Child Disability Questions

Attachment 1b- Child Disability 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 55 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

OMB #0920-0222; Expiration Date: 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?

1. Yes

2. 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?

1. Yes

2. 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]