed

AND

|___|___|___|___|
ENTER YEAR

CHQ.420
During this school year, did {CHILD} receive any services for children with special needs such as speech or
occupational therapy or did (he/she) participate in a special education program?
CAPI INSTRUCTIONS: DISPLAY 'this school year' IN UNDERLINED TEXT.
1. YES (CHQ.430)
2. NO (BOX 22)
DK Allowed (BOX 22)
Refusal Allowed (BOX 22)

CHQ.430
Overall, how satisfied are you with the progress {CHILD} has made in the special services or special education program
this school year? Are you…
CAPI INSTRUCTIONS: DISPLAY 'this school year' IN UNDERLINED TEXT.
1
2
3
4
5

Completely satisfied,
Very satisfied,
Fairly satisfied,
Somewhat dissatisfied, or
Very dissatisfied?

DK Allowed
Refusal Allowed
BOX 22
GO TO SECTION PPQ (PARENT’S PSYCHOLOGICAL WELL-BEING AND HEALTH).

PARENT’S PSYCHOLOGICAL WELL-BEING AND HEALTH - PPQ
BOX 1
IF PERSON FLAGGED AS R SCORES '1' OR '2' AT FSQ.130
OR IF NO HOUSEHOLD MEMBER SCORES '1' OR '2' AT FSQ.130,
CONTINUE WITH PPQ.100. OTHERWISE, GO TO PPQ.261.
PPQ.100

I'm going to read some statements that may relate to how you have felt about yourself and your life
during the past week. For each statement I read, please indicate how often in the past week you felt or
behaved this way. There are no right or wrong answers.
How often during the past week have you felt that you were bothered by things that don't usually bother
you? Would you say never, some of the time, a moderate amount of the time, or most of the time?
NEVER ....................................................... 1
SOME OF THE TIME................................... 2
A MODERATE AMOUNT OF THE TIME ...... 3
MOST OF THE TIME...………………………… 4
REFUSED……………………………………….. 8
DON’T KNOW…………………………………… 9

PPQ.110

How often during the past week have you felt that you did not feel like eating, that your appetite was
poor?
[PROBE: Would you say never, some of the time, a moderate amount of the time, or most of the time?]
NEVER .......................................................
SOME OF THE TIME...................................
A MODERATE AMOUNT OF THE TIME ......
MOST OF THE TIME...…………………………
REFUSED………………………………………..
DON’T KNOW……………………………………

PPQ.120

1
2
3
4
8
9

How often during the past week have you felt that you could not shake off the blues even with help from
your family or friends?
[PROBE: Would you say never, some of the time, a moderate amount of the time, or most of the time?]
NEVER .......................................................
SOME OF THE TIME...................................
A MODERATE AMOUNT OF THE TIME ......
MOST OF THE TIME...…………………………
REFUSED………………………………………..
DON’T KNOW……………………………………

1
2
3
4
8
9

PPQ.130

How often during the past week have you felt that you had trouble keeping your mind on what you were
doing?
[PROBE: Would you say never, some of the time, a moderate amount of the time, or most of the time?]
NEVER .......................................................
SOME OF THE TIME...................................
A MODERATE AMOUNT OF THE TIME ......
MOST OF THE TIME...…………………………
REFUSED………………………………………..
DON’T KNOW……………………………………

PPQ.140

1
2
3
4
8
9

How often during the past week have you felt depressed?
[PROBE: Would you say never, some of the time, a moderate amount of the time, or most of the time?]
NEVER ....................................................... 1
SOME OF THE TIME................................... 2
A MODERATE AMOUNT OF THE TIME ...... 3
MOST OF THE TIME...………………………… 4
REFUSED……………………………………….. 8
DON’T KNOW…………………………………… 9

PPQ.150

How often during the past week have you felt that everything you did was an effort?
[PROBE: Would you say never, some of the time, a moderate amount of the time, or most of the time?]
NEVER .......................................................
SOME OF THE TIME...................................
A MODERATE AMOUNT OF THE TIME ......
MOST OF THE TIME...…………………………
REFUSED………………………………………..
DON’T KNOW……………………………………

PPQ.160

1
2
3
4
8
9

How often during the past week have you felt fearful?
[PROBE: Would you say never, some of the time, a moderate amount of the time, or most of the time?]
NEVER ....................................................... 1
SOME OF THE TIME................................... 2
A MODERATE AMOUNT OF THE TIME ...... 3
MOST OF THE TIME...………………………… 4
REFUSED……………………………………….. 8
DON’T KNOW…………………………………… 9

PPQ.170

How often during the past week have you felt that your sleep was restless?
[PROBE: Would you say never, some of the time, a moderate amount of the time, or most of the time?]
NEVER .......................................................
SOME OF THE TIME...................................
A MODERATE AMOUNT OF THE TIME ......
MOST OF THE TIME...…………………………
REFUSED………………………………………..
DON’T KNOW……………………………………

PPQ.180

1
2
3
4
8
9

How often during the past week have you felt that you talked less than usual?
[PROBE: Would you say never, some of the time, a moderate amount of the time, or most of the time?]
NEVER ....................................................... 1
SOME OF THE TIME................................... 2
A MODERATE AMOUNT OF THE TIME ...... 3
MOSTO F THE TIME...………………………… 4
REFUSED……………………………………….. 8
DON’T KNOW…………………………………… 9

PPQ.190

How often during the past week have you felt lonely?
[PROBE: Would you say never, some of the time, a moderate amount of the time, or most of the time?]
NEVER ....................................................... 1
SOME OF THE TIME................................... 2
A MODERATE AMOUNT OF THE TIME ...... 3
MOST OF THE TIME...………………………… 4
REFUSED……………………………………….. 8
DON’T KNOW…………………………………… 9

PPQ.200

How often during the past week have you felt sad?
[PROBE: Would you say never, some of the time, a moderate amount of the time, or most of the time?]
NEVER ....................................................... 1
SOME OF THE TIME................................... 2
A MODERATE AMOUNT OF THE TIME ...... 3
MOST OF THE TIME...………………………… 4
REFUSED……………………………………….. 8
DON’T KNOW…………………………………… 9

PPQ.210

How often during the past week have you felt that you could not get going?
[PROBE: Would you say never, some of the time, a moderate amount of the time, or most of the
time?]
NEVER ....................................................... 1
SOME OF THE TIME................................... 2
A MODERATE AMOUNT OF THE TIME ...... 3
MOST OF THE TIME...………………………… 4
REFUSED……………………………………….. 8
DON’T KNOW…………………………………… 9

PPQ.220

Now, I would like to ask you about your health. In general, would you say that your health is…
Excellent, ...................................................
Very good, ..................................................
Good, .........................................................
Fair, or ........................................................
Poor? .........................................................
REFUSED ...................................................
DON’T KNOW .............................................

PPQ.230

1
2
3
4
5
8
9

HELP AVAILABLE
Does any impairment or health problem now keep you from working at a job or business?
HELP TEXT:
Impairment/health problem: an ongoing health problem that limits one's strength or mental alertness.
Examples might be a heart condition, severe asthma, sickle cell anemia, leukemia, or autism.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

PPQ.240

1
2
8
9

HELP AVAILABLE
Are you limited in the kind or amount of work you can do because of any impairment or health
problem?
HELP TEXT:
Impairment/health problem: An ongoing health problem that limits one's strength or mental alertness.
Examples might be a heart condition, severe asthma, sickle cell anemia, leukemia, or autism.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

PPQ.250

HELP AVAILABLE
During the past 12 months, have you felt or has anyone suggested that you needed professional help
for any emotional problem or for drug or alcohol use?
HELP TEXT:
Emotional problems: Conditions in which an individual shows one or more of the following
characteristics to a significant and noticeable degree: (1) an inability to get along with others; (2) display
of inappropriate feelings or actions in normal circumstances; (3) depression; (4) unreasonable fears. This
term includes those who are schizophrenic.
YES ............................................................ 1 (PPQ.260)
NO .............................................................. 2 (PPQ.261)
REFUSED ................................................... 8 (PPQ.261)
DON'T KNOW…………………………………...9 (PPQ.261)

PPQ.260

Did you get help for your problem?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

PPQ.261

1
2
8
9

About how tall are you without shoes?
ENTER FEET AND INCHES
CAPI INSTRUCTION: RANGE FOR FEET: 4 TO 7
CAPI INSTRUCTION: RANGE FOR INCHES: 0-11

|___|___|
FEET

|___|___|
INCHES

REFUSED ................................................... 8
DON'T KNOW…………………………………… 9

PPQ.262

About how much do you weigh without shoes?
ENTER POUNDS
CAPI INSTRUCTION: SOFT RANGE: 95-400

|___|___||___|
POUNDS
REFUSED ................................................... 8
DON'T KNOW…………………………………… 9

BOX 2
ASK PPQ.270 ONLY IF BIOLOGICAL FATHER IS NOW LIVING WITH CHILD (FSQ.150=1 FOR AT LEAST ONE
HOUSEHOLD MEMBER) AND R IS NOT CHILD'S BIOLOGICAL FATHER. ELSE GO TO BOX 3.

PPQ.270

HELP AVAILABLE
During the past 12 months, has {CHILD}'s biological father felt or has anyone suggested that he
needed professional help for any emotional problem or for drug or alcohol use?
HELP TEXT:
Emotional problems: Conditions in which an individual shows one or more of the following
characteristics to a significant and noticeable degree: (1) an inability to get along with others; (2) display
of inappropriate feelings or actions in normal circumstances; (3) depression; (4) unreasonable fears. This
term includes those who are schizophrenic.
YES ............................................................ 1 (PPQ.280)
NO .............................................................. 2 (BOX 3)
REFUSED ................................................... 8 (BOX 3)
DON'T KNOW…………………………………...9 (BOX 3)

PPQ.280

Did he get help for his problem?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

1
2
8
9

BOX 3
ASK PPQ.290 ONLY IF THERE IS A STEPFATHER LIVING IN THE HOME (FSQ.150=3) AND R IS NOT CHILD'S
STEPFATHER. OTHERWISE, GO TO BOX 4.

PPQ.290

HELP AVAILABLE
During the past 12 months, has {CHILD}'s stepfather felt or has anyone suggested that he needed
professional help for any emotional problem or for drug or alcohol use?

HELP TEXT:
Emotional problems: Conditions in which an individual shows one or more of the following
characteristics to a significant and noticeable degree: (1) an inability to get along with others; (2) display
of inappropriate feelings or actions in normal circumstances; (3) depression; (4) unreasonable fears. This
term includes those who are schizophrenic.
YES ............................................................ 1 (PPQ.300)
NO .............................................................. 2 (BOX 4)
REFUSED ................................................... 8 (BOX 4)
DON'T KNOW…………………………………...9 (BOX 4)
PPQ.300

Did he get help for his problem?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW……………………………………

BOX 4
GO TO SECTION FDQ (FOOD SECURITY).

1
2
8
9

FOOD SECURITY – FDQ
NOTE: FDQ HAS BEEN REORDERED BASED ON THE 2007 CPS-FSS
FDQ.130a

These next questions are about whether your family is able to afford the food that you need. I am going
to read you several statements that people have made about their food situation. For these statements,
please tell me whether the statement was often true, sometimes true, or never true for {you/your
household} in the last 12 months, that is, since last {CURRENT MONTH}, 2010.
PROBE: Was that often true, sometimes true, or never true for {you/your household} in the last 12
months?
CAPI INSTRUCTIONS: DISPLAY CURRENT MONTH.
CAPI INSTRUCTIONS: DISPLAY "often," "sometimes," AND "never" IN THE MAIN QUESTION TEXT
AND PROBE AS UNDERLINED.
CAPI INSTRUCTIONS: USE "you," "I," AND "my" IF THE RESPONDENT IS THE ONLY
HOUSEHOLD MEMBER AGE 18 OR OVER OR IF THERE ARE NO HOUSEHOLD MEMBERS 18
OR OVER OR WITH AN AGE OTHER THAN DK OR RF. OTHERWISE, DISPLAY “your household,”
“we,” “we were,” AND “our.”
CAPI INSTRUCTIONS: DISPLAY “PROBE…months?” IN SQUARE BRACKETS FOR C.
OFTEN
TRUE

SOMETIMES
TRUE

NEVER
TRUE

REF

DK

a. {I/We} worried whether {my/our} food would run

out before {I/we} got money to buy more. Was that
often true, sometimes true, or never true for
{you/your household} in the last 12 months?

1

2

3

8

9

{I/we} didn’t have money to get more. Was that
often true, sometimes true, or never true for
{you/your household} in the last 12 months?

1

2

3

8

9

c.{I/We} couldn’t afford to eat balanced meals.

1

2

3

8

9

b. The food that {I/we} bought just didn’t last, and

BOX 1
IF (FDQ.130a = 1 OR 2) OR (FDQ.130b = 1 OR 2) OR (FDQ.130c = 1 OR 2), THEN GO TO FDQ.140. ELSE, GO TO
FDQ.192.
FDQ.140

In the last 12 months, did {you/you or other adults in your household} ever cut the size of your meals
or skip meals because there wasn't enough money for food?
CAPI INSTRUCTIONS: DISPLAY "you" IF THE RESPONDENT IS THE ONLY HOUSEHOLD MEMBER
AGE 18 OR OVER OR IF THERE ARE NO HOUSEHOLD MEMBERS 18 OR OVER OR WITH AN AGE
OTHER THAN DK OR REF. OTHERWISE, DISPLAY “you or other adults in your household.”
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON’T KNOW .............................................

1
2 (FDQ.160)
8 (FDQ.160)
9 (FDQ.160)

FDQ.150

How often did this happen? Would you say…
Almost every month .....................................
Some months, but not every month, or .........
In only 1 or 2 months? .................................
REFUSED ...................................................
DON’T KNOW .............................................

FDQ.160

In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money
for food?
YES. ...........................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW ............................................

FDQ.170

1
2
8
9

In the last 12 months, were you ever hungry but didn't eat because there wasn't enough money for food?
YES. ...........................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW ............................................

FDQ.180

1
2
3
8
9

1
2
8
9

In the last 12 months, did you lose weight because there wasn't enough money for food?
YES. ...........................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW ............................................

1
2
8
9

BOX 2
IF (FDQ.140=1) OR (FDQ.160 =1) OR (FDQ.170 = 1) OR (FDQ.180=1), ASK FDQ.190.
OTHERWISE, GO TO FDQ.192.
FDQ.190

In the last 12 months, did {you/you or other adults in your household} ever not eat for a whole day
because there wasn't enough money for food?
CAPI INSTRUCTIONS: DISPLAY "you" IF THE RESPONDENT IS THE ONLY HOUSEHOLD
MEMBER AGE 18 OR OVER OR IF THERE ARE NO HOUSEHOLD MEMBERS 18 OR OVER OR
WITH AN AGE OTHER THAN DK OR REF. OTHERWISE, DISPLAY “you or other adults in your
household.”
YES. ...........................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW ............................................

1
2 (FDQ.192)
8 (FDQ.192)
9 (FDQ.192)

FDQ.191

How often did this happen? Would you say…
Almost every month .....................................
Some months, but not every month, or .........
In only 1 or 2 months? .................................
REFUSED ...................................................
DON’T KNOW .............................................

FDQ.192

1
2
3
8
9

Now I am going to read you several statements that people have made about the food situation of their
children. For these statements, please tell me whether the statement was often true, sometimes true, or
never true in the last 12 months, that is, since last {current month}, 2010, for {your child/children living in
the household who are under 18 years old}.
PROBE: Was that often true, sometimes true, or never true for {you/your household} in the last 12
months?
CAPI INSTRUCTIONS: DISPLAY CURRENT MONTH.
CAPI INSTRUCTIONS: DISPLAY "often," "sometimes," AND "never" IN THE MAIN QUESTION TEXT
AND PROBE AS UNDERLINED.
CAPI INSTRUCTIONS: USE “I,” “I was,” and “you” IF THE RESPONDENT IS THE ONLY
HOUSEHOLD MEMBER AGE 18 OR OVER OR IF THERE ARE NO HOUSEHOLD MEMBERS 18
OR OVER OR WITH AN AGE OTHER THAN DK OR RF. OTHERWISE, DISPLAY “your household,”
“we,” AND “we were”
CAPI INSTRUCTIONS: DISPLAY “children living in the household who are under 18 years old “ AND
“the children” IF (NumberOfChildren > 1) OR (THERE ARE CHILDREN IN THE HOUSEHOLD AGE 17
OR YOUNGER OTHER THAN THE FOCAL CHILD). OTHERWISE, DISPLAY “{CHILD}” AND
“{CHILD} was.”
CAPI INSTRUCTIONS: DISPLAY "PROBE:…months?" IN SQUARE BRACKETS FOR C.

OFTEN SOMETIMES NEVER
TRUE
TRUE
TRUE

a. {I/We} relied on only a few kinds of low-cost
food to feed {{CHILD}/the children} because
{I was/we were} running out of money to buy food.
Was that often true, sometimes true, or never true for
{you/your household} in the last 12 months?

REF

DK

1

2

3

8

9

{you/your household} in the last 12 months?

1

2

3

8

9

c. {{CHILD} was/The children were} not eating
enough because {I/we} just couldn't afford enough food.

1

2

3

8

9

b.{I/We} couldn't feed {{CHILD}/the children} a
balanced meal because {I/we} couldn't afford that. ..
Was that often true, sometimes true, or never true for

BOX 3
IF (FDQ.192a = 1 OR 2) OR (FDQ.192b = 1 OR 2) OR (FDQ.192c = 1 OR 2), GO TO FDQ.210. ELSE, GO TO BOX 4.

FDQ.210

In the last 12 months, that is, since last {CURRENT MONTH}, 2010, did you ever cut the size
of {CHILD}'s/any of the children's} meals because there wasn't enough money for food?
CAPI INSTRUCTIONS: DISPLAY “any of the children’s” IF (NumberOfChildren > 1) OR (THERE ARE
CHILDREN IN THE HOUSEHOLD AGE 17 OR YOUNGER OTHER THAN THE FOCAL CHILD).
OTHERWISE, DISPLAY “{CHILD}’s.”
CAPI INSTRUCTIONS: DISPLAY THE CURRENT MONTH IN {CURRENT MONTH}
YES. ...........................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW ............................................

FDQ.240

1
2
8
9

In the last 12 months, {was {CHILD}/were any of the children} ever hungry but you just couldn't afford
more food?

CAPI INSTRUCTIONS: DISPLAY “were any of the children” IF (NumberOfChildren > 1) OR (THERE
ARE CHILDREN IN THE HOUSEHOLD AGE 17 OR YOUNGER OTHER THAN THE FOCAL CHILD).
OTHERWISE, DISPLAY “was {CHILD}.”
YES. ...........................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW…………………………………..
FDQ.242

1
2
8
9

In the last 12 months, did {{CHILD}/any of the children} ever skip a meal because there wasn't enough
money for food?
CAPI INSTRUCTIONS: DISPLAY “any of the children” IF (NumberOfChildren > 1) OR (THERE ARE
CHILDREN IN THE HOUSEHOLD AGE 17 OR YOUNGER OTHER THAN THE FOCAL CHILD).
OTHERWISE, DISPLAY “{CHILD}.”
YES. ...........................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW…………………………………..

FDQ.243

1
2 (FDQ.250)
8 (FDQ.250)
9 (FDQ.250)

How often did this happen? Would you say…

Almost every month, ....................................
Some months, but not every month, or .........
In only 1 or 2 months? .................................
REFUSED ...................................................
DON’T KNOW .............................................

1
2
3
8
9

FDQ.250

In the last 12 months, did {CHILD}/any of the children} ever not eat for a whole day because there
wasn't enough money for food?
CAPI INSTRUCTIONS: DISPLAY “any of the children” IF (NumberOfChildren > 1) OR (THERE ARE
CHILDREN IN THE HOUSEHOLD AGE 17 OR YOUNGER OTHER THAN THE FOCAL CHILD).
OTHERWISE, DISPLAY “{CHILD}.”
YES. ...........................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW…………………………………..

BOX 4
GO TO SECTION WPQ (WELFARE AND OTHER PUBLIC TRANSFERS).

1
2
8
9

WELFARE AND OTHER PUBLIC TRANSFERS - WPQ

HELP AVAILABLE

WPQ.100

(Since {DATE OF LAST INTERVIEW})/In the past 12 months), have you or anyone in your household
received Temporary Assistance for Needy Families, sometimes called TANF {or {STATE TANF
PROGRAM NAME}}?
PROBE: TANF was formerly known as Aids to Families with Dependent Children, or AFDC.
CAPI INSTRUCTION: IF FALL K NON-RESPONDENT, DISPLAY 'In the past 12 months'.
CAPI INSTRUCTION: IF CONTINUING HOUSEHOLD, DISPLAY 'Since {DATE OF LAST INTERVIEW}.'
USE THE LATEST DATE COMPLETED.
CAPI INSTRUCTION: DISPLAY STATE TANF PROGRAM NAME.
HELP TEXT:
TANF: Temporary Assistance for Needy Families (TANF) or {STATE TANF PROGRAM NAME} in
{STATE} is a government program that provides cash benefits to low-income families with children.
Past 12 Months: For this question, consider whether or not TANF (or AFDC) was received in the past 12
calendar months, not the last calendar year.
YES. ...........................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW ............................................

WPQ.105

1
2 (WPQ.110)
8
9

(Since {DATE OF LAST INTERVIEW}/During those 12 months), how many months did your household
receive TANF {or {STATE TANF PROGRAM NAME}}?
ENTER NUMBER OF MONTH(S).
CAPI INSTRUCTION: DISPLAY 'Since {DATE OF LAST INTERVIEW}' ONLY IF CONTINUING
HOUSEHOLD. USE THE LATEST DATE COMPLETED. OTHERWISE, DISPLAY 'During those 12
months'.
CAPI INSTRUCTIONS: RANGE: 1 TO 12
CAPI INSTRUCTION: DISPLAY STATE TANF PROGRAM NAME.
|___|___|
NUMBER OF MONTHS
REFUSED ..................................................
DON'T KNOW ............................................

8
9

HELP AVAILABLE
WPQ.110

(Since {DATE OF LAST INTERVIEW}/In the past 12 months), have you or anyone in your household
received food stamps, also called SNAP (the Supplemental Nutrition Assistance Program), or food
benefits on EBT (Electronic Benefit Transfer)?
CAPI INSTRUCTION: DISPLAY 'Since {DATE OF LAST INTERVIEW}' ONLY IF CONTINUING
HOUSEHOLD. USE THE LATEST DATE COMPLETED. OTHERWISE, DISPLAY 'In the past 12
months'.
HELP TEXT: Food Stamps or SNAP (Supplemental Nutrition Assistance Program). A government
program that provides plastic cards that can be used to buy food. In the past, SNAP was called the Food
Stamp Program and gave people benefits in paper coupons or food stamps.
Past 12 Months: For this question, consider whether or not food stamps were received in the past 12
calendar months, not the last calendar year.
YES. ...........................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW…………………………………..

1
2
8
9

(WPQ.120)
(WPQ.150)
(WPQ.150)
(WPQ.150)

BOX 0
IF WPQ.110 = 1, GO TO WPQ.120. ELSE, IF WPQ.100 = 1 AND WPQ.110 = 2, DK, OR REF, GO TO WPQ.125.
ELSE, GO TO WPQ.150.

WPQ.120

(Since {DATE OF LAST INTERVIEW}/During those 12 months), how many months did your
household receive food stamps or food benefits on EBT (Electronic Benefit Transfer) from SNAP?
CAPI INSTRUCTIONS: DISPLAY 'Since {DATE OF LAST INTERVIEW}' ONLY IF CONTINUING
HOUSEHOLD. USE THE LATEST DATE COMPLETED. OTHERWISE, DISPLAY 'During those 12
months'.
CAPI INSTRUCTIONS: RANGE: 1 TO 12.
|___|___|
ENTER NUMBER OF MONTH(S).
REFUSED ..................................................
DON'T KNOW…………………………………..

WPQ.125

8
9

Are you or anyone in your family required to work, attend school or anything else in order to receive
these benefits?
YES. ...........................................................
NO ..............................................................
REFUSED ..................................................
DON'T KNOW…………………………………..

1
2
8
9

(WPQ.130)
(WPQ.150)
(WPQ.150)
(WPQ.150)

WPQ.130

What are you or anyone in your family required to do?
PROBE: Anything else?
CODE ALL THAT APPLY
LOOK FOR A JOB....................................... 1
WORK IN A PAID JOB ................................ 2
WORK IN AN UNPAID JOB ......................... 3
ATTEND SCHOOL OR TRAINING ............... 4
SOMETHING ELSE? (SPECIFY) ................. 91
REFUSED .................................................. 8
DON'T KNOW ............................................ 9

BOX 1
IF WPQ.130 = 91, GO TO WPQ.130OS. ELSE, GO TO WPQ.150.
WPQ.130OS [What are you or anyone in your family required to do?]
SPECIFY OTHER
_____________________________
WPQ.150

Does {CHILD}'s school offer lunch for its students?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

WPQ.160

1
2
8
9

(WPQ.160)
(WPQ.200)
(WPQ.200)
(WPQ.200)

Does {CHILD} usually receive a complete lunch offered at school?
PROBE: By complete school lunch, I mean a complete meal such as a salad, soup, a sandwich, or a
hot meal that is offered each day at a fixed price, not just milk, snacks, or ice cream. This does not
include a lunch (he/she) brought from home.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

WPQ.170

1
2
8
9

(WPQ.170)
(WPQ.200)
(WPQ.200)
(WPQ.200)

Does {Child} receive free or reduced price lunches at school?
CAPI INSTRUCTION: DISPLAY 'free' AND 'reduced price' IN UNDERLINED TEXT.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

1
2
8
9

(WPQ.180)
(WPQ.200)
(WPQ.200)
(WPQ.200)

WPQ.180

Are these lunches free or reduced price?
FREE ..........................................................
REDUCED PRICE .......................................
REFUSED ...................................................
DON'T KNOW .............................................

WPQ.190

1
2
8 (WPQ.200)
9 (WPQ.200)

During the last five days {CHILD} was in school, how many complete school lunches did (he/she)
receive?
CAPI INSTRUCTIONS: RANGE: 0 TO 5.
|___|
NUMBER OF DAYS
REFUSED ...................................................
DON'T KNOW .............................................

WPQ.200

Does {CHILD}'s school offer breakfast for its students?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

WPQ.210

1
2
8
9

(WPQ.210)
(BOX 2)
(BOX 2)
(BOX 2)

Does {CHILD} usually receive a breakfast provided by the school?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

WPQ.215

8
9

1
2 (BOX 2)
8 (BOX 2)
9 (BOX 2)

Does {CHILD} receive free or reduced price breakfasts at school?
CAPI INSTRUCTION: DISPLAY "free" AND "reduced price" IN UNDERLINED TEXT
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

WPQ.216

1
2
8
9

(WPQ.216)
(BOX 2)
(BOX 2)
(BOX 2)

Are these breakfasts free or reduced price?
FREE ..........................................................
REDUCED PRICE .......................................
REFUSED ...................................................
DON'T KNOW .............................................

1
2
8 (BOX 2)
9 (BOX 2)

WPQ.220

During the last five days {CHILD} was in school, how many school breakfasts did (he/she) receive?
CAPI INSTUCTIONS: RANGE: 0 TO 5.
|___|
NUMBER OF DAYS
REFUSED ...................................................
DON'T KNOW .............................................

BOX 2
GO TO SECTION PAQ (PARENT INCOME AND ASSETS).

8
9

PARENT INCOME AND ASSETS - PAQ
PAQ.100

In studies like this, households are sometimes grouped according to income. What was the total
income of all persons in your household over the past year, including salaries or other earnings,
interest, retirement, and so on for all household members?
Was it…
$25,000 or less, or ......................................
More than $25,000?.....................................
REFUSED ...................................................
DON'T KNOW .............................................

PAQ.110

1
2
8
9

Was it…
CAPI INSTRUCTION: IF PAQ.100=1, DISPLAY SET 1. IF PAQ.100=2, DISPLAY SET 2.
[SET 1]
$5,000 or less…………………… 1
$5,001 to $10,0002
$10,001 to $15,000………………..3
$15,001 to $20,000………………..4
$20,001 to $25,000………………..5
REFUSED……………………………88
DON’T KNOW………………………..99
[SET 2]
$25,001 to $30,000………………..6
$30,001 to $35,000………………..7
$35,001 to $40,000………………..8
$40,001 to $45,000………………..9
$45,001 to $50,000……………….10
$50,001 to $55,000……………….11
$55,001 to $60,000……………….12
$60,001 to $65,000……………….13
$65,001 to $70,000……………….14
$70,001 to $75,000……………….15
$75,001 to $100,000……………...16
$100,001 to $200,000…………….17
$200,001 or more………………... 18
REFUSED…………………………88
DON’T KNOW………………………..99

BOX 1
PAQ.120 IS ASKED IF HOUSEHOLD IS AT 200 PERCENT OF POVERTY OR BELOW.
ASK PAQ.120 IF
(NUMBER IN HH = 1 AND PAQ.110 < 6) OR
(NUMBER IN HH = 2 AND PAQ.110 < 7) OR
(NUMBER IN HH = 3 AND PAQ.110 < 8) OR
(NUMBER IN HH = 4 AND PAQ.110 < 10) OR
(NUMBER IN HH = 5 AND PAQ.110 < 12) OR
(NUMBER IN HH = 6 AND PAQ.110 < 13) OR
(NUMBER IN HH = 7 AND PAQ.110 < 15) OR
(NUMBER IN HH = 8 AND PAQ.110 < 16) OR
(NUMBER IN HH g.e. 9 AND PAQ.110 < 17).
ELSE, GO TO PAQ.135..
PAQ.120

What was your total household income last year, to the nearest thousand?
CAPI INSTRUCTION: RANGE CHECK-TOTAL INCOME SHOULD BE IN RANGE OF ANSWER TO
PAQ. 110.
|___|___|___|,|___|___|___|,|___|___|___|.
TOTAL INCOME
REFUSED……………………………888
DON’T KNOW………………………..999

PAQ.135

Is tuition paid for {CHILD}'s education?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

PAQ137

1
2
8
9

(PAQ.137)
(BOX 2)
(BOX 2)
(BOX 2)

Approximately, how much does {CHILD}'s family pay in tuition per year for {CHILD}’s education?
CAPI INSTRUCTION: SOFT RANGE: 1 TO 33000.
$ |___|___| , |___|___|___|
ENTER AMOUNT OF TUITION
REFUSED ...................................................
DON'T KNOW .............................................

BOX 2
GO TO SECTION CMQ (MOBILITY AND TRACKING UPDATES).

8
9

MOBILITY AND TRACKING UPDATES – CMQ
BOX 1
IF FALL K CONTINUING HOUSEHOLD (INCLUDES FALL K RESPONDENTS AND NEW SPRING RESPONDENTS):
CHECK FALL K CMQ.070:
IF FALL K CMQ.070=1, GO TO CMQ.100.
IF FALL K CMQ.070=2, DK, RF, CONTINUE WITH CMQ.060.
IF FALL K NONRESPONSE HOUSEHOLD, CONTINUE WITH CMQ.060.

CMQ.060

Just to make sure I can reach you for the next interview, which will take place next school year, I'd like to
ask a few questions about how to find you.
Is there a second phone number, such as a work number, a friend or relative's number, or a beeper or
cell phone number, where you can sometimes be reached?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON'T KNOW .............................................

CMQ.100

1
2
8
9

(CMQ.140)
(BOX 2)
(BOX 2)
(BOX 2)

Just to make sure I can reach you for the next interview, which will take place next school year, I'd like to
ask a few questions about how to find you. I have recorded {PHONE NUMBER} as a second phone
number where you can sometimes be reached. Is this the right number?
CAPI INSTRUCTION: DISPLAY SECOND PHONE NUMBER FROM FALL K COLLECTED AT
CMQ.080.
YES ............................................................ 1 (BOX 2)
NO .............................................................. 2 (CMQ.140)
REFUSED ................................................... 8 (BOX 2)
DON'T KNOW ............................................. 9 (BOX 2)

CMQ.140

What is that telephone number?
ENTER {NEW} SECOND PHONE NUMBER.
CAPI INSTRUCTION: DISPLAY 'NEW' IF CMQ.100=2. OTHERWISE, USE A NULL DISPLAY.
|__|__|__| – |__|__|__| –|__|__|__|__|
SECOND TELEPHONE NUMBER
REFUSED ...................................................
DON'T KNOW .............................................

_______________
EXTENSION
8 (BOX 2)
9 (BOX 2)

CMQ.150

Where is that telephone located?
OFFICE/PLACE OF BUSINESS................... 1 (BOX 2)
RELATIVE (SPECIFY)_________________ 2 (CMQ.155)
NEIGHBOR (SPECIFY) ________________ 3 (CMQ.155)
FRIEND (SPECIFY)___________________ 4 (CMQ.155)
BEEPER NUMBER...................................... 5 (BOX 2)
CELL PHONE ............................................. 6 (BOX 2)
OTHER (SPECIFY) ___________________ 91 (CMQ.155)
REFUSED ................................................... 88 (BOX 2)
DON’T KNOW ............................................. 99 (BOX 2)

CMQ.155

[Where is that telephone located?]
SPECIFY {RELATIVE / NEIGHBOR / FRIEND / OTHER}.
CAPI INSTRUCTION: DISPLAY 'RELATIVE' IF CMQ.150=2.
CAPI INSTRUCTION: DISPLAY 'NEIGHBOR' IF CMQ.150=3.
CAPI INSTRUCTION: DISPLAY 'FRIEND' IF CMQ.150=4.
CAPI INSTRUCTION: DISPLAY 'OTHER' IF THE OTHER SPECIFY BOX OF CMQ.150 IS CHECKED.

BOX 2
IF FALL K CMQ100=1, CONTINUE WITH CMQ200.
IF CMQ.100 FROM FALL K WAS CODED AS NO, DK, OR RF, OR IF FALL K NONRESPONSE HOUSEHOLD, GO TO
CMQ.205.

CMQ.200
CAPI INSTRUCTION: DISPLAY FIRST CONTACT NAME, PHONE NUMBER, AND ADDRESS FROM
FALL K CMQ.110.
CAPI INSTRUCTION: DK AND RF FROM ROUND 1 MUST SHOW UP AS PART OF THE ITEM TEXT
AS "REFUSED," "REF," "DK," OR "DON'T KNOW."
CAPI INSTRUCTION: DISPLAY CITY, STATE, AND ZIP ON 1 LINE.
I have recorded that {NAME OF RELATIVE/FRIEND}
at {PHONE NUMBER}
on
{STREET ADDRESS, LINE 1}
{STREET ADDRESS, LINE 2}
{CITY}
{STATE}
{ZIP CODE}
will always know where you are if you move. Is this still true?
IF NECESSARY SAY: I will only contact this person if I cannot locate you for the next interview.

YES --- NO CORRECTION NEEDED………..1 (BOX 3)
YES --- MINOR CORRECTIONS NEEDED…2 (CMQ.210)
NO………………………………………………..3 (CMQ.205)
REFUSED……………………………………….8 (BOX 3)
DON’T KNOW…………………………………...9 (BOX 3)
CMQ.205

Is there a relative or friend, who does not live in this household, who will always know where you are if
you move?
IF NECESSARY SAY: I will only contact this person if I cannot locate you for the next interview.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON’T KNOW .............................................

CMQ.210

1
2
8
9

(CMQ.210)
(BOX 5)
(BOX 3)
(BOX 3)

What is the name, address, and telephone number of that person?
{ENTER / CORRECT / ENTER NEW} FIRST AND LAST NAME.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}
CAPI INSTRUCTIONS: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ.100=1, DISPLAY
THE OLD INFORMATION FROM FALL K CMQ.110 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'CORRECT." IF CMQ200=3, DISPLAY 'ENTER NEW."
OTHERWISE, DISPLAY 'ENTER."
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'IF FIELD…INFORMATION."
OTHERWISE, USE A NULL DISPLAY.

CMQ.220

[What is the name, address, and telephone number of that person?]
{ENTER / CORRECT / ENTER NEW} STREET ADDRESS, LINE 1.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ.100=1, DISPLAY THE
OLD INFORMATION FROM FALL K CMQ.110 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'CORRECT." IF CMQ.200=3, DISPLAY 'ENTER NEW."
OTHERWISE, DISPLAY 'ENTER."
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'IF FIELD…INFORMATION."
OTHERWISE, USE A NULL DISPLAY.
REFUSED ...................................................
DON’T KNOW .............................................

CMQ.230

8
9

[What is the name, address, and telephone number of that person?]
{ENTER / CORRECT / ENTER NEW} STREET ADDRESS, LINE 2.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ100=1, DISPLAY THE
OLD INFORMATION FROM FALL K CMQ.110 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'CORRECT." IF CMQ.200=3, DISPLAY 'ENTER NEW."
OTHERWISE, DISPLAY 'ENTER."
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'IF FIELD…INFORMATION."
OTHERWISE, USE A NULL DISPLAY.
REFUSED ...................................................
DON’T KNOW .............................................

CMQ.240

8
9

[What is the name, address, and telephone number of that person?]
{ENTER / CORRECT / ENTER NEW} CITY.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ.100=1, DISPLAY
THE OLD INFORMATION FROM FALL K CMQ.110 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'CORRECT." IF CMQ.200=3, DISPLAY 'ENTER NEW."
OTHERWISE, DISPLAY 'ENTER."
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'IF FIELD…INFORMATION."
OTHERWISE, USE A NULL DISPLAY.
REFUSED ...................................................
DON’T KNOW .............................................

8
9

CMQ.250

HELP AVAILABLE
[What is the name, address, and telephone number of that person?]

{ENTER / CORRECT / ENTER NEW} STATE.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}
CAPI INSTRUCTION: DISPLAY STATE ABBREVIATIONS.
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ.100=1, DISPLAY
THE OLD INFORMATION FROM FALL K CMQ.110 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'CORRECT." IF CMQ.200=3, DISPLAY 'ENTER NEW."
OTHERWISE, DISPLAY 'ENTER."
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'IF FIELD…INFORMATION."
OTHERWISE, USE A NULL DISPLAY.

REFUSED ...................................................
DON’T KNOW .............................................
CMQ.260

8
9

[What is the name, address, and telephone number of that person?]
{ENTER / CORRECT / ENTER NEW} ZIP CODE.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ.100=1, DISPLAY
THE OLD INFORMATION FROM FALL K CMQ.110 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'CORRECT." IF CMQ.200=3, DISPLAY 'ENTER NEW."
OTHERWISE, DISPLAY 'ENTER."
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'IF FIELD…INFORMATION."
OTHERWISE, USE A NULL DISPLAY.
REFUSED ...................................................
DON’T KNOW .............................................

8
9

CMQ.270

[What is the name, address, and telephone number of that person?]
{ENTER / CORRECT / ENTER NEW} PHONE NUMBER, INCLUDING AREA CODE.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ100=1, DISPLAY THE
OLD INFORMATION FROM FALL K CMQ.110 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'CORRECT." IF CMQ.200=3, DISPLAY 'ENTER NEW."
OTHERWISE, DISPLAY 'ENTER."
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'IF FIELD…INFORMATION."
OTHERWISE, USE A NULL DISPLAY.
CAPI INSTRUCTION: IF NO TELEPHONE, ENTER '000.'
REFUSED ...................................................
DON’T KNOW .............................................

CMQ.280

8
9

What is the person's relationship to you?
{ENTER / CORRECT / ENTER NEW} RELATIONSHIP OF PERSON TO RESPONDENT.
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ.100=1, DISPLAY
THE OLD INFORMATION FROM FALL K CMQ.110 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'CORRECT." IF CMQ.200=3, DISPLAY 'ENTER NEW."
OTHERWISE, DISPLAY 'ENTER."
CAPI INSTRUCTION: IF CMQ.200=2, DISPLAY 'IF FIELD…INFORMATION." IF FIELD IS
INCOMPLETE, ASK FOR NEW INFORMATION. OTHERWISE, USE A NULL DISPLAY.
REFUSED ...................................................
DON’T KNOW .............................................

