Attachment 1- Four sets of Health Related Questions to be cognitively tested
The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).
OMB #0920-0222; Expiration Date: 06/30/2015
CHILD DISABILITY QUESTIONS
PREAMBLE: These questions ask about difficulties your child may have in doing certain activities…
NOTE:
Unless noted otherwise, all response categories are:
1) No difficulty
2) Some difficulty
3) A lot of difficulty
4) Cannot do at all
All questions include the following response categories:
7) Refused
9) Don’t know
SEEING
Children aged 2-17 years
1a) Does [he/she] wear glasses?
Yes
No
1b) Does [he/she] have difficulty seeing [if (1a) is Yes], when wearing his/her glasses?
Would you say… [Read response categories]
HEARING
Children aged 2-17 years
2a) Does [he/she] use a hearing aid?
Yes
No
2b) Does [he/she] have difficulty hearing [if (2a) is Yes], when using his/her hearing aid(s)? Would you say… [Read response categories]
WALKING
Children aged 2-4 years
3a) Compared with children of the same age, does [he/she] have difficulty walking? Would you say… [Read response categories]
Children aged 5-17 years
3b) Compared with children of the same age, does [he/she] have difficulty walking 500 meters on level ground? (That would be about 1,640 feet or 546 yards. Would you say… [Read response categories]
1) No difficulty (skip 3c)
3c) Compared with children of the same age, does [he/she] have difficulty walking 100 meters on level ground? (That would be about 328 feet or 109 yards. Would you say… [Read response categories]
SELF-CARE
Children aged 5- 17 years
4) Compared with children of the same age, does [he/she] have difficulty with self-care such as feeding or dressing him/herself? Would you say… [Read response categories]
COMMUNICATION/COMPREHENSION
Children aged 2-4 years (Order of questions to be determined.)
5a) Does [he/she] have difficulty understanding you? Would you say… [Read response categories]
6a) Do you have difficulty understanding your child’s needs/what your child wants? Would you say… [Read response categories]
Children aged 5-17 years (Order of questions and skip patterns to be determined)
5b) Compared with children of the same age and using [his/her] usual (customary) language, does [he/she] have difficulty understanding other people? Would you say… [Read response categories]
6b) Compared with children of the same age and using [his/her] usual (customary) language, does [he/she] have difficulty being understood by other people? Would you say… [Read response categories]
LEARNING
Children aged 2-3 years
7a) Compared with children of the same age, does [he/she] have difficulty learning the names of common objects? Would you say… [Read response categories]
Children aged 3-17 years
7b) Compared with children of the same age, does [he/she] have difficulty learning to do new things? Would you say… [Read response categories]
Children aged 5-17 years
8) Compared with children of the same age, does [he/she] have difficulty remembering things that they have learned? Would you say… [Read response categories]
EMOTIONS
Children aged 5-17
9) Compared with children of the same age, how much does (he /she) worry or feel sad? Would you say… [Read response categories]
1) Less/Not at all
2) The same
3) More
4) A lot more
BEHAVIOR
Children aged 2-4 years (MICS Early Childhood Development Questionnaire)
10) Compared with children of the same age, how much does (he/she) kick, bite or hit other children or adults?
1) Less/Not at all
2) The same
3) More
4) A lot more
Children aged 5-17 years
10) Compared with children of the same age, how much difficulty does (he/she) have controlling his/her behavior? Would you say… [Read response categories]
ATTENTION
Children aged 5-17
11) Compared with children of the same age, does (he/she) have difficulty concentrating on a task? Would you say… [Read response categories]
…difficulty completing a task/staying on task…
COPING WITH CHANGE
Children aged 5-17 years
12) Compared with children of the same age, does (he/she) have difficulty accepting change to plans or routine? Would you say… [Read response categories]
RELATIONSHIPS
Children aged 5-17 years
13a) Does [he/she] have difficulty getting along with children of his/her age? Would you say… [Read response categories]
13b) Does [he/she] have difficulty making and keeping friends? Would you say … [Read response categories]
PLAYING
Children aged 5-12 years
14a) Compared with children of the same age, does [he/she] have difficulty playing? Would you say… [Read response categories]
Children aged 2-5 years
14 a1) Compared with children of the same age, does [he/she] have difficulty playing with toys or household objects?
Children aged 2-12 years
14a2) Compared with children of the same age, does [he/she] have difficulty playing with other children?
Children aged 13-17 years (It is intended to test this question for the age group 13-17 years.)