8
9

BOX 3
IF FALL K CONTINUING HOUSEHOLD:
IF FALL K CMQ.130=1, CONTINUE WITH CMQ300.
IF FALL K CMQ.130=2, DK, RF, AND SPRING CMQ.205=2, DK, RF, GO TO BOX 5.
IF FALL K CMQ.130=2, DK, RF, AND SPRING CMQ.205 =1 (YES) OR WAS NOT ASKED, GO TO CMQ.305.
IF FALL K NONRESPONSE HOUSEHOLD:
IF CMQ.205=2, DK, RF, GO TO BOX 5.
IF CMQ.205=1, GO TO CMQ.305.

CMQ.300

I have also recorded that {NAME OF RELATIVE/FRIEND}
at {PHONE NUMBER}
on
{STREET ADDRESS, LINE 1}
{STREET ADDRESS, LINE 2}
{CITY}
{STATE}
{ZIP CODE}
will always know where you are if you move. Is this still true?
IF NECESSARY SAY: I will only contact this person if I cannot locate you for the next interview.
CAPI INSTRUCTION: DISPLAY NAME, ADDRESS, AND PHONE NUMBER OF RELATIVE FROM FALL
K CMQ.140.
CAPI INSTRUCTION: DK AND RF FROM ROUND 1 MUST SHOW UP AS PART OF THE ITEM TEXT
AS "REFUSED," "REF," "DK," OR "DON'T KNOW."
CAPI INSTRUCTION: DISPLAY CITY, STATE, AND ZIP ON 1 LINE.

YES --- NO CORRECTION NEEDED………..1 (BOX 5)
YES --- MINOR CORRECTIONS NEEDED…2 (CMQ.310)
NO………………………………………………..3 (BOX 4)
REFUSED……………………………………….8 (BOX 5)
DON’T KNOW…………………………………...9 (BOX 5)
BOX 4
IF CMQ.205=2, DK, RF, GO TO BOX 5.
IF CMQ.205 WAS NOT ASKED, CONTINUE WITH CMQ.305.

CMQ.305

Besides {PERSON AT CMQ.210}, is there another relative or friend, who does not live in this
household, who will always know where you are if you move?
IF NECESSARY SAY: I will only contact this person if I cannot locate you for the next interview.
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON’T KNOW .............................................

1
2
8
9

(CMQ.310)
(BOX 5)
(BOX 5)
(BOX 5)

CMQ.310

What is the name, address, and telephone number of that person?
{ENTER / CORRECT / ENTER NEW} FIRST AND LAST NAME.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ.130=1, DISPLAY
THE OLD INFORMATION FROM FALL K CMQ.140 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'CORRECT.'
IF CMQ.300=3, DISPLAY 'ENTER NEW.'
OTHERWISE, DISPLAY 'ENTER.'
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'IF FIELD…INFORMATION.'
OTHERWISE, USE A NULL DISPLAY.

CMQ.320

[What is the name, address, and telephone number of that person?]
{ENTER / CORRECT / ENTER NEW} STREET ADDRESS, LINE 1.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ.130=1, DISPLAY
THE OLD INFORMATION FROM FALL K CMQ.140 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'CORRECT.'
IF CMQ.300=3, DISPLAY 'ENTER NEW.'
OTHERWISE, DISPLAY 'ENTER.'
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'IF FIELD…INFORMATION.'
OTHERWISE, USE A NULL DISPLAY.

REFUSED ...................................................
DON’T KNOW .............................................
CMQ.330

8
9

[What is the name, address, and telephone number of that person?]
{ENTER / CORRECT / ENTER NEW} STREET ADDRESS, LINE 2.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ130=1, DISPLAY THE
OLD INFORMATION FROM FALL K CMQ1.40 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'CORRECT.'
IF CMQ.300=3, DISPLAY 'ENTER NEW.'
OTHERWISE, DISPLAY 'ENTER.'
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'IF FIELD…INFORMATION.'
OTHERWISE, USE A NULL DISPLAY.
REFUSED ...................................................
DON’T KNOW .............................................

8
9

CMQ.340

[What is the name, address, and telephone number of that person?]
{ENTER / CORRECT / ENTER NEW} CITY.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ.130=1, DISPLAY
THE OLD INFORMATION FROM FALL K CMQ140 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'CORRECT.'
IF CMQ.300=3, DISPLAY 'ENTER NEW.'
OTHERWISE, DISPLAY 'ENTER.'
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'IF FIELD…INFORMATION.'
OTHERWISE, USE A NULL DISPLAY.
REFUSED ...................................................
DON’T KNOW .............................................

CMQ.350

8
9

HELP AVAILABLE
[What is the name, address, and telephone number of that person?]
{ENTER / CORRECT / ENTER NEW} STATE.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}

CAPI INSTRUCTION: DISPLAY STATE ABBREVIATIONS.
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ.130=1, DISPLAY
THE OLD INFORMATION FROM FALL K CMQ140 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'CORRECT.'
IF CMQ.300=3, DISPLAY 'ENTER NEW.'
OTHERWISE, DISPLAY 'ENTER.'
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'IF FIELD…INFORMATION.'
OTHERWISE, USE A NULL DISPLAY.
REFUSED ...................................................
DON’T KNOW .............................................

8
9

CMQ.360

[What is the name, address, and telephone number of that person?]
{ENTER / CORRECT / ENTER NEW} ZIP CODE.
{IF FIELD IS INCOMPLETE, ENTER NEW INFORMATION.}
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ.130=1, DISPLAY
THE OLD INFORMATION FROM FALL K CMQ140 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'CORRECT.'
IF CMQ.300=3, DISPLAY 'ENTER NEW.'
OTHERWISE, DISPLAY 'ENTER.'
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'IF FIELD…INFORMATION.'
OTHERWISE, USE A NULL DISPLAY.
REFUSED ...................................................
DON’T KNOW .............................................

CMQ.370

8
9

[What is the name, address, and telephone number of that person?]
IF NO TELEPHONE, ENTER '000.'
{ENTER / CORRECT / ENTER NEW} PHONE NUMBER, INCLUDING AREA CODE.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ.130=1, DISPLAY
THE OLD INFORMATION FROM FALL K CMQ.140 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'CORRECT.'
CAPI INSTRUCTION: IF CMQ.300=3, DISPLAY 'ENTER NEW.'
OTHERWISE, DISPLAY 'ENTER.'
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'IF FIELD…INFORMATION.'
OTHERWISE, USE A NULL DISPLAY.

REFUSED ...................................................
DON’T KNOW .............................................

8
9

CMQ.380

What is the person's relationship to you?
{ENTER / CORRECT / ENTER NEW} RELATIONSHIP OF PERSON TO RESPONDENT.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}
CAPI INSTRUCTION: IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ.130=1, DISPLAY
THE OLD INFORMATION FROM FALL K CMQ.140 IN THE RESPONSE FIELDS.
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'CORRECT.'
IF CMQ.300=3, DISPLAY 'ENTER NEW.'
OTHERWISE, DISPLAY 'ENTER.'
CAPI INSTRUCTION: IF CMQ.300=2, DISPLAY 'IF FIELD…INFORMATION.'
OTHERWISE, USE A NULL DISPLAY.

REFUSED ...................................................
DON’T KNOW .............................................

8
9

BOX 5
IF FALL K NONRESPONSE HOUSEHOLD, GO TO CMQ.383.
FALL K CONTINUING HOUSEHOLD:
IF FALL K CMQ.092 HAD AN ANSWER, CONTINUE WITH CMQ.382.
IF FALL K (CMQ.091=2, DK, RF) OR CMQ.092 = DK OR RF, GO TO CMQ.383.
CMQ.382

I have also recorded that your e-mail address is {EMAIL ADDRESS}. Is that correct?
CAPI INSTRUCTION: DISPLAY E-MAIL ADDRESS FROM FALL K CMQ092.

YES --- NO CORRECTION NEEDED………..1 (BOX 6)
YES --- MINOR CORRECTIONS NEEDED…2 (CMQ.384)
NO………………………………………………..3 (CMQ.383)
REFUSED……………………………………….8 (BOX 6)
DON’T KNOW…………………………………...9 (BOX 6)

CMQ.383

Is there an e-mail address where we could reach you?
YES ............................................................
NO ..............................................................
REFUSED ...................................................
DON’T KNOW .............................................

1
2 (BOX 6)
7 (BOX 6)
9 (BOX 6)

CMQ.384

What is your e-mail address?
IF EMAIL ADDRESS WILL NOT FIT THE SPACE PROVIDED, ENTER IT IN COMMENTS.
{CORRECT / ENTER NEW} E-MAIL ADDRESS.
{IF FIELD IS INCOMPLETE, ASK FOR NEW INFORMATION.}
CAPI INSTRUCTIONS:
RESPONSE FIELDS.

DISPLAY THE OLD INFORMATION FROM FALL K CMQ.092 IN THE

CAPI INSTRUCTIONS: IF CMQ.382=2, DISPLAY 'CORRECT.' IF CMQ382=3, DISPLAY 'ENTER
NEW.'
CAPI INSTRUCTIONS: IF CMQ.382=2, DISPLAY 'IF FIELD…INFORMATION.'
OTHERWISE, USE A NULL DISPLAY.
CAPI INSTRUCTIONS: ALLOW 33 TOTAL CHARACTERS FOR THE E-MAIL ADDRESS.
CAPI INSTRUCTIONS: ALLOW FOR REFUSED AND DON’T KNOW ANSWERS.
______________________________________________________________________
ENTER E-MAIL ADDRESS

BOX 6
IF FALL K CONTINUING HOUSEHOLD AND FALL K CMQ170 IS COMPLETED, CONTINUE WITH CMQ395.
OTHERWISE, GO TO BOX 7.
DEFINITION OF "COMPLETED" NON-RESIDENT PARENT INFORMATION:
EITHER NAME + PHONE NUMBER OR NAME + CITY+ STATE ARE COLLECTED IN FALL K.
IF THE NON-RESIDENT PARENT ADDRESS COLLECTED IN FALL K DOES NOT MEET THE DEFINITION OF
"COMPLETE," THEN CAPI ROUTES THAT CASE TO BOX 7.

CMQ.395

I have recorded {NAME OF NONRESIDENTIAL PARENT} at {PHONE NUMBER}
on
{STREET ADDRESS, LINE 1}
{STREET ADDRESS, LINE 2}
{CITY}
{STATE}
{ZIP CODE}
is {CHILD}'s {RELATIONSHIP AT CMQ170}.
Is this information still correct?
IF NECESSARY SAY: I will only contact this person if I cannot locate you for the next interview.
CAPI INSTRUCTION: DISPLAY THE NAME, ADDRESS, PHONE NUMBER, AND RELATIONSHIP OF
NON-RESIDENTIAL PARENT FROM FALL K CMQ.170.
CAPI INSTRUCTION: DK AND RF FROM ROUND 1 MUST SHOW UP AS PART OF THE ITEM TEXT
AS "REFUSED," "REF," "DK," OR "DON'T KNOW."
CAPI INSTRUCTION: DISPLAY CITY, STATE, AND ZIP ON 1 LINE.

YES --- NO CORRECTION NEEDED…………………………………..1 (CMQ.680)
YES --- MINOR CORRECTIONS NEEDED……………………………2 (CMQ.400)
NO…………………………………………………………………………..3 (BOX 7)
INFORMATION ALREADY PROVIDED IN PREVIOUS ITEMS……..4 (CMQ.680)
REFUSED………………………………………………………………….8 (CMQ.680)
DON’T KNOW……………………………………………………………...9 (CMQ.680)
BOX 7
IF CMQ.395 WAS NOT ASKED AND IF FOCAL CHILD HAS AT LEAST ONE NON-RESIDENT PARENT WHO THE
CHILD HAS HAD CONTACT WITH (NRQ.040=1 OR 2 FOR AT LEAST ONE NON-RESIDENT PARENT), CONTINUE
WITH CMQ.400.
IF CMQ.395=3 (NO) AND THE FOCAL CHILD HAS AT LEAST ONE NON-RESIDENT PARENTS WHO THE CHILD
HAS HAD CONTACT WITH (NRQ.040=1 OR 2 FOR AT LEAST ONE NON-RESIDENT PARENT), ALSO CONTINUE
WITH CMQ.400.
OTHERWISE, GO TO CMQ.680.

CMQ.400

What is the name, address, and telephone number of {CHILD}'s {biological mother/ {or} biological
father / {or} adoptive mother / {or} adoptive father}?
ENTER FIRST AND LAST NAME.
IF THE PARENT IS DECEASED OR THERE HAS BEEN NO CONTACT SINCE BIRTH/ADOPTION OR
THERE IS NO ADOPTIVE MOTHER/FATHER, THEN CODE “6.”
CAPI INSTRUCTION: DISPLAY 'biological mother' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
BIOLOGICAL MOTHER.
CAPI INSTRUCTION: DISPLAY '{or} biological father] IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
BIOLOGICAL FATHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER ALSO.
CAPI INSTRUCTION: DISPLAY '{or} adoptive mother' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
ADOPTIVE MOTHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER OR NONRESIDENT BIOLOGICAL FATHER ALSO.
CAPI INSTRUCTION: DISPLAY '{or} adoptive father' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
ADOPTIVE FATHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER OR NONRESIDENT BIOLOGICAL FATHER ALSO.
IF NECESSARY SAY: I will only contact this person if I cannot locate you for the next interview.

CMQ.410

[What is the name, address, and telephone number of {CHILD}'s {biological mother/ {or} biological
father / {or} adoptive mother / {or} adoptive father}?]
ENTER STREET ADDRESS, LINE 1.
IF THE PARENT IS DECEASED OR THERE HAS BEEN NO CONTACT SINCE BIRTH/ADOPTION OR
THERE IS NO ADOPTIVE MOTHER/FATHER, THEN CODE “6.”
CAPI INSTRUCTION: DISPLAY 'biological mother' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
BIOLOGICAL MOTHER.
CAPI INSTRUCTION: DISPLAY '{or} biological father] IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
BIOLOGICAL FATHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER ALSO.
CAPI INSTRUCTION: DISPLAY '{or} adoptive mother' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
ADOPTIVE MOTHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER OR NONRESIDENT BIOLOGICAL FATHER ALSO.
CAPI INSTRUCTION: DISPLAY '{or} adoptive father' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
ADOPTIVE FATHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER OR NONRESIDENT BIOLOGICAL FATHER ALSO.
REFUSED………………………………………….8
DON’T KNOW……………………………………...9

CMQ.420

[What is the name, address, and telephone number of {CHILD}'s {biological mother/ {or} biological
father / {or} adoptive mother / {or} adoptive father}?]
ENTER STREET ADDRESS, LINE 2.
IF THE PARENT IS DECEASED OR THERE HAS BEEN NO CONTACT SINCE BIRTH/ADOPTION OR
THERE IS NO ADOPTIVE MOTHER/FATHER, THEN CODE “6.”
CAPI INSTRUCTION: DISPLAY 'biological mother' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
BIOLOGICAL MOTHER.
CAPI INSTRUCTION: DISPLAY '{or} biological father] IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
BIOLOGICAL FATHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER ALSO.
CAPI INSTRUCTION: DISPLAY '{or} adoptive mother' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
ADOPTIVE MOTHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER OR NONRESIDENT BIOLOGICAL FATHER ALSO.
CAPI INSTRUCTION: DISPLAY '{or} adoptive father' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
ADOPTIVE FATHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER OR NONRESIDENT BIOLOGICAL FATHER ALSO.

REFUSED………………………………………….8
DON’T KNOW……………………………………...9

CMQ.430

[What is the name, address, and telephone number of {CHILD}'s {biological mother/ {or} biological
father / {or} adoptive mother / {or} adoptive father}?]
ENTER CITY.
IF THE PARENT IS DECEASED OR THERE HAS BEEN NO CONTACT SINCE BIRTH/ADOPTION OR
THERE IS NO ADOPTIVE MOTHER/FATHER, THEN CODE “6.”
CAPI INSTRUCTION: DISPLAY 'biological mother' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
BIOLOGICAL MOTHER.
CAPI INSTRUCTION: DISPLAY '{or} biological father] IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
BIOLOGICAL FATHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER ALSO.
CAPI INSTRUCTION: DISPLAY '{or} adoptive mother' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
ADOPTIVE MOTHER.
DISPLAY THE 'OR' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER OR NONRESIDENT BIOLOGICAL FATHER ALSO.
CAPI INSTRUCTION: DISPLAY '{or} adoptive father' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
ADOPTIVE FATHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER OR NONRESIDENT BIOLOGICAL FATHER ALSO.
REFUSED………………………………………….8
DON’T KNOW……………………………………...9

CMQ.440

HELP AVAILABLE
[What is the name, address, and telephone number of {CHILD}'s {biological mother/ {or} biological
father / {or} adoptive mother / {or} adoptive father}?]
ENTER STATE.
IF THE PARENT IS DECEASED OR THERE HAS BEEN NO CONTACT SINCE BIRTH/ADOPTION OR
THERE IS NO ADOPTIVE MOTHER/FATHER, THEN CODE “6.”
CAPI INSTRUCTION: DISPLAY 'biological mother' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
BIOLOGICAL MOTHER.
CAPI INSTRUCTION: DISPLAY '{or} biological father] IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
BIOLOGICAL FATHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER ALSO.
CAPI INSTRUCTION: DISPLAY '{or} adoptive mother' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
ADOPTIVE MOTHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER OR NONRESIDENT BIOLOGICAL FATHER ALSO.
CAPI INSTRUCTION: DISPLAY '{or} adoptive father' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
ADOPTIVE FATHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER OR NONRESIDENT BIOLOGICAL FATHER ALSO.
REFUSED………………………………………….8
DON’T KNOW……………………………………...9

CMQ.450

[What is the name, address, and telephone number of {CHILD}'s {biological mother/ {or} biological
father / {or} adoptive mother / {or} adoptive father}?]
ENTER ZIP CODE.
IF THE PARENT IS DECEASED OR THERE HAS BEEN NO CONTACT SINCE BIRTH/ADOPTION OR
THERE IS NO ADOPTIVE MOTHER/FATHER, THEN CODE “6.”
CAPI INSTRUCTION: DISPLAY 'biological mother' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
BIOLOGICAL MOTHER.
CAPI INSTRUCTION: DISPLAY '{or} biological father] IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
BIOLOGICAL FATHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER ALSO.
CAPI INSTRUCTION: DISPLAY '{or} adoptive mother' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
ADOPTIVE MOTHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER OR NONRESIDENT BIOLOGICAL FATHER ALSO.
CAPI INSTRUCTION: DISPLAY '{or} adoptive father' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
ADOPTIVE FATHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER OR NONRESIDENT BIOLOGICAL FATHER ALSO.

REFUSED………………………………………….8
DON’T KNOW……………………………………...9

CMQ.460

[What is the name, address, and telephone number of {CHILD}'s {biological mother/ {or} biological
father / {or} adoptive mother / {or} adoptive father}?]

CMQ.460

[What is the name, address, and telephone number of {CHILD}'s {biological mother/ {or} biological
father / {or} adoptive mother / {or} adoptive father}?]
IF THE PARENT IS DECEASED OR THERE HAS BEEN NO CONTACT SINCE BIRTH/ADOPTION OR
THERE IS NO ADOPTIVE MOTHER/FATHER, THEN CODE “6.”
IF NO TELEPHONE, ENTER '000.'
ENTER PHONE NUMBER, INCLUDING AREA CODE.
CAPI INSTRUCTION: DISPLAY 'biological mother' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
BIOLOGICAL MOTHER.
CAPI INSTRUCTION: DISPLAY '{or} biological father] IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
BIOLOGICAL FATHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER ALSO.
CAPI INSTRUCTION: DISPLAY '{or} adoptive mother' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
ADOPTIVE MOTHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER OR NONRESIDENT BIOLOGICAL FATHER ALSO.
CAPI INSTRUCTION: DISPLAY '{or} adoptive father' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT
ADOPTIVE FATHER.
DISPLAY THE 'or' IF NRQ.040=1 OR 2 FOR A NON-RESIDENT BIOLOGICAL MOTHER OR NONRESIDENT BIOLOGICAL FATHER ALSO.
REFUSED………………………………………….8
DON’T KNOW……………………………………...9

CMQ.470

{Let me just confirm our information}. What is the person's relationship to {CHILD}?
ENTER RELATIONSHIP OF PERSON TO CHILD.
IF THE PARENT IS DECEASED OR THERE HAS BEEN NO CONTACT SINCE BIRTH/ADOPTION OR
THERE IS NO ADOPTIVE MOTHER/FATHER, THEN CODE “6.”
CAPI INSTRUCTION: DISPLAY “Let me…information” IF ONLY ONE TYPE OF NONRESIDENT
PARENT WAS DISPLAYED IN CMQ.460 (E.G., ONLY “BIOLOGICAL MOTHER” AND NOT
“BIOLOGICAL FATHER”, “ADOPTIVE MOTHER”, OR “ADOPTIVE FATHER”. ELSE, USE A NULL
DISPLAY.
REFUSED………………………………………….8
DON’T KNOW……………………………………...9

CMQ.680

WAS THIS INTERVIEW CONDUCTED BY TELEPHONE OR IN-PERSON?
TELEPHONE………………….1
IN-PERSON……………………2

CMQ.690

WAS THIS INTERVIEW CONDUCTED IN ENGLISH, SPANISH, OR ANOTHER LANGUAGE?
ENGLISH.................................................................. 1 (CMQ.695)
SPANISH .................................................................. 2 (CMQ.695)
ANOTHER LANGUAGE ............................................ 91 (CMQ.690OS)

CMQ.690OS SPECIFY OTHER LANGUAGE.
[WAS THIS INTERVIEW CONDUCTED IN ENGLISH, SPANISH, OR ANOTHER LANGUAGE?]

CMQ.695

WHERE WAS THIS INTERVIEW CONDUCTED?
CHILD’S HOME ........................................................
CHILD’S SCHOOL ....................................................
SOMEWHERE ELSE ................................................

1
2
3

BOX 8
SET FINAL DISPOSITION CODE:
IF CMQ.680=1 (TELEPHONE) AND CMQ.690=1 (ENGLISH), SET DISPOSITION CODE TO 60.
IF CMQ.680=1 (TELEPHONE) AND CMQ.690=2 (SPANISH), SET DISPOSITION CODE TO 61.
IF CMQ.680=1 (TELEPHONE) AND CMQ.690=3 (ANOTHER LANGUAGE), SET DISPOSITION CODE TO 62.
IF CMQ.680=2 (IN-PERSON) AND CMQ.690=1 (ENGLISH), SET DISPOSITION CODE TO 63.
IF CMQ.680=2 (IN-PERSON) AND CMQ.690=2 (SPANISH), SET DISPOSITION CODE TO 64.
IF CMQ.680=2 (IN-PERSON) AND CMQ.690=3 (ANOTHER LANGUAGE), SET DISPOSITION CODE TO 65.

CMQ.700
Thank you very much for your cooperation and for taking the time to participate in the Early Childhood Longitudinal
Study.
PRESS ENTER TO CONTINUE.
BOX 9
GO TO CMQ.720.

CMQ.701
We would like to call the parent or guardian for {CHILD} at the household where {he/she} lives. Please give me the
name and telephone number for the home that I should call. AFTER EXITING ON THE NEXT SCREEN, ENTER
CONTACT INFORMATION FOR CHILD’S RESIDENCE INTO THE ELECTRONIC RECORD OF CALLS.
BOX 10
GO TO CMQ.720.

CMQ.702
We would like to call back when {CHILD}’s parent or guardian is available. Please tell me when we should call back.
AFTER EXITING ON THE NEXT SCREEN, ENTER CALL BACK TIME INTO THE ELECTRONIC RECORD OF
CALLS.
BOX 11
GO TO CMQ.720.

CMQ.703
Thank you. AFTER EXITING ON THE NEXT SCREEN, ENTER INTO THE ELECTRONIC RECORD OF CALLS
WHETHER YOU SPOKE TO THE CONTACT PERSON AND ANY INFORMATION YOU HAVE ABOUT WHY
AN APPROPRIATE RESPONDENT WAS NOT AVAILABLE, NOT IN THE HOUSEHOLD, OR THE
INFORMATION WAS REFUSED/DON’T KNOW.

CMQ.720
PRESS 1 AND ENTER TO SAVE AND EXIT THIS CASE.