14b) Compared with children of the same age, does [he/she] have difficulty doing things with other children? (Include things that children usually do together.) Would you say… [Read response categories]
PAIN
Children aged 2-17 years (revised from NCHS: National Survey of Children with Special Health Care Needs)
14a) Compared with children of the same age, does [he/she] have difficulty with repeated or chronic physical pain, including headaches? Would you say… [Read response categories]
Trust in Official Statistics Questions
PREAMBLE: The next questions ask about your awareness of and trust in federal statistics on death rates in the United States…
Have you ever heard of the death rate for the United States?
Yes
No [go to question 4]
Where have you heard of this statistic? [open code all that apply]
Reports in the media, including TV, radio, newspapers
Through school
Through work
From discussions with friends or relatives
Other
Do you believe that the death rate or life expectancy is correct?
Yes
No
The National Center for Health Statistics produces the death rate for the United States. Prior to this survey, had you ever heard of the National Center for Health Statistics?
Yes
No
Would you tend to believe information produced by the National Center for Health Statistics, a part of the federal statistical system, more or less than information produced by other sources?
More
Less
About the same
Health Insurance Questions
PREAMBLE: The next questions ask about your health insurance…
As you may know, two years ago Congress passed a law that restructures the nation’s healthcare system. A few of the provisions of the healthcare law have already gone into effect. In 2014, health care exchanges will be set up that will allow individuals to purchase health insurance with the financial assistance of the federal government. Are you familiar with the health care exchanges?
If yes, do you intend to purchase insurance from an exchange in 2014?
Do you have health insurance now?
(If yes) Who pays the cost of premiums on your health insurance? Do you or someone in your household pay the total cost, does an employer pay the total cost, or is the cost shared between the employer and you or someone in your household?
Second Hand Smoke Questions
To be asked of smokers, non-smokers, and parents of children 2-11 years of age
During the past 7 days, did you use smoke cigarettes or any other tobacco product?
YES 1
NO 2 (SMQ.NEW5)
REFUSED 7 (SMQ.NEW5)
DON'T KNOW 9 (SMQ.NEW5)
BOX NEW2
CHECK ITEM SMQ.NEW: IF SP AGE 0-11, GO SMQ.NEW5, ELSE CONTINUE. |
SMQ.NEW3 During the last 7 days, were you working at a job or business outside of the home?
YES 1
NO 2 (SMQ.NEW5)
REFUSED 7 (SMQ.NEW5)
DON'T KNOW 9 (SMQ.NEW5)
SMQ.NEW4 While you were working at a job or business outside of the home, did someone else smoke cigarettes or other tobacco products indoors?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
SMQ.NEW5 During the last 7 days, did {you/your child} spend time in a restaurant?
YES 1
NO 2 (BOX.NEW3)
REFUSED 7 (BOX.NEW3)
DON'T KNOW 9 (BOX .NEW3)
SMQ.NEW6 While {you were/your child was} in a restaurant, did someone else smoke cigarettes or other tobacco products indoors?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
BOX NEW3
CHECK ITEM SMQ.NEW: IF SP >=18 YEARS CONTINUE, ELSE GO TO SMQ.NEW9.
|
SMQ.NEW7 During the last 7 days, did spend time in a bar?
YES 1
NO 2 (SMQ.NEW9)
REFUSED 7 (SMQ.NEW9)
DON'T KNOW 9 (SMQ.NEW9)
SMQ.NEW8 While you were in a bar, did someone else smoke cigarettes or other tobacco products indoors?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
SMQ.NEW9 During the last 7 days, did {you/your child} ride in a car or motor vehicle?
YES 1
NO 2 (SMQ.NEW11)
REFUSED 7 (SMQ.NEW11)
DON'T KNOW 9 (SMQ.NEW11)
SMQ.NEW10 While {you were/your child was} riding in a car or motor vehicle, did someone else smoke cigarettes or other tobacco products?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
SMQ.NEW11 During the last 7 days, did {you/your child} spend time in a home other than {your/his/her} own?
YES 1
NO 2 (SMQ.NEW13)
REFUSED 7 (SMQ.NEW13)
DON'T KNOW 9 (SMQ.NEW13)
SMQ.NEW12 While {you were/your child was} in a home other than {your/his/her} own, did someone else smoke cigarettes or other tobacco products indoors?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
SMQ.NEW13 During the last 7 days,{were you/ was your child} in any other indoor area?
YES 1
NO 2 (END OF SESSION)
REFUSED 7 (END OF SESSION)
DON'T KNOW 9 (END OF SESSION)
SMQ.NEW14 While {you were/your child was} in the other indoor area, did someone else smoke cigarettes or other tobacco products indoors?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CDC User |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |