Form 25.1 Survey
Provider-Based Sampling Feasibility Study for the Vanguard (Pilot) Study and Data Collection Updates for the National Children's Study (NICHD)
Core Questionnare 20120413
Core Questionnaire (PB, EH, TT-HI, TT-LI, PBS)
OMB: 0925-0593
OMB #: 0925-0593
OMB Expiration Date: 07/31/ 2013
Core Questionnaire, Phase 2e
Core Questionnaire
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Core Questionnaire
TABLE OF CONTENTS
CHILD CARE/DAYCARE ARRANGEMENTS 12
VIEWING OF MEDIA/READING BOOKS 16
PESTICIDE APPLICATIONS IN PAST SIX MONTHS 30
Neighborhood Characteristics 38
HEALTH CARE UTILIZATION/ACCESS 56
WELL CHILD CARE/IMMUNIZATIONS 66
EMERGENCY ROOM/URGENT CARE VISITS 72
CORE QUESTIONNAIRE
(TIME_STAMP_HC_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
PRELOAD ALL PARTICIPANT IDS (P_ID) FOR CHILD(REN) AND RESPONDENT IDS (R_P_ID) FOR PARENT/CAREGIVER.
IF CHILD_NUM > 1 AND:
IF THE CHILD PRIMARY ADDRESS VARIABLES ARE THE SAME FOR ALL CHILDREN:
LOOP THROUGH HOUSEHOLD COMPOSITION FOR CHILD_QNUM =1.
THEN LOOP THROUGH CHILD CARE/DAYCARE, VIEWING OF MEDIA/READING BOOKS, AND SLEEP SECTIONS FOR EACH CHILD UNTIL NUMBER OF LOOPS = CHILD_NUM.
THEN LOOP THROUGH HOUSING CHARACTERISTICS, PESTICIDE APPLICATIONS, SMOKING IN HOME, PETS, NEIGHBORHOOD CHARACTERISTICS SECTIONS, AND OCCUPATION AND INCOME SECTIONS (IF ELIGIBLE VISIT) FOR CHILD_QNUM = 1.
THEN LOOP THROUGH PROGRAM PARTICIPATION AND HEALTHCARE UTILIZATION SECTIONS (IF ELIGIBLE VISIT), MEDICAL CONDITIONS, WELL CHILD CARE/IMMUNIZATIONS, EMERGENCY ROOM/URGENT VISITS, INTERIM HOSPITALIZATIONS, INTERIM MEDICATIONS, CONCERN ABOUT CHILD’S DEVELOPMENT, AND DISABILITY SECTIONS UNTIL THE NUMBER OF LOOPS = CHILD_NUM.
IF THE CHILD PRIMARY ADDRESS VARIABLES DIFFER FOR CHILDREN:
LOOP THROUGH HOUSEHOLD COMPOSITION, CHILD CARE/DAYCARE, VIEWING OF MEDIA/READING BOOKS, SLEEP HOUSING CHARACTERISTICS, PESTICIDE APPLICATIONS, SMOKING IN HOME, PETS, NEIGHBORHOOD CHARACTERISTICS SECTIONS, OCCUPATION, INCOME, PROGRAM PARTICIPATION AND HEALTHCARE UTILIZATION SECTIONS (IF ELIGIBLE VISIT), MEDICAL CONDITIONS, WELL CHILD CARE/IMMUNIZATIONS, EMERGENCY ROOM/URGENT VISITS, INTERIM HOSPITALIZATIONS, INTERIM MEDICATIONS, CONCERN ABOUT CHILD’S DEVELOPMENT, AND DISABILITY SECTIONS UNTIL THE NUMBER OF LOOPS = CHILD_NUM.
HC001. Now I have a few questions about {C_FNAME/the child}’s primary household.
PROGRAMMER INSTRUCTIONS:
IF NUM_HH COMPLETED DURING PREVIOUS INTERVIEW AND VALID RESPONSE PROVIDED, PRELOAD NUM_HH AND HH_MEM_DOB FOR EACH F_NAME FROM BIRTH INTERVIEW AND THEN GO TO HHCOMP_CHANGE.
OTHERWISE, GO TO NUM_HH.
HC002/(NUM_HH). How many persons are currently living in or staying in this household, not including the child?
|___|___|
NUMBER OF PERSONS
REFUSED -1 (TIME_STAMP_HC_ET)
DON’T KNOW -2 (TIME_STAMP_HC_ET)
HC002A/(MILITARY_HH). Have any household members ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard? Active duty does not include training for the Reserves or National Guard, but does include activation, for example, for the Persian Gulf War.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LOOP THROUGH FNAME_HH, CHILD_RELAT, CHILD_RELAT_OTH_1 (IF CHILD_RELAT = 7), CHILD_RELAT_OTH_2 (IF CHILD_RELAT = 8), HH_MEM_DOB, ACTIVE_DUTY (IF MILITARY_HH = 1 AND EITHER HH_MEM_AGE ≥ 18 YEARS OR HH_MEM_DOB = -1 OR -2), AND BRANCH_SERV (IF ACTIVE_DUTY = 1, 2 OR 3) UNTIL NUMBER OF LOOPS = NUM_HH.
THEN GO TO TIME_STAMP_HC_ET.
HC003/(FNAME_HH). {What are the names of all the persons living or staying in this household? Start with the name of the person, or one of the persons, who owns or rents this home}/{What is the name of the next person living or staying here?}
INTERVIEWER INSTRUCTION:
CONFIRM SPELLING.
_________________________________
FIRST NAME
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF FIRST LOOP CYCLE, DISPLAY “What are the names of all the persons…”
IF SUBSEQUENT LOOP CYCLE, DISPLAY “What is the name of the next person…”
HC004/(CHILD_RELAT). How is {F_NAME} related to the child?
MOTHER 1 (HH_MEM_DOB)
FATHER 2 (HH_MEM_DOB)
GRANDMOTHER 3 (HH_MEM_DOB)
GRANDFATHER 4 (HH_MEM_DOB)
SISTER 5 (HH_MEM_DOB)
BROTHER 6 (HH_MEM_DOB)
OTHER RELATIVE 7
OTHER NON-RELATIVE 8 (CHILD_RELAT_OTH_2)
REFUSED -1 (HH_MEM_DOB)
DON’T KNOW -2 (HH_MEM_DOB)
PROGRAMMER INSTRUCTION:
DISPLAY F_NAME.
HC004A/(CHILD_RELAT_OTH_1).
SPECIFY: _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
LIMIT TEXT TO 255 CHARACTERS.
GO TO HH_MEM_DOB.
HC004B/(CHILD_RELAT_OTH_2).
SPECIFY: _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
HC004C/(HH_MEM_DOB). What is {F_NAME}’s date of birth?
INTERVIEWER INSTRUCTIONS:
IF PARENT/CAREGIVER REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS
ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR.
IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE.
MONTH: |___|___|
M M
DAY: |___|___|
D D
YEAR: |___|___|___|___|
Y Y Y Y
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
FORMAT HH_MEM_DOB AS YYYYMMDD.
DISPLAY F_NAME.
IF MILITARY_HH = 1 AND,
IF VALID RESPONSE PROVIDED FOR HH_MEM_DOB, CALCULATE DERIVED VARIABLE, HH_MEM_AGE, BASED ON HH_MEM_DOB AND DATE OF CURRENT INTERVIEW;
IF HH_MEM_AGE > 18 YEARS, GO TO ACTIVE_DUTY.
IF VALID RESPONSE NOT PROVIDED FOR HH_MEM_DOB, GO TO ACTIVE_DUTY.
OTHERWISE, COMPLETE LOOP:
IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO FNAME_HH.
IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO TIME_STAMP_HC_ET.
HC004C/(ACTIVE_DUTY). Has {F_NAME} ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard?
INTERVIEWER INSTRUCTION:
READ AS NECESSARY: [Active duty does not include training for the Reserves or National Guard, but does include activation, for example, for the Persian Gulf War.]
Yes, they are now on active duty, 1
Yes, they were on active duty during the last 6
months, but not now, 2
Yes, they were on active duty in the past, but not
during the last 6 months, 3
No, they are training for Reserves or National
Guard only, or 4
No, they never served in the military? 5
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
DISPLAY F_NAME.
IF ACTIVE_DUTY = 1, 2, OR 3, GO TO BRANCH_SERV.
OTHERWISE, IF ACTIVE_DUTY = 4, 5, -1, OR -2, COMPLETE LOOP:
IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO FNAME_HH.
IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO TIME_STAMP_HC_ET.
HC004D/(BRANCH_SERV). What {is/was} {C_FNAME}’s branch of service?
Air Force, 1
Army, 2
Marine Corps, 3
Navy, or 4
Coast Guard? 5
NOT IN U.S. ARMED FORCES -7
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF ACTIVE_DUTY = 1, DISPLAY “is”.
IF ACTIVE_DUTY = 2 OR 3, DISPLAY “was”.
DISPLAY F_NAME.
IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO FNAME_HH TO BEGIN NEXT LOOP.
IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO TIME_STAMP_HC_ET.
HC005/(HHCOMP_CHANGE). Have there been any changes in your household members since the last interview on {DATE OF LAST INTERVIEW}?
YES 1
NO 2 (TIME_STAMP_HC_ET)
REFUSED -1 (TIME_STAMP_HC_ET)
DON’T KNOW -2 (TIME_STAMP_HC_ET)
PROGRAMMER INSTRUCTION:
PRELOAD AND DISPLAY DATE OF LAST INTERVIEW.
HC005a/(HHCOMP_CHANGE_MIL). Have there been any changes in military status of any household members since the last interview on {DATE OF LAST INTERVIEW}? This includes joining or leaving the military.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
PRELOAD AND DISPLAY DATE OF LAST INTERVIEW.
IF HHCOMP_CHANGE = 2, -1 OR -2, AND HHCOMP_CHANGE_MIL = 1, LOOP THROUGH HH_MIL_CHANGE_ROSTER, ACTIVE_DUTY_CHANGE, AND BRANCH_SERV_CHANGE (IF ACTIVE_DUTY_CHANGE = 1, 2, OR 3) FOR EACH F_NAME UNTIL NUMBER OF LOOPS = NUM_HH.
IF HH_COMP_CHANGE = 1 AND HHCOMP_CHANGE_MIL = 2, -1, OR -2, LOOP THROUGH HH_CHANGE_ROSTER FOR EACH F_NAME.
IF HH_COMP_CHANGE = 1 AND HHCOMP_CHANGE_MIL = 1, LOOP THROUGH HH_CHANGE_ROSTER, ACTIVE_DUTY_CHANGE, AND BRANCH_SERV_CHANGE (IF ACTIVE_DUTY_CHANGE = 1, 2, OR 3) FOR EACH F_NAME UNTIL NUMBER OF LOOPS = NUM_HH.
OTHERWISE, IF HHCOMP_CHANGE= 2, -1, OR -2, AND HHCOMP_CHANGE_MIL =2, -1, OR -2, GO TO TIME_STAMP_HC_ET.
HC006/(HH_CHANGE_ROSTER). We have listed that [READ NAMES FROM MATRIX] lived in this household at the time of our last interview on {DATE OF LAST INTERVIEW}. As I read each person's name again, please tell me whether he or she still lives in this household.
Does {F_NAME} still live in this household?
INTERVIEWER INSTRUCTION:
REMOVE HH MEMBERS AND ADD NEW HH MEMBERS AND RELATIONSHIP TO CHILD AS NEEDED.
_________________________________
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
PRELOAD AND DISPLAY DATE OF LAST INTERVIEW AND F_NAME.
LIMIT TEXT TO 255 CHARACTERS.
DISPLAY MATRIX PRELOADED WITH FIRST NAMES OF HH MEMBERS AND
LOOP THROUGH EACH NAME LISTED ON MATRIX IF HHCOMP_CHANGE_MIL = 1 AND,
IF HH_MEM_DOB COLLECTED DURING PREVIOUS INTERVIEW AND VALID RESPONSE PROVIDED, CALCULATE DERIVED VARIABLE, HH_MEM_AGE, BASED ON HH_MEM_DOB AND DATE OF CURRENT INTERVIEW;
IF HH_MEM_AGE > 18 YEARS, GO TO ACTIVE_DUTY_CHANGE AND LOOP THROUGH BRANCH_SERVICE_CHANGE (IF ACTIVE_DUTY_CHANGE = 1, 2 OR 3), THEN RETURN TO HH_CHANGE_ROSTER
IF HH_MEM_DOB NOT COLLECTED DURING PREVIOUS INTERVIEW OR VALID RESPONSE NOT PROVIDED, GO TO ACTIVE_DUTY_CHANGE AND LOOP THROUGH BRANCH_SERVICE_CHANGE (IF ACTIVE_DUTY_CHANGE = 1, 2 OR 3), THEN RETURN TO HH_CHANGE_ROSTER
WHEN NUMBER OF LOOPS = NUM_HH, GO TO OTHER_CHANGE_ROSTER.
HC006A/(HH_MIL_CHANGE_ROSTER). As I read each household member's name, please tell me whether he or she has had a change in military status. Has {F_NAME} had a change in military status?
INTERVIEWER INSTRUCTIONS:
READ NAMES FROM MATRIX.
SELECT THE APPROPRIATE RESPONSE FOR EACH HOUSEHOLD MEMBER.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
PRELOAD F_NAME.
LIMIT TEXT TO 255 CHARACTERS.
DISPLAY MATRIX PRELOADED WITH FIRST NAMES OF HH MEMBERS AND LOOP THROUGH EACH NAME LISTED ON MATRIX
IF HH_MEM_DOB COLLECTED DURING PREVIOUS INTERVIEW AND VALID PROVIDED, CALCULATE DERIVED VARIABLE, HH_MEM_AGE, A BASED ON HH_MEM_DOB AND DATE OF CURRENT INTERVIEW;
IF HH_MEM_AGE > 18 YEARS, GO TO ACTIVE_DUTY_CHANGE AND LOOP THROUGH BRANCH_SERVICE_CHANGE
(IF ACTIVE_DUTY_CHANGE = 1, 2 OR 3), THEN RETURN TO HH_MIL_CHANGE_ROSTER.
IF HH_MEM_DOB NOT COLLECTED DURING PREVIOUS INTERVIEW OR VALID RESPONSE NOT PROVIDED, GO TO ACTIVE_DUTY_CHANGE AND LOOP THROUGH BRANCH_SERVICE_CHANGE (IF ACTIVE_DUTY_CHANGE = 1, 2 OR 3), THEN RETURN TO HH_MIL_CHANGE_ROSTER
WHEN NUMBER OF LOOPS = NUM_HH, GO TO TIME_STAMP_HC_ET.
HC007/(OTHER_CHANGE_ROSTER). In addition to the people listed above, are there any persons living in the household that we have not mentioned?
YES 1
NO 2 (TIME_STAMP_HC_ET)
REFUSED -1 (TIME_STAMP_HC_ET)
DON’T KNOW -2 (TIME_STAMP_HC_ET)
HC008/(NUM_CHANGE_HH). How many persons are currently living in or staying in this this household that were not listed above?
|___|___|
NUMBER OF PERSONS
REFUSED -1 (TIME_STAMP_HC_ET)
DON’T KNOW -2 (TIME_STAMP_HC_ET)
HC009/(MILITARY_HH_CHANGE). Have any of these persons who are now living or staying in this household ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard? Active duty does not include training for the Reserves or National Guard, but does include activation, for example, for the Persian Gulf War.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
LOOP THROUGH FNAME_CHANGE_ROSTER, CHILD_RELAT_CHANGE, CHILD_RELAT_CHANGE_OTH_1 (IF CHILD_RELAT_CHANGE_OTH = 7), CHILD_RELAT_OTH_CHANGE_2 (IF CHILD_RELAT_CHANGE = 8), HH_MEM_DOB
_CHANGE, ACTIVE_DUTY_CHANGE (IF MILITARY_HH_CHANGE = 1 AND EITHER HH_MEM_AGE_CHANGE ≥ 18 YEARS OR HH_MEM_DOB_CHANGE = -1 OR -2), AND BRANCH_SERV_CHANGE (IF ACTIVE_DUTY_CHANGE = 1, 2 OR 3) UNTIL NUMBER OF LOOPS = NUM_CHANGE_HH.
THEN GO TO TIME_STAMP_HC_ET.
HC010/(FNAME_CHANGE_ROSTER). {Start with the name of the person, or one of the persons, who lives or stays in this home}/{What is the name of the next person living or staying here?}
INTERVIEWER INSTRUCTION:
CONFIRM SPELLING.
________________________________
FIRST NAME
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF FIRST LOOP CYCLE, DISPLAY “Start with the name of the person…”
IF SUBSEQUENT LOOP CYCLE, DISPLAY “What is the name of the next person…”
HC011/(CHILD_RELAT_CHANGE). How is {F_NAME} related to the child?
MOTHER 1 (HH_MEM_DOB_CHANGE)
FATHER 2 (HH_MEM_DOB_CHANGE)
GRANDMOTHER 3 (HH_MEM_DOB_CHANGE)
GRANDFATHER 4 (HH_MEM_DOB_CHANGE)
SISTER 5 (HH_MEM_DOB_CHANGE)
BROTHER 6 (HH_MEM_DOB_CHANGE)
OTHER RELATIVE 7
OTHER NON-RELATIVE 8 (CHILD_RELATE_CHANGE_OTH_2)
REFUSED -1 (HH_MEM_DOB_CHANGE)
DON’T KNOW -2 (HH_MEM_DOB_CHANGE)
PROGRAMMER INSTRUCTIONS:
DISPLAY F_NAME.
HC012/(CHILD_RELATE_CHANGE_OTH_1).
SPECIFY: _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
LIMIT FREE TEXT TO 255 CHARACTERS.
GO TO HH_MEM_DOB_CHANGE.
HC013/(CHILD_RELATE_CHANGE_OTH_2).
SPECIFY: _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
LIMIT FREE TEXT TO 255 CHARACTERS.
HC004C/(HH_MEM_DOB_CHANGE). What is {F_NAME}’s date of birth?
INTERVIEWER INSTRUCTIONS:
IF PARENT/CAREGIVER REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS
ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR.
IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE.
MONTH: |___|___|
M M
DAY: |___|___|
D D
YEAR: |___|___|___|___|
Y Y Y Y
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
FORMAT HH_MEM_DOB_CHANGE AS YYYYMMDD.
DISPLAY F_NAME.
IF MILITARY_HH_CHANGE = 1 AND,
VALID RESPONSE PROVIDED FOR HH_MEM_DOB_CHANGE, CALCULATE DERIVED VARIABLE, HH_MEM_AGE_CHANGE, BASED ON HH_MEM_DOB_CHANGE AND DATE OF CURRENT INTERVIEW;
IF HH_MEM_AGE_CHANGE > 18 YEARS, GO TO ACTIVE_DUTY_CHANGE.
IF VALID RESPONSE NOT PROVIDED FOR HH_MEM_DOB_CHANGE, GO TO ACTIVE_DUTY_CHANGE
IF NUMBER OF COMPLETED LOOPS < NUM_CHANGE_HH, GO TO FNAME_CHANGE_ROSTER.
OTHERWISE, IF NUMBER OF COMPLETED LOOPS = NUM_CHANGE_HH, GO TO TIME_STAMP_HC_ET.
HC016/(ACTIVE_DUTY_CHANGE). Has {F_NAME} ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard?
INTERVIEWER INSTRUCTION:
READ AS NECESSARY: [Active duty does not include training for the Reserves or National Guard, but does include activation, for example, for the Persian Gulf War.]
Yes, they are now on active duty, 1
Yes, they were on active duty during the last 6
months, but not now, 2
Yes, they were on active duty in the past, but not
during the last 6 months, 3
No, they were training for Reserves or National
Guard only, or 4
No, they never served in the military? 5
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
DISPLAY F_NAME.
IF ACTIVE_DUTY_CHANGE = 1, 2, OR 3, GO TO BRANCH_SERV_CHANGE.
IF HHCOMP_CHANGE = 2, -1, OR 2, AND HHCOMP_CHANGE_MIL = 1:
IF ACTIVE_DUTY_CHANGE = 4, 5, -1, OR -2, AND
IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO ACTIVE_DUTY_CHANGE.
IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO TIME_STAMP_ET.
IF HHCOMP_CHANGE = 1, AND HHCOMP_CHANGE_MIL = 1:
IF ACTIVE_DUTY_CHANGE = 4, 5, -1, OR -2, AND
IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO HH_CHANGE_ROSTER.
IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO OTHER_CHANGE_ROSTER.
OTHERWISE, IF ACTIVE_DUTY_CHANGE = 4, 5, -1, OR -2, COMPLETE LOOP:
IF NUMBER OF COMPLETED LOOPS < NUM_CHANGE_HH, GO TO FNAME_CHANGE_ROSTER.
IF NUMBER OF COMPLETED LOOPS = NUM_CHANGE_HH, GO TO TIME_STAMP_ET.
HC004B/(BRANCH_SERV_CHANGE). What {is/was} {C_FNAME}’s branch of service?
Air Force, 1
Army, 2
Marine Corps, 3
Navy, or 4
Coast Guard? 5
NOT IN U.S. ARMED FORCES -7
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF ACTIVE_DUTY_CHANGE= 1, DISPLAY “is”.
IF ACTIVE_DUTY_CHANGE = 2 OR 3, DISPLAY “was”.
IF HHCOMP_CHANGE = 2, -1, OR 2, AND HHCOMP_CHANGE_MIL = 1:
IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO ACTIVE_DUTY_CHANGE.
IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO TIME_STAMP_ET.
IF HHCOMP_CHANGE = 1, AND HHCOMP_CHANGE_MIL = 1:
IF NUMBER OF COMPLETED LOOPS < NUM_HH, GO TO HH_CHANGE_ROSTER.
IF NUMBER OF COMPLETED LOOPS = NUM_HH, GO TO OTHER_CHANGE_ROSTER.
IF NUMBER OF COMPLETED LOOPS < NUM_CHANGE_HH, GO TO FNAME_CHANGE_ROSTER TO BEGIN NEXT LOOP.
IF NUMBER OF COMPLETED LOOPS = NUM_CHANGE_HH, GO TO TIME_STAMP_ET.
(TIME_STAMP_HC_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
CHILD CARE/DAYCARE ARRANGEMENTS
(TIME_STAMP_CC_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
CC001. I’d like to ask you about different types of child care {C_FNAME/the child} may receive from someone other than parents or guardians. This includes regularly scheduled care arrangements with relatives and non-relatives, and day care or early childhood programs, whether or not there is a charge or fee, but not occasional baby-sitting.
PROGRAMMER INSTRUCTION:
IF CHILDCARE COMPLETED DURING PREVIOUS INTERVIEW AND VALID RESPONSE PROVIDED, GO TO CHILDCARE_CHANGE.
OTHERWISE, GO TO CHILDCARE.
CC003/(CHILDCARE_CHANGE). Has there been a change in {C_FNAME/ the child}’s childcare arrangements in the past six months?
YES 1
NO 2 (TIME_STAMP_CC_ET)
REFUSED -1 (TIME_STAMP_CC_ET)
DON’T KNOW -2 (TIME_STAMP_CC_ET)
CC005/(CHILDCARE). Does {C_FNAME/the child} currently receive any regularly scheduled care from someone other than a parent or guardian, for example from relatives, non-relatives, or a child care program?
YES 1
NO 2 (TIME_STAMP_CC_ET)
REFUSED -1 (TIME_STAMP_CC_ET)
DON’T KNOW -2 (TIME_STAMP_CC_ET)
CC008/(FAMILY_CARE). Does {C_FNAME/the child} receive any care from relatives, for example, from grandparents, brothers or sisters, or any other relatives. This includes all regularly scheduled care arrangements with relatives that happen at least weekly, but does not include occasional baby-sitting.
YES 1
NO 2 (CC014)
REFUSED -1 (CC014)
DON’T KNOW -2 (CC014)
CC011/(FAMILY_CARE_HRS). Approximately how many total hours each week does {C_FNAME/the child} receive care from relatives?
|___|___|
NUMBER OF HOURS PER WEEK
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
INCLUDE SOFT EDIT IF RESPONSE EXCEEDS 50 HOURS PER WEEK.
CC014.Now I’d like to ask you about any regularly scheduled care {C_FNAME/the child} receives from someone not related to {him/her}, either in your home or someone else’s home. This includes all regularly scheduled care arrangements with non-relatives that happen at least weekly, including home child care providers, regularly scheduled sitter arrangements, or neighbors. This does not include day care centers, early childhood programs, or occasional babysitting.
CC015/(HOMECARE). Does {C_FNAME/the child} receive any regularly scheduled care either in your home or someone else’s home from someone not related to {him/her}?
INTERVIEWER INSTRUCTIONS:
IF NECESSARY READ “This includes arrangements with non-relatives including home child care providers, regularly scheduled sitter arrangements, or neighbors. This does not include day care centers, early childhood programs, or occasional babysitting.”
YES 1
NO 2 (CC023)
REFUSED -1 (CC023)
DON’TKNOW -2 (CC023)
CC018/(HOMECARE_HRS). Approximately how many total hours each week does {C_FNAME/the child} receive care in a home from non-relatives?
|___|___|
NUMBER OF HOURS PER WEEK
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
INCLUDE SOFT EDIT IF RESPONSE EXCEEDS 50 HOURS PER WEEK.
CC023. Now I want to ask you about child care centers {C_FNAME/the child} may attend on a regular basis. Such centers include day care centers, early learning centers, nursery schools, and preschools.
CC024/(DAYCARE).Does {C_FNAME/the child} receive any care in child care centers? Such centers include day care centers, early learning centers, nursery schools, and preschools.
YES 1
NO 2 (TIME_STAMP_CC_ET)
REFUSED -1 (TIME_STAMP_CC_ET)
DON’T KNOW -2 (TIME_STAMP_CC_ET)
CC025/(CHILDCARE_NUMBER). How many different day care centers, nursery schools, preschools, or pre-kindergartens programs does {C_FNAME/the child} currently go to?
|___|___|
NUMBER OF CHILDCARE PROVIDERS
REFUSED -1 (DAYCARE_HRS)
DON’T KNOW -2 (DAYCARE_HRS)
PROGRAMMER INSTRUCTION:
INCLUDE SOFT EDIT IF RESPONSE EXCEEDS 5 DAYCARE PROVIDERS.
CC026/(CHILDCARE_TYPE). {Let’s talk about the center, school, or program where {C_FNAME/the child} spends the most time.} Would you call the program…
A day care center, 1 (CHILDCARE_ADDRESS)
A nursery school, 2 (CHILDCARE_ADDRESS)
A preschool, 3 (CHILDCARE_ADDRESS)
A pre-kindergarten, 4 (CHILDCARE_ADDRESS)
A kindergarten, or 5 (CHILDCARE_ADDRESS)
Some other place? -5
REFUSED -1 (CHILDCARE_ADDRESS)
DON’T KNOW -2 (CHILDCARE_ADDRESS)
PROGRAMMER INSTRUCTION:
IF CHILDCARE_NUMBER > 1, DISPLAY BRACKETED SENTENCE.
CC027/(CHILDCARE_TYPE_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
CC030/(CHILDCARE_ADDRESS). What is the address of the center, school, or program {where {C_FNAME/the child} spends the most time}?
__________________________________________________
ADDRESS 1 - STREET/PO BOX (C_ADDRESS_1)
REFUSED -1
DON’T KNOW -2
ADDRESS 2 (C_ADDRESS_2)
REFUSED -1
DON’T KNOW -2
UNIT (C_UNIT)
REFUSED -1
DON’T KNOW -2
CITY (C_CITY)
REFUSED -1
DON’T KNOW -2
|___|___|
STATE (C_STATE)
REFUSED -1
DON’T KNOW -2
|___|___|___|___|___| - |___|___|___|___|
ZIP CODE ZIP+4 (C_ZIP) (C_ZIP4)
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
IF CHILDCARE_NUMBER = 2, 3, OR 4, DISPLAY BRACKETED PHRASE.
CC035/(DAYCARE_HRS). Approximately how many total hours each week does {C_FNAME/the child} receive care in child care centers?
|___|___|
NUMBER OF HOURS PER WEEK
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
INCLUDE SOFT EDIT IF RESPONSE EXCEEDS 50 HOURS PER WEEK.
(TIME_STAMP_CC_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
VIEWING OF MEDIA/READING BOOKS
(TIME_STAMP_MDA_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
MDA001. Now I would like to ask you a few questions about the amount of time {C_FNAME/the child} spends watching TV or videos and reading books.
INTERVIEWER INSTRUCTION:
IF NECESSARY, REMIND THE PARENT/CAREGIVER THAT THE RESPONSES TO THIS SECTION SHOULD BE IN REFERENCE TO THE CHILD’S PRIMARY RESIDENCE, THE PLACE WHERE THE CHILD SPENDS MOST OF HIS OR HER TIME.
MDA002/(TIME_TV). On a typical day, how much time does {C_FNAME/the child} spend watching television or videos? By watching, we mean that your child was in a place where {he/she} could see a television or other media that was on.
INTERVIEWER INSTRUCTION:
ENTER HOURS AND MINUTES FOR A TYPICAL DAY.
|___|___| |___|___|
HOURS MINUTES
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
HARD EDIT: INCLUDE HARD EDIT IF HOURS OR MINUTES ARE NOT TWO DIGITS. (FILL THE SPACE WITH 0 AS NECESSARY).
HARD EDIT: INCLUDE HARD EDIT IF MINUTES ARE NOT BETWEEN 00 AND 59.
HARD EDIT: INCLUDE HARD EDIT IF HOURS ARE NOT BETWEEN 00 AND 24.
MDA002A/(TIME_MEDIA). On a typical day, how much time does {C_FNAME/the child} spend playing games displayed on media such as television, desktop computers, laptops, portable DVD players, iPads, or smartphones?
INTERVIEWER INSTRUCTION:
ENTER HOURS AND MINUTES FOR A TYPICAL DAY.
|___|___| |___|___|
HOURS MINUTES
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
HARD EDIT: INCLUDE HARD EDIT IF HOURS OR MINUTES ARE NOT TWO DIGITS. (FILL THE SPACE WITH 0 AS NECESSARY).
HARD EDIT: INCLUDE HARD EDIT IF MINUTES ARE NOT BETWEEN 00 AND 59.
HARD EDIT: INCLUDE HARD EDIT IF HOURS ARE NOT BETWEEN 00 AND 24.
MDA003/(FREQ_BOOKS). On average, how many days per week do you or someone else read or look at books with the child?
|___|
DAYS
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
HARD EDIT: INCLUDE HARD EDIT IF DAYS ARE NOT BETWEEN 0 AND 7.
MDA004/(TV_ROOM). Is there a TV in {C_FNAME/the child}’s bedroom, even if it doesn’t get any channels?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MDA004A/(MEDIA_ROOM). Are there any desktop computers, laptops, portable DVD players, IPads, or smartphones in {C_FNAME/the child}’s bedroom?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MDA005/(INTERNET_ACCESS). Does {C_FNAME/the child}’s {primary} residence have internet access?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
DISPLAY “primary” IF CHILD_TIME = 2, -,1, OR -1.
(TIME_STAMP_MDA_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
SLEEP
(TIME_STAMP_SL_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
SL001. Now I would like to ask you a few questions about {C_FNAME/the child}’s sleeping habits. When responding to the questions in this section, please think about the responses in relation to {C_FNAME/the child}’s primary address or the place where {he/she} spends most of the time.
INTERVIEWER INSTRUCTION:
IF NECESSARY, REMIND THE PARENT/CAREGIVER THAT THE RESPONSES TO THIS SECTION SHOULD BE IN REFERENCE TO THE CHILD’S PRIMARY RESIDENCE, THE PLACE WHERE THE CHILD SPENDS MOST OF HIS OR HER TIME.
SL002/(SLEEP_ROOM). In which room does the child sleep?
In {his/her} own room on {his/her own}, 1 (SLEEP_HRS_DAY)
In a room with other children, or 2 (SLEEP_HRS_DAY)
In your bedroom? 3 (SLEEP_HRS_DAY)
OTHER -5
REFUSED -1 (SLEEP_HRS_DAY)
DON’T KNOW -2 (SLEEP_HRS_DAY)
SL003/(SLEEP_ROOM _OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
SL014/(SLEEP_HRS_DAY). Approximately how many hours does {C_FNAME/the child} sleep during the day?
INTERVIEWER INSTRUCTION:
IF NONE, ENTER “00”.
|___|___|
HOURS
REFUSED -1
DON’T KNOW -2
SL016/(SLEEP_HRS_NIGHT). Approximately how many hours does {C_FNAME/the child} sleep at night?
|___|___|
HOURS
REFUSED -1
DON’T KNOW -2
SL018/(SLEEP_TIME_NIGHT)/(SLEEP_TIME_NIGHT_UNIT). On a normal day, what time in the evening does {C_FNAME/the child} go to sleep?
INTERVIEWER INSTRUCTION:
ENTER TIME IN HOURS AND MINUTES. THEN SELECT “AM” OR “PM”.
|___|___|:|___|___|
TIME
AM 1
PM 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
HARD EDIT: INCLUDE HARD EDIT IF HOURS OR MINUTES ARE NOT TWO DIGITS. (FILL THE SPACE WITH 0 AS NECESSARY).
HARD EDIT: INCLUDE HARD EDIT IF HOUR IS NOT BETWEEN 01 AND 12.
HARD EDIT: INCLUDE HARD EDIT IF MINUTES ARE NOT BETWEEN 00 AND 59.
SL020/(SLEEP_TIME_WAKE)/(SLEEP_TIME_WAKE_UNIT). On a normal day, what time does {C_FNAME/the child} wake up in the morning?
INTERVIEWER INSTRUCTION:
ENTER TIME IN HOURS AND MINUTES. THEN SELECT “AM” OR “PM”.
|___|___|:|___|___|
TIME
REFUSED -1
DON’T KNOW -2
AM 1
PM 2
PROGRAMMER INSTRUCTIONS:
HARD EDIT: INCLUDE HARD EDIT IF HOURS OR MINUTES ARE NOT TWO DIGITS. (FILL THE SPACE WITH 0 AS NECESSARY).
HARD EDIT: INCLUDE HARD EDIT IF HOUR IS NOT BETWEEN 01 AND 12.
HARD EDIT: INCLUDE HARD EDIT IF MINUTES ARE NOT BETWEEN 00 AND 59.
SL022/(SLEEP_DIFFICULT). How often is {C_FNAME/the child} difficult when {he/she} is put to bed?
Most of the time, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED -1
DON’T KNOW -2
SL024/(SLEEP_THROUGH). How often does {C_FNAME/the child} wake at night?
Never, 1
Occasionally, 2
Most nights, 3
Once per night, or 4
More than once per night? 5
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_SL_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
HOUSING CHARACTERISTICS
(TIME_STAMP_HCH_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
HCH001. We would now like to ask you some questions about {C_FNAME/the child}’s {home/primary residence}.
PROGRAMMER INSTRUCTIONS:
IF CHILD_TIME = 2, -1, OR -2, DISPLAY “primary residence”.
OTHERWISE, IF CHILD_TIME = 1, DISPLAY “home”.
IF (LENGTH_RESIDE)/(LENGTH_RESIDE_UNIT) COLLECTED DURING PREVIOUS EVENT AND VALID RESPONSE PROVIDED, GO TO RECENT_MOVE.
OTHERWISE, GO TO (LENGTH_RESIDE)/(LENGTH_RESIDE_UNIT).
HCH010/(RECENT_MOVE). Have you moved or changed your housing situation since we contacted you last?
YES 1
NO 2 (WATER)
REFUSED -1 (WATER)
DON’T KNOW -2 (WATER)
HCH020/(LENGTH_RESIDE)/(LENGTH_RESIDE_UNIT). How long has {C_FNAME/the child} lived in this home?
|___|___|
NUMBER
REFUSED -1
DON’T KNOW -2
WEEKS 1
MONTHS 2
YEARS 3
PROGRAMMER INSTRUCTION:
INCLUDE HARD EDIT IF RECENT_MOVE = 1 AND LENGTH_RESIDE > 28 WEEKS OR 7 MONTHS.
HCH040/(AGE_HOME). Can you tell us when {C_FNAME/the child}’s home or building was built? Was it between…
2001 to present, 1
1981 to 2000, 2
1961 to 1980, 3
1941 to 1960, or 4
1940 or before? 5
REFUSED -1
DON’T KNOW -2
HCH045/(BUILD_TYPE). How would you describe the building in which you live:
Single family home 1
Apartment Building or other multifamily building 2
Townhouse 3
Duplex, Triplex, Quadplex 4
Trailer 5
Group home, dormitory, etc. 6
Hotel /Motel 7
REFUSED -1
DON’T KNOW -2
HCH050/(HOME_SF). About how many square feet is {C_FNAME/the child}’s home or apartment?
Less than 500, 1 (HOME_GARAGE)
500 – 999, 2 (HOME_GARAGE)
1000 – 1999, 3 (HOME_GARAGE)
2000 – 2999, or 4 (HOME_GARAGE)
3000 square feet or more? 5 (HOME_GARAGE)
REFUSED -1
DON’T KNOW -2
HCH051/(HOME_BEDROOMS). How many bedrooms are in {C_FNAME/the child}’s home? Include any room that was planned as a bedroom even if it is being used for another purpose, for example as an office.
|___|___|
NUMBER OF BEDROOMS
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
INCLUDE SOFT EDIT IF HOME_BEDROOMS > 4.
HCH052 (HOME_STORIES). How many stories are in the house, including the basement?
INTERVIEWER INSTRUCTION:
IF SPLIT LEVEL OR PARTIAL BASEMENT, INCLUDE AND COUNT THE GREATEST NUMBER OF STORIES ON TOP OF EACH OTHER.
|___|___|
NUMBER OF STORIES
REFUSED -1
DON’T KNOW -2
HCH060/(HOME_GARAGE). Is there a garage attached to {C_FNAME/the child}’s home?
YES 1
NO 2 (WATER)
REFUSED -1 (WATER)
DON’T KNOW -2 (WATER)
HCH061/(GARAGE_WARMUP). On a cold day, how long do you normally let your vehicle warm up in the garage?
Less than 1 minute, 1
1-2 min, 2
3-5 min,. 3
More than 5 minutes, or 4
Never? 5
VEHICLE NOT KEPT IN GARAGE -7
REFUSED -1
DON’T KNOW -2
HCH062/(WATER).In the past six months, have you seen any water damage inside {C_FNAME/the child}’s home?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCH065/(MOLD). In the past six months, have you seen any mold or mildew on walls or other surfaces other than the shower or bathtub, inside {C_FNAME/the child}’s home?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCH070/(RENOVATE). In the past 6 months, have any additions been built onto {C_FNAME/the child}’s home to make it bigger, or renovations or other construction been done in {C_FNAME/the child}’s home? Include only major projects. Do not count smaller projects such as painting, wallpapering, refinishing floors, or installing new carpet.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCH071/(RENOVATE_ROOM). Which rooms were renovated?
INTERVIEWER INSTRUCTIONS:
PROBE: Any others?
SELECT ALL THAT APPLY
KITCHEN 1
LIVING ROOM 2
HALL/LANDING 3
{C_FNAME/the child}’s BEDROOM 4
OTHER BEDROOM 5
BATHROOM/TOILET 6
BASEMENT 7
OTHER -5
REFUSED -1 (DECORATE)
DON’T KNOW -2 (DECORATE)
PROGRAMMER INSTRUCTIONS:
IF RENOVATE_ROOM CODED WITH ANY COMBINATION OF VALUES 1 – 7, THEN GO TO DECORATE.
IF RENOVATE_ROOM CODED -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, GO TO RENOVATE_ROOM_OTH.
IF RENOVATE_ROOM CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO DECORATE.
HCH072/(RENOVATE_ROOM_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT FREE TEXT TO 255 CHARACTERS.
HCH075/(DECORATE). In the past 6 months, were any smaller projects done on {C_FNAME/the child}’s home, such as painting, wallpapering, refinishing floors, or installing new carpet?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCH080/(CARPET). About what proportion of rooms in {C_FNAME/the child}’s home are carpeted rooms or have room size rugs? By room size, I mean a rug that covers at least half of the floor in that room.
More than half, 1
About half, or 2
Less than half 3
REFUSED -1
DON’T KNOW -2
HCH090/(MAIN_HEAT). What is the main heating source in {C_FNAME/the child}’s home? {We have a show card we can provide you to help with your answer.}
INTERVIEWER INSTRUCTIONS:
IF USING SHOWCARDS, REFER PARENT/CAREGIVER TO SHOWCARD HC001.
OTHERWISE, READ RESPONSE CATEGORIES TO PARENT/CAREGIVER.
GAS-HEATED FORCED AIR (VENTS) 1 (OTHER_HEAT)
ELECTRIC-HEATED FORCED AIR (VENTS)
(INCLUDES HEAT PUMPS) 2 (OTHER_HEAT)
Oil/KEROSENE-fired furnace 3 (OTHER_HEAT
ELECTRIC BASEBOARD HEAT 4 (OTHER_HEAT)
RADIATORS (STEAM OR HOT WATER) 5 (OTHER_HEAT)
GAS STOVE/FIREPLACE/WALL FURNACE 6 (OTHER_HEAT)
WOOD BURNING STOVE/FIREPLACE 7 (OTHER_HEAT)
KEROSENE SPACE HEATER 8 (OTHER_HEAT)
RADIANT/CERAMIC HEATER 9 (OTHER_HEAT)
ELECTRIC SPACE HEATER 10 (OTHER_HEAT)
SOME OTHER SOURCE -5
NO SOURCE OF HEAT -7 (OTHER_HEAT)
REFUSED -1 (COOL)
DON’T KNOW -2 (COOL)
PROGRAMMER INSTRUCTIONS:
IF USING SHOWCARDS, DISPLAY “We have a show card we can provide you to help with your answer” AND DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS.
OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE.
HCH090A/(MAIN_HEAT_OTH).
SPECIFY _________________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEX TO 255 CHARACTERS.
HCH091/(OTHER_HEAT). Are there any other sources used in {C_FNAME/the child}’s home for heat? {You may refer to the card for your answer(s).}
INTERVIEWER INSTRUCTIONS:
SELECT ALL THAT APPLY.
Probe: “Any others?”
IF USING SHOWCARDS, REFER PARENT/CAREGIVER TO SHOWCARD HC001.
OTHERWISE, READ RESPONSE CATEGORIES TO PARENT/CAREGIVER.
GAS-HEATED FORCED AIR (VENTS) 1 (COOL)
ELECTRIC-HEATED FORCED AIR (VENTS)
(INCLUDES HEAT PUMPS) 2 (COOL)
Oil/KEROSENE fired furnace 3 (COOL)
ELECTRIC BASEBOARD HEAT 4 (COOL)
RADIATORS (STEAM OR HOT WATER) 5 (COOL)
GAS STOVE/FIREPLACE/WALL FURNACE 6 (COOL)
WOOD BURNING STOVE/FIREPLACE 7 (COOL)
KEROSENE SPACE HEATER 8 (COOL)
RADIANT/CERAMIC HEATER 9 (COOL)
ELECTRIC SPACE HEATER 10 (COOL)
SOME OTHER SOURCE -5
NO SOURCE OF HEAT -7 (COOL)
REFUSED -1 (COOL)
DON’T KNOW -2 (COOL)
PROGRAMMER INSTRUCTIONS:
IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS AND DISPLAY “You may refer to the card for your answer(s).”
OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE.
IF OTHER_HEAT = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES.
HCH092/(OTHER_HEAT_OTH).
SPECIFY _________________________________
REFUSED -1
DON’T KNOW -2
HCH100/(COOL). Which of these cooling systems are regularly used in {C_FNAME/the child}’s home?
INTERVIEWER INSTRUCTIONS:
SELECT ALL THAT APPLY.
Probe: “Any others?”
Window or wall air conditioners, 1
Central air conditioning, 2
Evaporative cooler (swamp cooler), or 3
Some other cooling system? 4
NO COOLING OR AIR CONDITIONING
REGULARLY USED -7
REFUSED -1
DON’T KNOW -2
HCH110/(OPEN_WINDOW). In the past six months, approximately how many hours a day were the windows or doors open in {C_FNAME/the child}’s home? Was it…
Less than 1 hour per day, 1
1-3 hours per day, 2
4-12 hours per day, 3
More than 12 hours per day, or 4
Not at all? 5
REFUSED -1
DON’T KNOW -2
HCH120/(DEHUMIDIFIER). In the past six months, has a dehumidifier been used in {C_FNAME/the child}’s home?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCH130/(AIR_CLEANING). What type of air cleaning device(s) is used in {C_FNAME/the child}’s home? {You may refer to the card for your answer(s).}
INTERVIEWER INSTRUCTIONS:
SELECT ALL THAT APPLY.
Probe: “Any others?”
IF USING SHOWCARDS, REFER PARENT/CAREGIVER TO SHOWCARD HC002.
OTHERWISE, READ RESPONSE CATEGORIES TO PARENT/CAREGIVER.
FILTER 1 (AIR_FILTER)
Electrostatic precipitator 2 (AIR_FILTER)
Ozone generator 3 (AIR_FILTER)
other -5
NO AIR CLEANING DEVICE USED IN HOME -7 (AIR_FILTER)
REFUSED -1 (AIR_FILTER)
DON’T KNOW -2 (AIR_FILTER)
PROGRAMMER INSTRUCTIONS:
IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS AND DISPLAY “You may refer to the card for your answer(s).”
OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE.
IF AIR_CLEANING = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES.
HCH140/(AIR_CLEANING_OTH).
SPECIFY _________________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT FREE TEXT TO 255 CHARACTERS.
HCH141/(AIR_FILTER). Does your furnace or air conditioning system use a special HEPA (High Efficiency Particulate Air) or other type of allergy filter to filter the air?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCH145/(FRESHENERS). In the past six months, have scented products such as plug-ins, gels or solids, or sprays been used in {C_FNAME/the child}’s home?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCH147/(CANDLES). In the past six months have candles, scented candles or incense been used?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCH148/(WELL_WATER). Is there tap water in your home from a private well?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCH150/(WATER_DRINK). What water source in {C_FNAME/the child}’s home is used most of the time for drinking?
Tap water, 1 (WATER_COOK)
Filtered tap water, 2 (WATER_COOK)
Bottled water, or 3 (WATER_COOK)
Some other source? -5
REFUSED -1 (WATER_COOK)
DON’T KNOW -2 (WATER_COOK)
HCH155/(WATER_DRINK_OTH).
SPECIFY _________________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT FREE TEXT TO 255 CHARACTERS.
HCH160/(WATER_COOK). What water source in {C_FNAME/the child}’s home is used most of the time for cooking?
Tap water, 1 (NOISE_OUTSIDE)
Filtered tap water, 2 (NOISE_OUTSIDE)
Bottled water, or 3 (NOISE_OUTSIDE)
Some other source? -5
REFUSED -1 (NOISE_OUTSIDE)
DON’T KNOW -2 (NOISE_OUTSIDE)
HCH165/(WATER_COOK_OTH).
SPECIFY _________________________________
REFUSED -1
DON’T KNOW -2
HCH180/(NOISE_OUTSIDE). When you are here at home, how much does noise from outdoors bother, disturb, or annoy you?
Extremely, 1
Very, 2
Moderately, 3
Slightly, or 4
Not at all? 5
REFUSED -1
DON’T KNOW -2
HCH190/(NOISE_INSIDE). When you are here at home, how much does noise from indoors bother, disturb, or annoy you?
Extremely, 1
Very, 2
Moderately, 3
Slightly, or 4
Not at all? 5
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_HCH_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
PESTICIDE APPLICATIONS IN PAST SIX MONTHS
(TIME_STAMP_PA_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
PA001. I would now like to ask about products that may have been used in the home or yard to control for mice, rats, ants, termites, cockroaches, bees, wasps, moths, or other insects and rodents during the past 6 months. When responding to the questions in this section, please think about {C_FNAME/the child}’s primary address or the place where {he/she} lives most of the time.
INTERVIEWER INSTRUCTION:
IF NECESSARY, REMIND THE PARENT/CAREGIVER THAT THE RESPONSES TO THIS SECTION SHOULD BE IN REFERENCE TO THE CHILD’S PRIMARY RESIDENCE, THE PLACE WHERE THE CHILD SPENDS MOST OF HIS OR HER TIME.
PA003/(WHEN_PEST). When were any pesticides last used inside or outside the residence to control for pests? Was it:
Within the last month, 1
1-3 months ago, 2
4-6 months ago,or 3
Not within the past 6 months? 4 (TIME_STAMP_PA_ET)
REFUSED -1 (TIME_STAMP_PA_ET)
DON’T KNOW .. -2 (TIME_STAMP_PA_ET)
PA004/(PEST_TYPE). What type of pests did you treat?
INTERVIEWER INSTRUCTION:
SELECT ALL THAT APPLY
PROBE: “Any others?”
Pests of plants and trees such as, gypsie moths,
japanese beetles, aphids, etc, 1
Flying insects such as, flies, mosquitoes, bees,
wasps, hornets, moths, 2
Crawling insects such as, ants, roaches, silverfish,
spiders, 3
Rodents such as, mice, rats, squirrels, 4
Fleas and ticks, or 5
Termites and carpenter ants? 6
REFUSED .-1 (TIME_STAMP_PA_ET)
DON’T KNOW -2 (TIME_STAMP_PA_ET)
PROGRAMMER INSTRUCTIONS:
IF PEST_TYPE = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES.
LOOP THROUGH WHO_APPLY, WHO_APPLY_OTH (IF WHO_APPLY = -5), HOW_APPLY, AND APPLY_AREAS FOR EACH PEST_TYPE UNTIL NUMBER OF LOOPS = NUMBER OF RESPONSES SELECTED IN PEST_TYPE.
THEN, GO TO TIME_STAMP_PA_ET.
PA005/(WHO_APPLY). Who treated for {PEST_TYPE}?
You, 1 (HOW_APP)
A friend or family member, 2 (HOW_APP)
Building maintenance, or 3 (HOW_APP)
A professional exterminator? 4 (HOW_APP)
OTHER -5
REFUSED -1 (HOW_APP)
DON’T KNOW -2 (HOW_APP)
PROGRAMMER INSTRUCTIONS:
DISPLAY PEST_TYPE FOR EACH PEST_TYPE:
IF PEST_TYPE = 1, DISPLAY “Pests of plants and trees such as, gypsie moths, Japanese beetles, aphids, bees, etc”.
IF PEST_TYPE = 2, DISPLAY “Flying insects such as, flies, mosquitoes, bees, wasps, hornets, moths”.
IF PEST_TYPE = 3, DISPLAY “Crawling insects such as, ants, roaches, silverfish, spiders”.
IF PEST_TYPE = 4, DISPLAY “Rodents such as, mice, rats, squirrels”.
IF PEST_TYPE = 5, DISPLAY “Fleas and ticks”.
IF PEST_TYPE = 6, DISPLAY “Termites and carpenter ants”.
PA005A/(WHO_APPLY_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
PA006/(HOW_APPLY). When you treated for {PEST_TYPE}, how was the product applied?
INTERVIEWER INSTRUCTIONS:
SELECT ALL THAT APPLY.
RECORD HOW PRODUCT WAS APPLIED WITHOUT ASKING IF PRODUCT CAN BE PROVIDED FOR INTERVIEW.
Spray, 1
Bomb, 2
Powder, 3
Strip, 4
Moth balls, 5
Foam, or 6
Other? -5
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
DISPLAY PEST_TYPE FOR EACH PEST_TYPE:
IF PEST_TYPE = 1, DISPLAY “Pests of plants and trees such as, gypsie moths, Japanese beetles, aphids, bees, etc”.
IF PEST_TYPE = 2, DISPLAY “Flying insects such as, flies, mosquitoes, bees, wasps, hornets, moths”.
IF PEST_TYPE = 3, DISPLAY “Crawling insects such as, ants, roaches, silverfish, spiders”.
IF PEST_TYPE = 4, DISPLAY “Rodents such as, mice, rats, squirrels”.
IF PEST_TYPE = 5, DISPLAY “Fleas and ticks”.
IF PEST_TYPE = 6, DISPLAY “Termites and carpenter ants”.
IF HOW_APP = ANY COMBINATION OF VALUES 1 –6, GO TO APPLY_AREAS.
IF HOW_APP = -5, OR ANY COMBINATION OF VALUES 1 – 6 AND -5, GO TO HOW_APP_OTH.
IF HOW_APP = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TOAPPLY_AREAS.
PA010/(APPLY_AREAS). Where did you treat for the {PEST_TYPE}? Was it…
Inside your home, 1
Outside your home, or 2
Both inside and outside your home? 3
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
DISPLAY PEST_TYPE FOR EACH PEST:
IF PEST_TYPE = 1, DISPLAY “Pests of plants and trees such as, gypsie moths, Japanese beetles, aphids, bees, etc”.
IF PEST_TYPE = 2, DISPLAY “Flying insects such as, flies, mosquitoes, bees, wasps, hornets, moths”.
IF PEST_TYPE = 3, DISPLAY “Crawling insects such as, ants, roaches, silverfish, spiders”.
IF PEST_TYPE = 4, DISPLAY “Rodents such as, mice, rats, squirrels”.
IF PEST_TYPE = 5, DISPLAY “Fleas and ticks”.
IF PEST_TYPE = 6, DISPLAY “Termites and carpenter ants”.
(TIME_STAMP_PA_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
SMOKING IN HOME
(TIME_STAMP_SM_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
SM001. Now I would like to ask you a few questions about smoking in {C_FNAME/the child}’s home. When responding to the questions in this section, please think about {C_FNAME/the child}’s primary address or the place where {he/she} spends most of the time.
INTERVIEWER INSTRUCTION:
IF NECESSARY, REMIND THE PARENT/CAREGIVER THAT THE RESPONSES TO THIS SECTION SHOULD BE IN REFERENCE TO THE CHILD’S PRIMARY RESIDENCE, THE PLACE WHERE THE CHILD SPENDS MOST OF HIS OR HER TIME.
SM007/(SMOKE). Currently, do you or others in the child’s household smoke cigarettes, cigarillos, cigars, pipes or other tobacco products?
YES 1
NO 2 (SMOKE_OTHER)
REFUSED -1 (SMOKE_OTHER)
DON’T KNOW -2 (SMOKE_OTHER)
SM010/(SMOKE_HOME). Do you or anyone else smoke inside the child’s home?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
SM011/(SMOKE_RULES). Which of the following statements best describes smoking inside the child’s home now?
No one is allowed to smoke anywhere inside the child’s home, 1
Smoking is allowed at some times or in some rooms in the child’s home, or 2
Smoking is allowed anywhere inside the child’s home? 3
REFUSED -1
DON’T KNOW -2
SM012/(SMOKE_OTHER). Other than in {C_FNAME’s/the child’s} home, is {he/she} around tobacco smoke? Please consider all the places your child is during the day, including at childcare, while traveling in a vehicle, or some other place.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_SM_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
PETS
(TIME_STAMP_PT_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
PT001. Now I would like to ask you a few questions about any pets in the home. When responding to the questions in this section, please think about {C_FNAME/the child}’s primary address or the place where {he/she} spends most of the time.
INTERVIEWER INSTRUCTION:
IF NECESSARY, REMIND THE PARENT/CAREGIVER THAT THE RESPONSES TO THIS SECTION SHOULD BE IN REFERENCE TO THE CHILD’S PRIMARY RESIDENCE, THE PLACE WHERE THE CHILD SPENDS MOST OF HIS OR HER TIME.
PROGRAMMER INSTRUCTIONS:
IF PETS_HOME COMPLETED DURING PREVIOUS INTERVIEW AND VALID RESPONSE PROVIDED, GO TO CHANGE_PETS.
OTHERWISE, GO TO PETS_HOME.
PT002/(CHANGE_PETS). Has there been a change in the number or type of pets in the home since the last interview on {DATE OF LAST INTERVIEW}?
YES 1
NO 2 (PET_MEDS)
REFUSED -1 (PET_MEDS)
DON’T KNOW -2 (PET_MEDS)
PROGRAMMER INSTRUCTION:
PRELOAD AND DISPLAY DATE OF LAST INTERVIEW.
PT003/(PETS_HOME). {Now I’d like to ask about any pets in the home.} Are there any pets that spend any time inside the home?
INTERVIEWER INSTRUCTIONS:
YOU MAY READ TO PARENT/CAREGIVER THIS MORE DETAILED EXPLANATION, AS NEEDED: “These pets include those that live indoors; pets that come indoors on a somewhat regular basis, such as an outside cat that comes inside during the winter; pets that spend more than 50 percent of their time indoors at this household, such as areas of the home where people spend time, not a garage or mudroom; and other people's pets that spend 50 percent of their time in your home. Do not include pets that have been inside only a handful of times, such as an outdoor pet that sneaks into the house; or agricultural animals that are pets, but do not come inside your home.
YES 1
NO 2 (TIME_STAMP_PT_ET)
REFUSED -1 (TIME_STAMP_PT_ET)
DON’T KNOW -2 (TIME_STAMP_PT_ET)
PROGRAMMER INSTRUCTION:
IF PETS_HOME COMPLETED DURING PREVIOUS INTERVIEW AND VALID RESPONSE PROVIDED, DISPLAY BRACKETED TEXT.
PT004/(PET_TYPE). What kind of pets are these?
INTERVIEWER INSTRUCTIONS:
IF USING SHOWCARDS, REFER PARENT/CAREGIVER TO SHOWCARD PT001.
OTHERWISE, READ RESPONSE CATEGORIES TO PARENT/CAREGIVER.
PROBE: Anything else?
SELECT ALL THAT APPLY.
DOG 1
CAT 2
SMALL MAMMAL, SUCH AS A RABBIT, GERBIL, HAMSTER,
GUINEA PIG, FERRET, OR MOUSE 3
BIRD 4
FISH OR REPTILE, SUCH AS A TURTLE,
SNAKE, OR LIZARD 5
OTHER -5
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS.
OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE.
PROGRAMMER INSTRUCTIONS:
IF PET_TYPE = ANY COMBINATION OF VALUES 1 – 5, GO TO PET_MEDS.
IF PET_TYPE = -5, OR ANY COMBINATION OF VALUES 1 – 5 AND -5, GO TO PET_TYPE_OTH.
IF PET_TYPE = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO PET_MEDS.
PT004A/(PET_TYPE_OTH). What kind of pets are these?
INTERVIEWER INSTRUCTION:
RECORD MORE THAN ONE TYPE OF PET SEPARATED BY A COMMA OR “AND.”
SPECIFY: ________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
PT009/(PET_MEDS). Are any products ever used on your pets to control fleas, ticks, or mites? Please include flea collars, powders, shampoos, or other flea, tick and mite control products, but do not include pills given to your pet to control for fleas or other insects.
YES 1
NO 2 (PET_ROOM_SLEEP)
REFUSED -1 (PET_ROOM_SLEEP)
DON’T KNOW -2 (PET_ROOM_SLEEP)
PT011/(PET_MED_TIME). When were any of these last used on any of the pets?
Within the last month, 1
1-3 months ago, 2
4-6 months ago, or 3
More than 6 months ago? 4
REFUSED -1
DON’T KNOW -2
PT013/(PET_ROOM_SLEEP). Do any of the pets go in the room where the child sleeps most of the time?
YES 1
NO 2 (LIVESTOCK)
REFUSED -1 (LIVESTOCK)
DON’T KNOW -2 (LIVESTOCK)
PT013A/(PET_BEDDING). Do any of the pets sleep on the same bedding as the child?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PT014/(LIVESTOCK). Now I’d like to ask about any other animals located at {C_FNAME/the child}’s primary residence. Are there any poultry, livestock, or farm animals that live outdoors or in outbuildings on the property?
YES 1
NO 2 (TIME_STAMP_PT_ET)
REFUSED -1 (TIME_STAMP_PT_ET)
DON’T KNOW -2 (TIME_STAMP_PT_ET)
PV15/(LIVESTOCK_TYPE). What types of animals are these? Please include all poultry, livestock, and farm animals that live outdoors as well as those that live in outbuildings.
IF USING SHOWCARDS, REFER PARENT/CAREGIVER TO SHOWCARD PT002.
OTHERWISE, READ RESPONSE CATEGORIES TO PARENT/CAREGIVER.
PROBE: Anything else?
SELECT ALL THAT APPLY.
CHICKENS 1
COWS 2
DUCKS 3
GEESE 4
GOATS 5
GUINEAFOWL 6
HENS 7
HORSES 8
MULES 9
PEAFOWL 10
PIGS 11
PIGEONS 12
RABBITS 13
ROOSTERS 14
SHEEP 15
TURKEYS 16
OTHER -5
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS.
OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE.
IF LIVESTOCK_TYPE = ANY COMBINATION OF VALUES 1 – 5, GO TO TIME_STAMP_PT_ET.
IF LIVESTOCK_TYPE = -5, OR ANY COMBINATION OF VALUES 1 – 5 AND -5, GO TO LIVESTOCK_TYPE_OTH.
IF LIVESTOCK_TYPE = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO TIME_STAMP_PT_ET.
PT004A/(LIVESTOCK_TYPE_OTH). What kind of poultry, livestock, or farm animals are these?
INTERVIEWER INSTRUCTION:
RECORD MORE THAN ONE TYPE OF POULTRY, LIVESTOCK, OR FARM ANIMAL SEPARATED BY A COMMA OR “AND.”
SPECIFY: ________________________
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_PT_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
Neighborhood Characteristics
(36-MONTH OR AFTER EACH MOVE)
(TIME_STAMP_NC_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
PROGRAMMER INSTRUCTIONS:
IF RECENT_MOVE = 1 OR IF EVENT_TYPE = 36-MONTH, GO TO NC001.
OTHERWISE, GO TO TIME_STAMP_TR_ST.
NC001. Now I’d like to ask a few questions about your neighborhood.
NC004/(NEIGH_DEFN). When you are talking to someone about your neighborhood, what do you mean? Is it
The block or street you live on, 1
Several blocks or streets in each direction, 2
The area within a 15 minute walk from your house, 3
An area larger than a 15 minute walk from your house? 4
REFUSED -1
DON’T KNOW -2
NC006/(NEIGH_FAM). How many of your relatives or in-laws live in your neighborhood? Would you say …
None, 1
A few, 2
Many, or 3
Most? 4
REFUSED -1
DON’T KNOW -2
NC008/(NEIGH_FRIEND). How many of your friends live in your neighborhood? Would you say…
None, 1
A few, 2
Many, or 3
Most? 4
REFUSED -1
DON’T KNOW -2
NC010/(NEIGHBORS). About how many adults do you recognize or know by sight in this neighborhood? Would you say you recognize …
None, 1
A few, 2
Many, or 3
Most? 4
REFUSED -1
DON’T KNOW -2
NC012/(NEIGH_NUM_TALK). In the past 30 days, that is since {DATE 30 DAYS PRIOR TO INTERVIEW DATE}, how many of your neighbors have you talked with for 10 minutes or more? Would you say …
None, 1
1 or 2, 2
3 to 5, or 3
6 or more? 4
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
CALCULATE AND DISPLAY DATE 30 DAYS PRIOR TO INTERVIEW DATE.
NC014/(NEIGH_HELP). About how often do you and people in your neighborhood do favors for each other? By favors, we mean such things as watching each other’s children, helping with shopping, lending garden or house tools. Would you say …
Often, 1
Sometimes, 2
Rarely, or 3
Never? 4
REFUSED -1
DON’T KNOW -2
NC016/(NEIGH_TALK). How often do you and other people in your neighborhood visit in each other’s homes or speak with each other on the street? Would you say …
Often, 1
Sometimes, 2
Rarely, or 3
Never? 4
REFUSED -1
DON’T KNOW -2
NC018/(NEIGH_WATCH_1). If children were skipping school and hanging out, how likely is it that your neighbors would do something about it? Would you say it is …
Very Likely, 1
Likely, 2
Unlikely, or 3
Very Unlikely? 4
REFUSED -1
DON’T KNOW -2
NC020/(NEIGH_WATCH_2). If children were showing disrespect to an adult, how likely is it that your neighbors would do something about it? Would you say it is…
Very Likely, 1
Likely, 2
Unlikely, or 3
Very Unlikely? 4
REFUSED -1
DON’T KNOW -2
NC022. Please tell me if you agree or disagree with the following statements.
NC024/(NEIGH_CLOSE). This is a close-knit neighborhood. Would you say you….
Strongly agree, 1
Agree, 2
Disagree, or 3
Strongly disagree? 4
REFUSED -1
DON’T KNOW -2
NC026/(NEIGH_TRUST). People in this neighborhood can be trusted. Would you say you…
Strongly agree, 1
Agree, 2
Disagree, or 3
Strongly disagree? 4
REFUSED -1
DON’T KNOW -2
NC028/(NEIGH_SAFE_1). I feel safe walking in my neighborhood, day or night.
Strongly agree, 1
Agree, 2
Disagree, or 3
Strongly disagree? 4
REFUSED -1
DON’T KNOW -2
NC030/(NEIGH_SAFE_2). Violence is not a problem in my neighborhood.
Strongly agree, 1
Agree, 2
Disagree, or 3
Strongly disagree? 4
REFUSED -1
DON’T KNOW -2
NC032/(NEIGH_SAFE_3). My neighborhood is safe from crime.
Strongly agree, 1
Agree, 2
Disagree, 3
Strongly disagree? 4
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_NC_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
OCCUPATION
(ANNUAL BEGINNING AT 30 MONTH)
(TIME_STAMP_OCC_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
PROGRAMMER INSTRUCTIONS:
IF EVENT_TYPE = 30 MONTH OR LATER ANNUAL EVENT (E.G., 42 MONTH , 54-MONTH, ETC), GO TO OCC001.
OTHERWISE, GO TO TIME_STAMP_MC_ST.
OCC001. The next set of questions are about your experiences in the past year. First, I would like to ask about work as people’s work situation can change.
OCC005/(WORK_LAST_CONTACT). In the past year, have you been employed at a job or business?
YES 1
NO 2 (EDUC)
REFUSED -1 (EDUC)
DON’T KNOW -2 (EDUC)
OCC010/(WORK_CURRENTLY). Are you currently employed?
YES 1
NO 2 (EDUC)
REFUSED -1 (EDUC)
DON’T KNOW -2 (TIME_STAMP_ OCC_ET)
OCC015/(WORK_HRS). How many hours per week do you work?
|___|___|
HOURS
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF WORK_NAME COLLECTED DURING PREVIOUS INTERVIEW AND VALID RESPONSE PROVIDED, GO TO WORK_NAME_CONFIRM.
OTHERWISE, GO TO WORK_NAME.
OCC016/(WORK_NAME_CONFIRM). Let me confirm the name of the place where you work. I have it as {PARENT/CAREGIVER’S WORK PLACE NAME}. Is this correct?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTUCTIONS:
PRELOAD WORK NAME.
IF WORK_NAME_CONFIRM =1, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING WORK_NAME.
OTHERWISE, IF WORK_NAME_CONFIRM = - 2, -1, OR -2, GO TO WORK_NAME.
OCC017/(WORK_NAME). What is the name of the place where you work?
______________________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTUCTION:
LIMIT TEXT TO 255 CHARACTERS.
OCC018/(STREET_ADDRESS_VARIABLES). Let me confirm your work address. I have it as {PARENT/CAREGIVER’S WORK ADDRESS}/{What is your work address?}.
INTERVIEWER INSTRUCTION:
MAKE CORRECTIONS TO WORK ADDRESS AS NEEDED.
PROBE AND ENTER AS MUCH INFORMATION AS PARENT/CAREGIVER KNOWS.
__________________________________________________
(WORK_ADDRESS_1) ADDRESS 1 - STREET/PO BOX
REFUSED -1
DON’T KNOW -2
(WORK_ADDRESS_2) ADDRESS 2
REFUSED -1
DON’T KNOW -2
(WORK_UNIT) UNIT
REFUSED -1
DON’T KNOW -2
(WORK_CITY) CITY
REFUSED -1
DON’T KNOW -2
|___|___|
STATE (WORK_STATE)
REFUSED -1
DON’T KNOW -2
|___|___|___|___|___|-|___|___|___|___|
ZIP CODE ZIP+4(WORK_ZIP) (WORK_ZIP4)
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF WORK ADDRESS VARIABLES COLLECTED PREVIOUSLY FOR (R_FNAME)(R_MNAME)(R_LNAME) AND VALID WORK ADDRESS PROVIDED, PRELOAD VALID WORK ADDRESS FROM MOST RECENT INTERVIEW AND DISPLAY “Let me confirm your work address. I have it as {PARENT/CAREGIVER’S WORK ADDRESS}”.
OTHERWISE, IF WORK ADDRESS VARIABLES NOT COLLECTED PREVIOUSLY FOR (R_FNAME)(R_MNAME)(R_LNAME) OR VALID WORK ADDRESS IS NOT AVAILABLE, DISPLAY “What is your work address?”.
ALLOW INTERVIEWER TO MAKE CORRECTIONS OR ADD NEW WORK ADDRESS INFORMATION.
OCC020/(EDUC). What is the highest degree or level of school you have completed?
INTERVIEWER INSTRUCTIONS:
IF USING SHOWCARDS, REFER PARENT/CAREGIVER TO SHOWCARD OCC001.
OTHERWISE, READ RESPONSE CATEGORIES TO PARENT/CAREGIVER.
LESS THAN A HIGH SCHOOL DIPLOMA OR GED 1
HIGH SCHOOL DIPLOMA OR GED 2
SOME COLLEGE BUT NO DEGREE 3
ASSOCIATE DEGREE 4
BACHELOR’S DEGREE (FOR EXAMPLE, BA, BS) 5
POST GRADUATE DEGREE (FOR EXAMPLE, MASTERS OR DOCTORAL) 6
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS.
OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE.
OCC025/(SCHOOL_CURRENTLY). Are you currently attending or enrolled in any courses from a school, college, or university?
YES 1
NO 2 (TIME_STAMP_ OCC_ET)
REFUSED -1 (TIME_STAMP_ OCC_ET)
DON’T KNOW -2 (TIME_STAMP_ OCC_ET)
OCC030/(SCHOOL_FT). Are you currently taking courses full-time or part-time?
FULL TIME 1
PART TIME 2
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_OCC_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
INCOME
(ANNUAL BEGINNING AT 30 MONTH)
(TIME_STAMP_INC_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
PROGRAMMER INSTRUCTIONS:
IF EVENT_TYPE = 30 MONTH OR LATER ANNUAL EVENT (E.G., 42 MONTH, 54-MONTH, ETC), GO TO INC001.
OTHERWISE, GO TO TIME_STAMP_MC_ST.
INC001. Now I have a few questions about your household.
INC010/(HH_INC_NUM). Including yourself, how many adults contribute to your household income?
|___|___|
NUMBER
REFUSED -1
DON’T KNOW -2
INC020/(INC_TWO_CAT). 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…
INTERVIEWER INSTRUCTION:
READ IF NECESSARY: Total income means gross income – that is, income before taxes are taken out.
$25,000 or less, or 1
More than $25,000? 2
REFUSED -1 (HH_TYPE)
DON’T KNOW -2 (HH_TYPE)
INC030/(INC_13_CAT). Was it…
{$5,000 or less, 1}
{$5,001 to $10,000, 2}
{$10,001 to $15,000, 3}
{$15,001 to $20,000, or 4}
{$20,001 to $25,000? 5}
{$25,001 to $30,000, 6}
{$30,001 to $35,000, 7}
{$35,001 to $40,000, 8}
{$40,001 to $50,000 9}
{$50,001 to $75,000, 10}
{$75,001 to $100,000, 11}
{$100,001 to $200,000, or 12}
{$200,001 or more? 13}
REFUSED -1 (HH_TYPE)
DON’T KNOW -2 (HH_TYPE)
PROGRAMMER INSTRUCTIONS:
IF INC_TWO_CAT = 1, DISPLAY CODES 1-5.
OTHERWISE, IF INC_TWO_CAT = 2, DISPLAY CODES 6-13.
IF HH_INC_NUM = 3 AND INC_13_CAT ≤ 3, OR
IF HH_INC_NUM = 4 AND INC_13_CAT≤ 4, OR
IF HH_INC_NUM = 5 AND INC_13_CAT ≤ 5, OR
IF HH_INC_NUM = 6 AND INC_13_CAT ≤ 5, OR
IF HH_INC_NUM = 7 AND INC_13_CAT≤ 6, OR
IF HH_INC_NUM = 8 AND INC_13_CAT ≤ 7, OR
IF HH_INC_NUM ≥ 9 AND INC_13_CAT ≤ 8, GO TO INC_TOTAL.
OTHERWISE, GO TO HH_TYPE.
INC040/(INC_TOTAL). What was your total household income last year, to the nearest thousand?
INTERVIEWER INSTRUCTION:
IF NECESSARY, EXPLAIN THAT TOTAL INCOME MEANS GROSS INCOME – THAT IS, INCOME BEFORE TAXES ARE TAKEN OUT.
$|___|,|___|___|___|, 000
TOTAL INCOME
REFUSED -1
DON’T KNOW -2
INC070/(HOME_OWN_TYPE). What is your current housing situation? Do you…
Own your own home, 1 (HOME_VALUE)
Rent your house or apartment, 2 (PUBLIC_HOUSING)
Exchange services for housing, 3 (OWN_AUTO)
Live with friends or relatives to pay part of the
expenses, 4 (OWN_AUTO)
Live with friends or relatives and not pay for
housing, 5 (OWN_AUTO)
Live in temporary housing or a shelter, 6 (OWN_AUTO)
Not pay for housing as part of a job
(e.g., military, clergy), or 7 (OWN_AUTO)
Have another type of housing arrangement? -5
REFUSED -1 (OWN_AUTO)
DON’T KNOW -2 (OWN_AUTO)
INC080/(HOME_OWN_TYPE _OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
INC090/(PUBLIC_HOUSING). Do you live in public housing or do you and your family receive a rent subsidy or pay lower rent because the government pays part of the cost?
YES 1 (OWN_AUTO)
NO 2(OWN_AUTO)
REFUSED -1
(OWN_AUTO)
DON’T
KNOW -2 (OWN_AUTO)
PROGRAMMER INSTRUCTIONS:
IF HOME_OWN_TYPE = 1, GO TO HOME_VALUE.
OTHERWISE, GO TO OWN_AUTO.
INC100/(HOME_VALUE). Could you tell me what the present value of your home is? I mean about how much would it being if you sold it today?
$|___|___|,|___|___|___|, |___|___|___|
HOME VALUE
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
IF VALID AMOUNT ENTERED, GO TO MORTGAGE.
OTHERWISE, GO TO HOME_VALUE_FIFTY.
INC110/(HOME_VALUE_FIFTY). Would it amount to $50,000 or more?
YES 1
NO 2 (HOME_VALUE_FIVE)
REFUSED -1
(MORTGAGE)
DON’T
KNOW -2 (MORTGAGE)
INC120/(HOME_VALUE_ONE_FIFTY). Would it amount to $150,000 or more?
YES 1 (MORTGAGE)
NO 2
(MORTGAGE)
REFUSED -1
(MORTGAGE)
DON’T
KNOW -2 (MORTGAGE)
INC130/(HOME_VALUE_FIVE). Would it amount to $5,000 or more?
YES 1
NO 2
REFUSED -1
DON’T
KNOW -2
INC140/(MORTGAGE). Do you have a mortgage on this property?
YES 1
NO 2
REFUSED -1
DON’T
KNOW -2
INC150/(OWN_AUTO). Do you {or anyone in your household} own a car or truck?
YES 1
NO 2
REFUSED -1
DON’T
KNOW -2
PROGRAMMER INSTRUCTIONS:
IF HH_MEM_AGE AND/OR HH_MEM_AGE_CHANGE > 16 FOR ANY HOUSEHOLD MEMBER OTHER THAN PARENT/CAREGIVER, DISPLAY “or anyone in your household”.
INC170/(INC_STOCK). Do you {or anyone in your household} have any shares or stock in publicly held corporations, mutual funds, or investement trusts, including stocks in IRAs?
YES 1
NO 2
REFUSED -1
DON’T
KNOW -2
PROGRAMMER INSTRUCTIONS:
IF HH_MEM_AGE AGE AND/OR HH_MEM_AGE_CHANGE > 16 FOR ANY HOUSEHOLD MEMBER OTHER THAN RESPONDENT, DISPLAY “or anyone in your household”.
INC170/(INC_ACCOUNTS). Do you {or anyone in your household} have any money in checking or savings accounts, money market funds, certificates of deposit, or government savings bonds, or treasury bills, including IRAs?
YES 1
NO 2
REFUSED -1
DON’T
KNOW -2
PROGRAMMER INSTRUCTIONS:
IF HH_MEM_AGE AGE AND/OR HH_MEM_AGE_CHANGE > 16 FOR ANY HOUSEHOLD MEMBER OTHER THAN RESPONDENT, DISPLAY “or anyone in your household”.
(TIME_STAMP_INC_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
PROGRAM PARTICIPATION
(ANNUAL BEGINNING AT 30 MONTH)
(TIME_STAMP_PP_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
PROGRAMMER INSTRUCTIONS:
IF EVENT_TYPE = 30 MONTH OR LATER ANNUAL EVENT (E.G., 42 MONTH , 54-MONTH, ETC), GO TO PP001.
OTHERWISE, GO TO TIME_STAMP_MC_ST.
PP001. The following questions ask about you or {C_FNAME/the child}’s participation in programs that provide different types of assistance to families.
PROGRAMMER INSTRUCTIONS:
IF CHILD_NUM =1 OR
IF CHILD_NUM > 1 AND CHILD_QNUM = 1, GO TO PP_TANF.
OTHERWISE, GO TO PP_FOOD_STAMPS.
PP005/(PP_TANF). At any time during the past 12 months, even for one month, did anyone in the household receive any cash assistance from a state or county welfare program, such as {STATE TANF NAME}?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
PRELOAD AND DISPLAY STATE TANF NAME.
IF CHILD_NUM > 1, LOOP FROM PP_FOOD_STAMPS THROUGH DIS_DRESS_BATH (IF CHILD AGE > 5 YEARS) OR DIS_SEEING (IF CHILD AGE < 5 YEARS) UNTI LNUMBER OF LOOPS = CHILD_NUM. THEN GO TO TIME_STAMP_DS_ET.
IF CHILD NUM = 1, GO TO PP_FOOD_STAMPS.
PP010/(PP_FOOD_STAMPS). During the past 12 months, did {C_FNAME/the child} receive Food Stamps or Supplemental Nutrition Assistance Program Benefits?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PP015/(PP_WIC). Does {C_FNAME/the child} currently receive benefits from the Women, Infants, and Children (WIC)?
INTERVIEWER INSTRUCTION:
READ IF NECESSARY: WIC is a federally-funded health and nutrition program for women, infants, and children. WIC benefits include food, checks or vouchers for food, health care referrals, and nutrition education.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PP020/(PP_OTHER_BENEFITS). Does {C_FNAME/the child} currently receive any other government benefits or assistance?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PP25/(PP_OTHER_BENEFITS_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
PP030/(PP_HEAD_START). Is {C_FNAME/the child} currently enrolled in Head Start or Early Head Start?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_PP_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
(ANNUAL BEGINNING AT 30 MONTH)
(TIME_STAMP_HI_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
PROGRAMMER INSTRUCTIONS:
IF EVENT_TYPE = 30 MONTH OR LATER ANNUAL EVENT (E.G., 42 MONTH , 54-MONTH, ETC), GO TO HI001.
OTHERWISE, GO TO TIME_STAMP_MC_ST.
HI001. Now I’m going to switch to another subject and ask about health insurance.
PROGRAMMER INSTRUCTION:
IF INSURE COLLECTED PREVIOUSLY AND VALID RESPONSE PROVIDED, GO TO INSURE_CONFIRM.
OTHERWISE, IF INSURE NOT COLLECTED PREVIOUSLY OR VALID RESPONSE NOT PROVIDED, GO TO INSURE.
HI002/(INSURE_CONFIRM). I’d like to confirm {C_FNAME/the child}’s health care coverage. I have it recorded as {{CHILD’S HEALTH INSURANCE}/{C_FNAME/the child} does not have health insurance}. Is this corrrect?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF INSURE = 1, PRELOAD CHILD’S HEALTH INSURANCE COLLECTED DURING MOST RECENT INTERVIEW AS FOLLOWS:
IF INS_EMPLOY = 1, DISPLAY, “Insurance through an employer or union”.
IF INS_MEDICAID = 1, DISPLAY “Medicaid or any government-assistance plan”.
IF INS_TRICARE = 1, DISPLAY “TRICARE, VA, or other military health care”.
IF INS_IHS = 1, DISPLAY “Indian Health Service”.
IF INS_MEDICARE =1, DISPLAY “Medicare”.
IF INS_OTHER = 1, DISPLAY “Another type of health plan”
SEPARATE EACH INSURANCE TYPE WITH A SEMI-COLON.
IF INSURE = 2, DISPLAY, “{C_FNAME/the child} does not have health insurance.”
IF INSURE_CONFIRM = 1 AND:
INSURE = 1 FROM MOST RECENT INTERVIEW, GO TO INS_NONE.
INSURE = 2, -1, OR -2 FROM MOST RECENT INTERVIEW, GO TO INS_DELAYED.
HI003/(INSURE). Is {C_FNAME/the child} currently covered by any kind of health insurance or some other kind of health care plan?
YES 1
NO 2 (TIME_STAMP_HI_ET)
REFUSED -1 (INS_DELAYED)
DON’T KNOW -2 (INS_DELAYED)
HI004. Now I’ll read a list of different types of insurance. Please tell me which types {C_FNAME/the child} currently has. Does {C_FNAME/the child} currently have…
INTERVIEWER INSTRUCTION:
RE-READ INTRODUCTORY STATEMENT (Does {C_FNAME/the child} currently have…) AS NEEDED.
HI005A/(INS_EMPLOY). Insurance through an employer or union either through yourself or another family member?
YES 1
NO 2
REFUSED -1
HI005B/(INS_SELF). Insurance purchased directly from an insurance company either through yourself or another family member?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HI006/(INS_MEDICAID). Medicaid or the State Children’s Health Insurance Program, S-CHIP? In this state, the program is sometimes called {MEDICAID NAME, SCHIP NAME}?
INTERVIEWER INSTRUCTION:
PRELOAD EXAMPLES OF LOCAL MEDICAID/S-CHIP PROGRAMS
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HI009/(INS_TRICARE). TRICARE, VA, or other military health care?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HI011/(INS_IHS). Indian Health Service?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HI013/(INS_MEDICARE). Medicare, for people with certain disabilities?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HI015/(INS_OTH). Any other type of health insurance or health coverage plan?
YES 1
NO 2 (INS_OTH_OTH)
REFUSED -1 (INS_OTH_OTH)
DON’T KNOW -2 (INS_OTH_OTH)
HI016/((INS_OTH_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
LIMIT TEXT TO 255 CHARACTERS.
HI017/(INS_NONE). During the past 12 months, was there any time when {C_FNAME/the child} was not covered by any health insurance?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HI019/(INS_MEET_NEEDS). Does {C_FNAME/the child}’s health insurance offer benefits or cover services that meet {his/her} needs? Would you say …
Never 1
Sometimes 2
Usually 3
Always 4
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_HI_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
HEALTH CARE UTILIZATION/ACCESS
(ANNUAL BEGINNING AT 30 MONTH)
(TIME_STAMP_HCU_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
PROGRAMMER INSTRUCTIONS:
IF EVENT_TYPE = 30 MONTH OR LATER ANNUAL EVENT (E.G., 42 MONTH , 54-MONTH, ETC), GO TO HCU001.
OTHERWISE, GO TO TIME_STAMP_MC_ST.
HCU001. Now I would like to ask a few questions about {C_FNAME/the child} and the health care services that {he/she} uses.
HCU010/(USUAL_CARE_PLACE). Is there a place {C_FNAME/the child} usually goes when {he/she} needs routine or preventive care, such as a physical examination or a (well baby/child) check up?
YES 1
NO 2 (pers_doc)
REFUSED -1 (pers_doc)
DON’T KNOW -2 (pers_doc)
HCU020/(USUAL_CARE_TYPE). What kind of place does {C_FNAME/the child} usually go to when {he/she} needs routine or preventive care, such as a physical examination or (well baby/child) check-up?
Clinic or Health Center, 1
Doctor’s office or Health Maintenance Organziation (HMO), 2
Hospital Emergency Room, 3
Hospital outpatient department, or 4
Some other place? - 5
DOESN'T GO TO ONE PLACE MOST OFTEN 6
DOESN'T GET WELL-CHILD CARE ANYWHERE 7
REFUSED -1
DON’T KNOW -2
HCU025/(pers_doc). A personal doctor or nurse is a health professional who knows your child well and is familiar with your child’s health history. This can be a general doctor, pediatrician, a special doctor, a nurse practitioner, or a physician assistant. Do you have one or more persons you think of as {C_FNAME/the child}’s personal doctor or nurse?
YES, ONE PERSON . 1
YES, MORE THAN ONE PERSON 2
NO 3
REFUSED -1
DON’T KNOW -2
HCU030/(PROVIDER_TROUBLE_FIND). During the past 12 months, did you have any trouble finding a general doctor or provider who would see {C_FNAME/the child}?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCU040/(PROVIDER_NOT_ACCEPT_NEW). During the past 12 months, were you told by a doctor’s office or clinic that they would not accept {C_FNAME/the child} as a new patient?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCU050/(PROVIDER_NOT_ACCEPT_COVER). During the past 12 months, were you told by a doctor’s office or clinic that they did not accept {C_FNAME/the child}’s health care coverage?
YES 1
NO 2
NO HEALTH INSURANCE -7
REFUSED -1
DON’T KNOW -2
HCU052/(DENTIST). During the past 12 months, has {C_FNAME/the child} been seen by a dentist? Please include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCU054/(INS_DELAYED). Sometimes people have difficulty getting healthcare when they need it. By health care, I mean medical care as well as other kinds of care like dental care and mental health services. During the past 12 months, was there any time when {C_FNAME/the child} needed health care but it was delayed or not received?
YES 1
NO 2 (TIME_STAMP_HCU_ET)
REFUSED -1 (TIME_STAMP_HCU_ET)
DON’T KNOW -2 (TIME_STAMP_HCU_ET)
HCU055/(INS_DELAYED_TYPE). What type of care was delayed or not received? Was it medical care, dental care, mental health services, or something else?
INTERVIEWER INSTRUCTION:
SELECT ALL THAT APPLY
MEDICAL CARE 1
DENTAL CARE 2
MENTAL HEALTH SERVICES 3
OTHER -5
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF INS_DELAYED_TYPE = ANY COMBINATION OF 1, 2, AND 3, GO TO HCU060.
IF INS_DELAYED_TYPE = -5, OR ANY COMBINATION OF 1, 2, 3, AND -5, GO TO INS_DELAYED_TYPE_OTH.
OTHERWISE, IF INS_DELAYED_TYPE = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO HCU060.
HCU056/(INS_DELAYED_TYPE_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
HCU060. There are many reasons people delay getting medical care.
HCU062. Have you delayed getting medical care for {C_FNAME/the child} for any of the following reasons in the past 12 months …
HCU065/(PHONE_PROBLEM). You couldn’t get through on the telephone?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
INTERVIEWER INSTRUCTION:
RE-READ INTRODUCTORY STATEMENT (Have you delayed getting medical care for {C_FNAME/the child} for any of the following reasons in the past 12 months …) AS NEEDED FOR APPOINTMENT_PROBLEM, WAIT_TOO_LONG, OFFICE_CLOSED, AND NO_TRANSPORTATION.
HCU070/(APPOINTMENT_PROBLEM). You couldn’t get an appointment for {C_FNAME/the child} soon enough.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCU080/(WAIT_TOO_LONG). Once there, {C_FNAME/the child} has to wait too long to see the doctor.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCU090/(OFFICE_CLOSED). The (clinic/doctor’s) office wasn’t open when {C_FNAME/the child} could get there.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCU100/(NO_TRANSPORTATION). You didn’t have transportation.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCU106/(AFFORD_MED_TX) You couldn’t afford it?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
HCU108/(AFFED_MED_BILLS) In the past 12 months, did your family have problems paying or were unable to pay any of {C_FNAME/the child}’s medical bills? Include bills for doctors, dentists, hospitals, therapists, medications, equipments, or home care.
YES 1
NO 2
NO EXPENSES 3
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_HCU_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
MEDICAL CONDITIONS
(ANNUAL BEGINNING AT 36 MONTH)
(TIME_STAMP_MC_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
PROGRAMMER INSTRUCTIONS:
IF EVENT_TYPE = 36 MONTH OR LATER ANNUAL EVENT (E.G., 48 MONTH , 60-MONTH, ETC), GO TO MC001.
OTHERWISE, GO TO TIME_STAMP_HL_ST.
MC001. Now I’d like to change the subject and ask about {C_FNAME/the child}’s health and about some medical conditions {he/she} may have had.
MC001/(CURRENT_WT_LBS)/(CURRENT_WT_OZ). What is {C_FNAME/the child}’s current weight?
INTERVIEWER INSTRUCTION:
RECORDS CHILD’S WEIGHT IN POUNDS AND OUNCES.
|___|___|
POUNDS
REFUSED -1
DON’T KNOW -2
|___|___|
OUNCES
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
HARD EDIT: INCLUDE HARD EDIT IF OUNCES IS NOT BETWEEN 01 AND 15.
MC010/(CURRENT_HT). What is {C_FNAME/the child}’s current height?
|___|___|
INCHES
REFUSED -1
DON’T KNOW -2
MC030. In the past six months has a doctor, nurse, or other medical professional told you that {C_FNAME/the child} has...
INTERVIEWER INSTRUCTIONS:
FOR DOC_ASTHMA, DOC_BRONCH, DOC_GASTRO, DOC_EAR, DOC_INJURY, DOC_DELAY, DOC_EPILEPSY, DOC_ANEMIA, DOC_ECZEMA, DOC_FOODALLERG, DOC_HAYFEVER, DOC_OVERWEIGHT, DOC_ADD, DOC_AUTISM, DOC_DIABETES, DOC_OTHER_COND, AND DOC_OTHER_COND_OTH RE-READ INTRODUCTORY STATEMENT (In the past six months has a doctor, nurse, or other medical professional told you that {C_FNAME/the child}...) AS NEEDED.
MC030/(DOC_BRONCH). Has a respiratory illness, such as bronchitis, pneumonia, or bronchiolitis?
YES 1
NO 2 (DOC_GASTRO)
REFUSED -1 (DOC_GASTRO)
DON’T KNOW -2 (DOC_GASTRO)
MC031/(DOC_BRONCH_FREQ). How many times in the last 12 months did a doctor tell you that {C_FNAME/the child} has a respiratory illness?
INTERVIEWER INSTRUCTION:
IF NEEDED, ADD “such as bronchitis, pneumonia, or bronchiolitis.”
|___|___|
TIMES
REFUSED -1
DON’T KNOW -2
MC032/(DOC_GASTRO). Has a severe gastrointestinal illness, as indicated by frequent vomiting, diarrhea, or dehydration?
YES 1
NO 2 (DOC_EAR)
REFUSED -1 (DOC_EAR)
DON’T KNOW -2 (DOC_EAR)
MC033/(DOC_GASTRO_FREQ). How many times in the last 12 months did a doctor tell you that {C_FNAME/the child} has a severe gastrointestinal illness?
INTERVIEWER INSTRUCTION:
IF NEEDED, ADD “as indicated by frequent vomiting, diarrhea, or dehydration.”
|___|___|
TIMES
REFUSED -1
DON’T KNOW -2
MC0334/(DOC_EAR). Has an ear infection?
YES 1
NO 2 (DOC_STREP)
REFUSED -1 (DOC_STREP)
DON’T KNOW -2 (DOC_STREP)
MC033/(DOC_EAR_FREQ). How many times in the last 12 months did a doctor tell you that {C_FNAME/the child} has an ear infection?
|___|___|
TIMES
REFUSED -1
DON’T KNOW -2
MC034/(DOC_STREP). Has strep throat?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MC035/(DOC_STREP_FREQ). How many times in the last 12 months did a doctor tell you that {C_FNAME/the child} has strep throat?
|___|___|
TIMES
REFUSED -1
DON’T KNOW -2
MC036/(DOC_UNKN_FEVER). Has a fever without a cause?
YES 1
NO 2 (DOC_ASTHMA)
REFUSED -1 (DOC_ASTHMA)
DON’T KNOW -2 (DOC_ASTHMA)
MC037/(DOC_FEVER_FREQ). How many times in the last 12 months did a doctor tell you that {C_FNAME/the child} has a fever without a cause?
|___|___|
TIMES
REFUSED -1
DON’T KNOW -2
MC038/(DOC_ASTHMA). Has asthma or wheezing?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MC039/(DOC_DELAY). Has a developmental delay?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MC040/(DOC_EPILEPSY). Has epilepsy or seizures?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MC041/(DOC_ANEMIA). Has anemia?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MC042/(DOC_ECZEMA). Has eczema?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MC043/(DOC_FOOD_ALLERG). Has food allergies or sensitivities?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MC044/(DOC_HAYFEVER). Has hay fever or other (non-food) allergies?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MC045/(DOC_DIABETES). Has diabetes?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MC046(DOC_OVERWEIGHT). Is overweight?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF EVENT_TYPE = 24 MONTH OR AFTER (30-MONTH, 36-MONTH, ETC), GO TO DOC_ADD.
OTHERWISE, FOR ALL EVENT_TYPE PRIOR TO 24-MONTHS, GO TO DOC_OTHER_COND.
MC047/(DOC_ADD). Has attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MC048/(DOC_AUTISM). Has autism, Asperger syndrome, or any other autism spectrum disorder?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MC049/(DOC_OTHER_COND). Has any other medical condition or health problem?
YES 1
NO 2 (TIME_STAMP_MC_ET)
REFUSED -1 (TIME_STAMP_MC_ET)
DON’T KNOW -2 (TIME_STAMP_MC_ET)
MC050/(DOC_OTHER_COND_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
(TIME_STAMP_MC_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
(ANNUAL BEGINNING AT 36 MONTH)
(TIME_STAMP_WCC_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
WCC001. Now I would like to ask you about {C_FNAME/the child}’s well care visits and immunizations. It would be helpful if you referred to {C_FNAME/the child}’s shots record, or the Infant and Child Health Care Log that you received as part of this study, or to any other personal record or calendar that you keep that would help you to remember the dates of these shots. If you have this information available, will you please go and get it now?
INTERVIEWER INSTRUCTIONS:
IF THE PARENT/CAREGIVER DOES NOT HAVE THE LOG OR CHILD’S SHOT RECORD, REASSURE HIM/HER IT IS NOT A PROBLEM AND THEY SHOULD TRY TO RESPOND TO THE NEXT QUESTIONS AS WELL AS POSSIBLE FROM MEMORY.
WCC001A/(WCC_VISIT). Since the last interview on {DATE OF LAST INTERVIEW}, has {C_FNAME/the child} had a visit to a doctor, nurse or other health care provider for a well care visit or immunization such as a check-up? Do not include visits because of illness. I will ask about those later.
YES 1
NO 2 (ALL_SHOTS)
REFUSED -1 (ALL_SHOTS)
DON’T KNOW -2 (ALL_SHOTS)
PROGRAMMER INSTRUCTION:
PRELOAD AND DISPLAY DATE OF LAST INTERVIEW.
WCC001B/(NUM_WELL_CHILD_VISIT)/(NUM_WELL_CHILD_VISIT_UNIT). How many well-child visits or check-ups has {C_FNAME/the child} had since the last interview on {DATE OF LAST INTERVIEW}?
INTERVIEWER INSTRUCTION:
ENTER “0” IF NONE.
|___|___|
WELL-CHILD VISITS
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF NUM_WELL_CHILD_VISIT = 0, -1, OR -2, GO TO TIME_STAMP_WCC_ET.
LOOP THROUGH (LAST_VISIT_DATE_MM)(LAST_VISIT_DATE_DD)( LAST_VISIT_DATE_YY), (LAST_VISIT_AGE)(LAST_VISIT_AGE_UNIT) (IF LAST_VISIT_DATE_MM OR LAST_VISIT_DATE_YY = -2), (VISIT_WT_LBS)(VISIT_WEIGHT_OZ), VACCINATION, SHOTS_TYPE (IF VACCINATION = 1), SHOTS_TYPE_OTH (IF SHOTS_TYPE = -5) FOR EACH WELL-CHILD VISIT UNTIL TOTAL NUMBER OF LOOPS = NUM_WELL_CHILD_VISIT.
AFTER COMPLETING FINAL LOOP, GO TO RXN_SHOTS_MILD.
WCC002/(LAST_VISIT_DATE_MM)/(LAST_VISIT_DATE_DD)(LAST_VISIT_DATE_YY). What was the date of {C_FNAME/the child}’s {most recent/next most recent} well-child visit or checkup?
INTERVIEWER INSTRUCTION:
ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND FOUR-DIGIT YEAR.
MONTH:
|___|___| (VISIT_WT_LBS)/(LAST_WT_LBS)
M M
REFUSED -1 (ALL_SHOTS)
DON’T KNOW -2 (LAST_VISIT_AGE)/(LAST_VISIT_AGE_UNIT)
DAY:
|___|___| (VISIT_WT_LBS)/(LAST_WT_LBS)
D D
REFUSED -1 (ALL_SHOTS)
DON’T KNOW -2 (VISIT_WT_LBS)/(LAST_WT_LBS)
YEAR: (VISIT_WT_LBS)/(LAST_WT_LBS)
|___|___|___|___|
Y Y Y Y
REFUSED -1 (ALL_SHOTS)
DON’T KNOW -2 (LAST_VISIT_AGE)/(LAST_VISIT_AGE_UNIT)
PROGRAMMER INSTRUCTIONS
IF FIRST LOOP CYCLE, DISPLAY “most recent”.
IF SUBSEQUENT LOOP CYCLE DISPLAY “next most recent”.
WCC003/(LAST_VISIT_AGE)/(LAST_VISIT_AGE_UNIT). How old was {C_FNAME/the child} at {his/her} {most recent/next most recent} well-child visit or checkup?
INTERVIEWER INSTRUCTIONS:
IF NECESSARY, REMIND PARENT/CAREGIVER TO REFER TO HEALTH CARE LOG OR OTHER RECORDS IF AVAILABLE.
RECORD AGE IN MONTHS IF CHILD YOUNGER THAN 36 MONTHS. OTHERWISE, RECORD AGE IN YEARS.
|___|___|
AGE
REFUSED -1
DON’T KNOW -2
MONTHS 1
YEARS 2
PROGRAMMER INSTRUCTIONS
IF FIRST LOOP CYCLE, DISPLAY “most recent”.
IF SUBSEQUENT LOOP CYCLE DISPLAY “next most recent”.
WCC004/(VISIT_WT_LBS)/(VISIT_WEIGHT_OZ). What was {C_FNAME/the child}’s weight at {his/her} {most recent/next most recent} visit?
|___|___|
POUNDS
REFUSED -1
DON’T KNOW -2
|___|___|
OUNCES
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
HARD EDIT: INCLUDE HARD EDIT IF OUNCES IS NOT BETWEEN 01 AND 15.
IF FIRST LOOP CYCLE, DISPLAY “most recent”.
IF SUBSEQUENT LOOP CYCLE DISPLAY “next most recent”.
WCC005/(VACCINATION). Was {C_FNAME/the child} given any vaccinations at {his/her} {most recent/next most recent} visit? Vaccinations are usually injections or shots that strengthen people’s immune systems so that their bodies can fight off serious infectious diseases. Do not include allergy shots.
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF FIRST LOOP CYCLE, DISPLAY “most recent”.
IF SUBSEQUENT LOOP CYCLE DISPLAY “next most recent”.
IF VACCINATION = 2, -1, OR -2, COMPLETE LOOP:
IF NUMBER OF LOOPS < NUM_WELL_CHILD_VISIT, GO TO (LAST_VISIT_DATE_MM)/(LAST_VISIT_DATE_DD)(LAST_VISIT_DATE_YY)
IF NUMBER OF LOOPS = NUM_WELL_CHILD_VISIT, GO TO RXN_SHOTS_MILD.
WCC005A/(SHOTS_TYPE). Please tell me the name of each vaccination {C_FNAME/the child] received at this visit.
INTERVIEWER INSTRUCTIONS:
PROBE: Anything else?
SELECT ALL THAT APPLY.
DTaP (TETANUS, WHOOPING COUGH, DIPHTHERIA) 1
HepA (HEPATITIS A) 2
HepB (HEPATITIS B) 3
Hib (HAEMOPHILUS INFLUENZA TYPE B) 4
INFLUENZA (INFLUENZA) 5
IPV (POLIO) 6
MMR (MEASLES, MUMPS, RUBELLA) 7
PCV (PNEUMOCOCCUS) 8
RV (ROTAVIRUS) 9
VARICELLA (CHICKENPOX) 10
OTHER -5
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF SHOTS_TYPE = ANY COMBINATION OF 1 – 10, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING SHOTS_TYPE_OTH.
IF SHOTS_TYPE = -5, OR ANY COMBINATION OF 1 – 10 AND -5, GO TO SHOTS_TYPE_OTH.
IF SHOTS_TYPE -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND THEN COMPLETE LOOP:
IF NUMBER OF LOOPS < NUM_WELL_CHILD_VISIT, GO TO (LAST_VISIT_DATE_MM)/(LAST_VISIT_DATE_DD)(LAST_VISIT_DATE_YY)
IF NUMBER OF LOOPS = NUM_WELL_CHILD_VISIT, GO TO RXN_SHOTS_MILD.
WCC006/(SHOTS_TYPE_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
WCC007/(RXN_SHOTS_MILD). Please tell me whether your child experienced any side effects after receiving any vaccine since the last interview {DATE OF LAST INTERVIEW}.
YES 1
NO 2 (ALL_SHOTS)
REFUSED -1 (ALL_SHOTS)
DON’T KNOW -2 (ALL_SHOTS)
PROGRAMMER INSTRUCTIONS:
PRELOAD AND DISPLAY DATE OF LAST INTERVIEW.
WCC007A/(RXN_SHOTS_TYPE). What was the side effect?
INTERVIEWER INSTRUCTIONS:
PROBE: Anything else?
SELECT ALL THAT APPLY.
ABDOMINAL PAIN 1 (RXN_SHOTS_DOC)
BODY ACHES 2 (RXN_SHOTS_DOC)
CHILLS 3 (RXN_SHOTS_DOC)
DIARRHEA 4 (RXN_SHOTS_DOC)
FEVER 5 (RXN_SHOTS_DOC)
FUSSINESS 6 (RXN_SHOTS_DOC)
HEADACHE 7 (RXN_SHOTS_DOC)
HOARSENESS/ SORE THROAT/COUGH 8 (RXN_SHOTS_DOC)
LOSS OF APPETITE 9 (RXN_SHOTS_DOC)
NASAL CONGESTION/ RUNNY NOSE 10 (RXN_SHOTS_DOC)
MUSCLE/ JOINT PAIN 11 (RXN_SHOTS_DOC)
NAUSEA/ VOMITING 12 (RXN_SHOTS_DOC)
RASH/ HIVES 13 (RXN_SHOTS_DOC) REDNESS/ WARMTH/ SWELLING WHERE
THE SHOT WAS GIVEN 14 (RXN_SHOTS_DOC)
SEIZURE 15
SORENESS/ TENDERNESS
WHERE THE SHOT WAS GIVEN 16 (RXN_SHOTS_DOC)
SORE/ RED/ ITCHY EYES 17 (RXN_SHOTS_DOC)
SWOLLEN GLANDS 18 (RXN_SHOTS_DOC)
TEMPORARY LOW PLATELET COUNT 19 (RXN_SHOTS_DOC)
TIREDENESS/ FATIGUE 20 (RXN_SHOTS_DOC)
WEAKNESS 21 (RXN_SHOTS_DOC)
WHEEZING/ TROUBLE BREATHING 22 (RXN_SHOTS_DOC)
OTHER -5
REFUSED -1 (RXN_SHOTS_DOC)
DON’T KNOW -2 (RXN_SHOTS_DOC)
PROGRAMMER INSTRUCTIONS:
IF RXN_SHOTS_MILD = ANY COMBINATION OF 1 – 21, GO TO RXN_SHOTS_DOC.
IF RXN_SHOTS_MILD = -5, OR ANY COMBINATION OF 1 – 21 AND -5, GO TO RXN_SHOTS_MILD_OTH.
IF RXN_SHOTS_MILD -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO RXN_SHOTS_DOC.
WCC007B/(RXN_SHOTS_MILD_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
WCC007C/(RXN_SHOTS_DOC). Did {C_FNAME/the child? See a physician or health care provider for this side effect?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
WCC020/(ALL_SHOTS). In your opinion, has {C_FNAME/the child} received all of the recommended shots for {his/her} age?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_WCC_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
EMERGENCY ROOM/URGENT CARE VISITS
(ANNUAL BEGINNING AT 36 MONTH)
(TIME_STAMP_ER_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
ER001. I am now going to ask some questions about any visits {C_FNAME/the child} may have had to an emergency department or urgent care center in the past six months. Include only those visits where the child was treated and released. Do not include visits where the child was first seen in the emergency department and then admitted to the hospital.
ER002/(ER_VISIT). In the past six months, has {C_FNAME/the child} ever been taken to an emergency room or urgent care center?
YES 1
NO 2 (FREQ_INJURY)
REFUSED -1 (FREQ_INJURY)
DON’T KNOW -2 (FREQ_INJURY)
ER003/(ER _VISIT_NUM). In the past six months, how many times has {C_FNAME/the child} been taken to an emergency room or urgent care center?
|___|___|
TIMES
REFUSED -1 (FREQ_INJURY)
DON’T KNOW -2 (FREQ_INJURY)
PROGRAMMER INSTRUCTIONS:
LOOP THROUGH (ER_VISIT_DATE_MM)(ER_VISIT_DATE_DD)(ER_VISIT_DATE_YY), (ER_VISIT_AGE)/(ER_VISIT_AGE_UNIT)(IF ER_VISIT_DATE_MM OR ER_VISIT_DATE_YY = -2), ER_VISIT_DIAG, AND ER_VISIT_OTH (IF ER_VISIT_DIAG = -5) FOR EACH ER VISIT UNTIL TOTAL NUMBER OF LOOPS = ER_VISIT_NUM.
AFTER COMPLETING FINAL LOOP, GO TO FREQ_INJURY.
ER004/(ER_VISIT_DATE_MM)/(ER_VISIT_DATE_DD)/(ER_VISIT_DATE_YYYY). What was the date of the {most recent emergency room or urgent care visit since {DATE OF MOST RECENT INTERVIEW}/next most recent visit}?
INTERVIEWER INSTRUCTION:
ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND FOUR-DIGIT YEAR.
-
MONTH:
|___|___| (ER_VISIT_DIAG)
M M
REFUSED -1 (FREQ_INJURY)
DON’T KNOW -2 (ER_VISIT_AGE)
-
DAY:
|___|___| (ER_VISIT_DIAG)
D D
REFUSED -1 (FREQ_INJURY)
DON’T KNOW -2 (ER_VISIT_DIAG)
-
YEAR:
|___|___|___|___| (ER_VISIT_DIAG)
Y Y Y Y
REFUSED -1 (FREQ_INJURY)
DON’T KNOW -2 (ER_VISIT_AGE)
PROGRAMMER INSTRUCTIONS:
IF FIRST LOOP CYCLE, DISPLAY “most recent emergency room or urgent care visit since” AND PRELOAD AND DISPLAY DATE OF MOST RECENT INTERVIEW.
IF SUBSEQUENT LOOP CYCLE DISPLAY “next most recent visit”.
FORMAT (ER_VISIT_DATE_MM)(ER_VISIT_DATE_DD)(ER_VISIT_YY) AS YYYYMMDD.
INCLUDE HARD EDIT IF MONTH IS NOT BETWEEN 01 AND 12.
INCLUDE HARD EDIT IF DAY IS NOT BETWEEN 01 AND 31.
INCLUDE HARD EDIT IF YEAR IS < 2011.
ER005/(ER_VISIT_AGE)/(ER_VISIT_AGE_UNIT). How old was {C_FNAME/the child} at the {first emergency room or urgent care visit since {DATE OF MOST RECENT INTERVIEW}/next visit} to an emergency room or urgent care center?
INTERVIEWER INSTRUCTIONS:
IF NECESSARY, REMIND PARENT/CAREGIVER TO REFER TO HEALTH CARE LOG OR OTHER RECORDS IF AVAILABLE.
RECORD AGE IN MONTHS IF CHILD YOUNGER THAN 36 MONTHS. OTHERWISE, RECORD AGE IN YEARS
|___|___|
AGE
REFUSED -1
DON’T KNOW -2
MONTHS 1
YEARS 2
PROGRAMMER INSTRUCTIONS:
IF FIRST LOOP CYCLE, DISPLAY “first emergency room or urgent care visit since” AND PRELOAD AND DISPLAY DATE OF MOST RECENT INTERVIEW.
IF SUBSEQUENT LOOP CYCLE DISPLAY “next visit”.
ER006/(ER_VISIT_DIAG). What did the doctor or other health care professional tell you was the reason or diagnosis for {C_FNAME/the child}’s {first emergency room or urgent care visit since {DATE OF MOST RECENT INTERVIEW}/next visit} to an emergency room or urgent care center?
INTERVIEWER INSTRUCTION:
SELECT ALL THAT APPLY.
PROBE: “Any others?”
ABDOMINAL PAIN 1
ACUTE UPPER respiratory iNFECTION 2
ASTHMA 3
CONTUSION (bruising) 4
FRACTURE(S) 5
OPEN WOUND, head injury 6
OPEN WOUND, EXCLUDING HEAD 7
EAR INFECTION OR EAR ACHE (OTITIS MEDIA) 8
FEVER 9
SORE THROAT (ACUTE PHARYNGITIS) 10
SKIN RASH 11
PNEUMONIA 12
APPENDICITIS 13
DEHYDRATION(FLUID & ELECTROLYE IMBALANCE) 14
SEIZURE 15
URINARY TRACT INFECTION 16
VOMITING AND/OR DIARREHEA 17
SKIN INFECTION 18
FRACTURE(S) 19
HEAD INJURY 20
OTHER -5
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF FIRST LOOP CYCLE, DISPLAY “first emergency room or urgent care visit since” AND PRELOAD AND DISPLAY DATE OF MOST RECENT INTERVIEW.
IF SUBSEQUENT LOOP CYCLE DISPLAY “next visit”.
IF ER_VISIT_DIAG = ANY COMBINATION OF VALUES 1 –20, GO TO FREQ_INJURY.
IF ER_VISIT_DIAG = -5, OR ANY COMBINATION OF VALUES 1 – 20 AND -5, GO TO ER_VISIT_DIAG_OTH.
IF ER_VISIT_DIAG = -1 OR -2, DO NOT ALLOW SELECTION OF OTHER RESPONSES AND GO TO FREQ_INJURY.
ER007/(ER_VISIT_DIAG_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
LIMIT TEXT TO 255 CHARACTERS.
ER008/(FREQ_INJURY). Now, I want to ask you about any injuries {C_FNAME/the child} has had. In the past 3 months, how many times has {he/she} seen a doctor or other medical professional or visited a emergency room or urgent care center for an injury?
INTERVIEWER INSTRUCTION:
ENTER “0” IF NONE.
|___|___|
INJURIES
REFUSED -1 (TIME_STAMP_ER_ET)
DON’T KNOW -2 (TIME_STAMP_ER_ET)
PROGRAMMER INSTRUCTIONS:
IF FREQ_INJURY > 1, LOOP THROUGH CAUSE_INJURY, CAUSE_INJURY_OTH (IF CAUSE_INJURY = -5), AUTO_CRASH_SAFE (IF CAUSE_INJURY = 10), AND HELMET_BIKE (IF CAUSE_INJURY = 12) FOR EACH INJURY UNTIL TOTAL NUMBER OF LOOPS = FREQ_INJURY.
AFTER COMPLETING FINAL LOOP, GO TO TIME_STAMP_ER_ET.
IF FREQ_INJURY = 1, GO TO CAUSE_INJURY
OTHERWISE, IF FREQ_INJURY = 0, GO TO TIME_STAMP_ER_ET.
ER009/(CAUSE_INJURY). Tell me about the {most serious/next most serious} injury. What caused it?
INTERVIEWER INSTRUCTIONS:
FOR CAUSE_INJURY,
IF USING SHOWCARDS, REFER PARENT/CAREGIVER TO SHOWCARD ER001.
OTHERWISE, READ RESPONSE CATEGORIES TO PARENT/CAREGIVER.
FALLS 1 (TIME_STAMP_ER_ET)
STRUCK BY/AGAINST 2 (TIME_STAMP_ER_ET)
BITES/STINGS 3 (TIME_STAMP_ER_ET)
CUT/PIERCED WITH SHARP OBJECT 4 (TIME_STAMP_ER_ET)
SWALLOWING FOREIGN BODY 5 (TIME_STAMP_ER_ET)
DISLOCATION 6 (TIME_STAMP_ER_ET)
NURSEMAID’S ELBOW 7 (TIME_STAMP_ER_ET)
STRAINS AND SPRAINS 8 (TIME_STAMP_ER_ET)
POISONING (ATE/DRANK/INHALED) 9 (TIME_STAMP_ER_ET)
FIRE/BURNS 10 (TIME_STAMP_ER_ET)
MOTOR VEHICLE CRASH 11 (AUTO_CRASH_SAFE)
SUFFOCATION/INHALATION 12 (TIME_STAMP_ER_ET)
PEDAL CYCLE 13 (HELMET_BIKE)
OTHER TRANSPORT 14 (TIME_STAMP_ER_ET)
PEDESTRIAN 15 (TIME_STAMP_ER_ET)
OTHER -5
REFUSED -1 (TIME_STAMP_ER_ET)
DON’T KNOW -2 (TIME_STAMP_ER_ET)
PROGRAMMER INSTRUCTIONS:
IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS.
OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE.
IF FIRST LOOP CYCLE, DISPLAY “most serious”.
IF SUBSEQUENT LOOP CYCLE DISPLAY “next most serious”.
ER010/(CAUSE_INJURY_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
LIMIT TEXT TO 255 CHARACTERS.
GO TO TIME_STAMP_ER_ET.
ER011/(AUTO_CRASH_SAFE). Was {C_FNAME/the child} in a car seat or wearing a seat belt when the accident happened?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
GO TO TIME_STAMP_ER_ET.
ER012/(HELMET_BIKE). Was {C_FNAME/the child} wearing a helmet when the accident happened?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_ER_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
INTERIM HOSPITALIZATIONS
(ANNUAL BEGINNING AT 36 MONTH)
(TIME_STAMP_HL_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
HL001. I am now going to ask some questions about {C_FNAME/the child}’s visits to a hospital.
HL002/(HOSP_VISIT). Since the last interview on {DATE OF LAST INTERVIEW} was {C_FNAME/the child} hospitalized overnight? Do not include an overnight stay in the emergency room.
YES 1
NO 2 (TIME_STAMP_HL_ET)
REFUSED -1 (TIME_STAMP_HL_ET)
DON’T KNOW -2 (TIME_STAMP_HL_ET)
PROGRAMMER INSTRUCTION:
PRELOAD AND DISPLAY DATE OF LAST INTERVIEW.
HL003/(HOSP_VISIT_NUM). How many different times did {C_FNAME/the child} stay in any hospital overnight or longer during the past 6 months?
|___|___|
TIMES
REFUSED -1 (TIME_STAMP_HL_ET)
DON’T KNOW -2 (TIME_STAMP_HL_ET)
PROGRAMMER INSTRUCTION:
LOOP THROUGH(HOSP_VISIT_DATE_MM)/(HOSP_VISIT_DATE_DD) /(HOSP_VISIT_DATE_YY), (HOSP_VISIT_AGE)/(HOSP_AGE_UNIT) (IF HOSP_VISIT_DATE_MM = -1 OR -2), (HOSP_VISIT_DIAG, AND HOSP_VISIT_DIAG_OTH (IF HOSP_VISIT_DIAG = -5) FOR EACH HOSPITALIZATION UNTIL TOTAL NUMBER OF LOOPS = HOSP_VISIT_NUM.
AFTER COMPLETING FINAL LOOP, GO TO TIME_STAMP_HL_ET.
HL004/(HOSP_VISIT_DATE_MM)/(HOSP_VISIT_DATE_DD) /(HOSP_VISIT_DATE_YY). What was the admission date of the {most recent/next most recent} hospitalization where {C_FNAME/the child} spent at least one night in the hospital?
INTERVIEWER INSTRUCTION:
ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND FOUR-DIGIT YEAR.
-
MONTH:
|___|___|
M M
REFUSED -1 (HOSP_VISIT_AGE)(HOSP_VISIT_AGE_UNIT)
DON’T KNOW -2 (HOSP_VISIT_AGE)(HOSP_VISIT_AGE_UNIT)
-
DAY:
|___|___|
D D
REFUSED -1
DON’T KNOW -2
-
YEAR:
|___|___|___|___|
Y Y Y Y
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF FIRST LOOP CYCLE, DISPLAY “most recent”.
IF SUBSEQUENT LOOP CYCLE, DISPLAY “next most recent”.
FORMAT (HOSP_VISIT_DATE_MM)(HOSP_VISIT_DATE_DD)(HOSP_VISIT_DATE_YY) AS YYYYMMDD.
HL005/(HOSP_VISIT_AGE)/(HOSP_VISIT_AGE_UNIT). How old was {C_FNAME/the child} at the {first hospitalization since {DATE OF MOST RECENT INTERVIEW}/next} hospitalization where {he/she} spent at least one night in the hospital?
INTERVIEWER INSTRUCTIONS:
IF NECESSARY, REMIND PARENT/CAREGIVER TO REFER TO HEALTH CARE LOGS OR OTHER RECORDS IF AVAILABLE.
RECORD AGE IN MONTHS IF CHILD YOUNGER THAN 36 MONTHS. OTHERWISE, RECORD AGE IN YEARS
|___|___|
AGE
REFUSED -1
DON’T KNOW -2
MONTHS 1
YEARS 2
PROGRAMMER INSTRUCTIONS:
IF FIRST LOOP CYCLE, DISPLAY DISPLAY “first hospitalization since” AND PRELOAD AND DISPLAY DATE OF MOST RECENT INTERVIEW.
IF SUBSEQUENT LOOP CYCLE DISPLAY “next”.
HL005A/(HOSP_VISIT_DIAG). What did the doctor or other health care professional tell you was the main reason or diagnosis for {C_FNAME/the child}’s {first hospitalization since {DATE OF MOST RECENT INTERVIEW}/next hospitalization}?
ACUTE BRONCHITIS 1 (TIME_STAMP_HL_ET)
APPENDICITIS 2 (TIME_STAMP_HL_ET)
ASTHMA 3 (TIME_STAMP_HL_ET)
BIRTH DEFECT COMPLICATIONS 4 (TIME_STAMP_HL_ET)
CANCER TREATMENT 5 (TIME_STAMP_HL_ET)
DEHYDRATION 6 (TIME_STAMP_HL_ET)
DIABETES 7 (TIME_STAMP_HL_ET)
EPILEPSY OR SEIZURES 8 (TIME_STAMP_HL_ET)
FEVER OF UNKNOWN ORIGIN 9 (TIME_STAMP_HL_ET)
FRACTURES, UPPER LIMB 10 (TIME_STAMP_HL_ET)
FRACTURES, LOWER LIMB 11 (TIME_STAMP_HL_ET)
GASTROINTESTINAL INFECTION 12 (TIME_STAMP_HL_ET)
HEAD INJURY 13 (TIME_STAMP_HL_ET)
INFLUENZA 14 (TIME_STAMP_HL_ET)
JAUNDICE (YELLOWNESS OF SKIN) 15 (TIME_STAMP_HL_ET)
MOOD DISORDER 16 (TIME_STAMP_HL_ET)
OTHER RESPIRATORY INFECTION 17 (TIME_STAMP_HL_ET)
OTHER VIRAL INFECTION 18 (TIME_STAMP_HL_ET)
PNEUMONIA 19 (TIME_STAMP_HL_ET)
SKIN INFECTION 20 (TIME_STAMP_HL_ET)
URINARY TRACT INFECTION 21 (TIME_STAMP_HL_ET)
OTHER -5
REFUSED -1 (TIME_STAMP_HL_ET)
DON’T KNOW -2 (TIME_STAMP_HL_ET)
PROGRAMMER INSTRUCTIONS:
IF FIRST LOOP CYCLE, DISPLAY “first hospitalization since” AND PRELOAD AND DISPLAY DATE OF MOST RECENT INTERVIEW.
IF SUBSEQUENT LOOP CYCLE DISPLAY “next hospitalization”.
HL006/(HOSP_VISIT_DIAG_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
LIMIT TEXT TO 255 CHARACTERS.
IF WCC_VISIT = 1 AND/OR ER_VISIT = 1 AND/OR HOSP_VISIT = 1, GO TO RECORD_RECALL.
OTHERWISE, GO TO TIME_STAMP_HL_ET.
HL010/(RECORD_RECALL). It is important for the study to know what type of records you used to help answer these questions. Which of the following did you use to help you recall {C_FNAME/the child}’s visits to the hospital or emergency room and {his/her} sick visits, well care visits, and the immunizations you told me about? Did you use…
INTERVIEWER INSTRUCTION:
SELECT ALL THAT APPLY
The Infant and Child Health Care Log, 1
A shot or immunization record (other than
the Infant and Child Health Care Log), 2
Some other type of personal record, -5
Your memory 4
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF RECORD_RECALL = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES.
(TIME_STAMP_HL_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
INTERIM MEDICATIONS
(TIME_STAMP_MED_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
MED001. Now I am going to ask some questions about presctiption medicines, over-the-counter medicines, and dietary supplements. If you have them available, please go and get the containers for all the medicines and supplements that have been given to {C_FNAME/the child}.
MED005/(PRESCR_TAKE). In the past 30 days, has {C_FNAME/the child} used or taken any medication for which a prescription is needed? Include only those products prescribed by a health professional such as a doctor or dentist. Do not include prescription vitamins or minerals.
YES 1
NO 2 (MED040)
REFUSED -1 (MED040)
DON’T KNOW -2 (MED040)
MED010/(PRESCRMED). Please list the name of all prescription medicines taken by {C_FNAME/the child} in the past 30 days:
INTERVIEWER INSTRUCTIONS:
ENTER ALL MEDICATIONS IN FIELD SEPARATED BY COMMAS OR “AND”.
ENTER UP TO 10 MEDICATIONS; IF MORE THAN 10 MEDICATIONS PROVIDED, ENTER FIRST 10 PROVIDED BY PARENT/CAREGIVER.
PROBE: “Anything else?”
REFUSED -1 (MED040)
DON’T KNOW -2 (MED040)
PROGRAMMER INSTRUCTIONS:
LIMIT TEXT TO 100 CHARACTERS PER MEDICATION.
IF FIRST LOOP, DISPLAY MED010A.
OTHERWISE, DISPLAY MED010B.
THEN LOOP THROUGH PRESCRMED_TIME AND PRESCRMED_12MO FOR EACH PRESCRIPTION LISTED IN PRESCRMED FOR UP TO 10 MEDICATIONS.
FOR MED010A, MED010B, PRESCRMED_TIME, AND PRESCRMED_12MO, DISPLAY CORRECT MEDICATION PRESCRMED for appropriate LOOP.
AFTER FINAL LOOP, GO TO MED040.
MED010A. First, let’s talk about {PRESCRMED_1}.
MED010B. Now let’s talk about {PRESCRMED_2_10}.
MED020/(PRESCRMED_TIME). How long has {C_FNAME/the child} taken this prescription medicine?
0-14 days 1
15-30 days 2
More than 30 days 3
REFUSED -1
DON’T KNOW -2
MED030/(PRESCRMED_12MO). Is this medication taken for a condition that has lasted or is expected to last for at least 12 months?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
MED040. Now I’d like to ask about non-prescription medications and over-the-counter medications that {C_FNAME/the child} may have taken in the last 30 days.
MED040A/(OTC_TAKE). Has {C_FNAME/the child} used or taken any non-prescription medicines in the past 30 days? Include only those products purchased over the counter that do not require a prescription. Do not include over-the-counter vitamins or minerals.
YES 1
NO 2 (SUPPL_TAKE)
REFUSED -1 (SUPPL_TAKE)
DON’T KNOW -2 (SUPPL_TAKE)
MED040B/(OTCMED). Please list the name of all non-prescription medicines taken by {C_FNAME/the child} in the past 30 days:
INTERVIEWER INSTRUCTIONS:
ENTER ALL MEDICATIONS IN FIELD SEPARATED BY COMMAS OR “AND”.
ENTER UP TO 10 MEDICATIONS; IF MORE THAN 10 MEDICATIONS PROVIDED, ENTER FIRST 10 PROVIDED BY PARENT/CAREGIVER.
PROBE: “Anything else?”
________________________________
REFUSED -1 (SUPPL_TAKE)
DON’T KNOW -2 (SUPPL_TAKE)
PROGRAMMER INSTRUCTIONS:
LIMIT TEXT TO 100 CHARACTERS PER MEDICATION.
IF FIRST LOOP, DISPLAY MED040C.
OTHERWISE, DISPLAY MED040D.
THEN DISPLAY OTCMED_TIME FOR EACH OTC MEDICATION LISTED IN OCTMED FOR UP TO 10 MEDICATIONS.
FOR MED040C, MED040D, and OTC_MED_time, DISPLAY CORRECT MEDICATION OTCMED for appropriate LOOP.
AFTER FINAL LOOP, GO TO MED060.
MED040C. First, let’s talk about {OTCMED_1}.
MED040D. Now let’s talk about {OTCMED_2_10}.
MED050/(OTCMED_TIME). How long has {C_FNAME/the child} taken this non-prescription medicine?
0-14 days 1
15-30 days 2
More than 30 days 3
REFUSED -1
DON’T KNOW -2
MED060/(SUPPL_TAKE). Has {C_FNAME/the child} used or taken any vitamins, minerals, herbals, or other dietary supplements in the past 30 days? Please include prescription vitamins and minerals in your answer.
YES 1
NO 2 (HOMEOPATH_TAKE)
REFUSED -1 (HOMEOPATH_TAKE)
DON’T KNOW -2 (HOMEOPATH_TAKE)
MED070/(SUPPLMED). Please list the names of all vitamins, minerals, herbals, and other dietary supplements taken by {C_FNAME/the child} in the past 30 days:
INTERVIEWER INSTRUCTIONS:
ENTER ALL MEDICATIONS IN FIELD SEPARATED BY COMMAS OR AN “AND”.
ENTER UP TO 10 SUPPLEMENTS; IF MORE THAN 10 SUPPLEMENTS PROVIDED, ENTER FIRST 10 PROVIDED BY PARENT/CAREGIVER.
________________________________
REFUSED -1 (HOMEOPATH_TAKE)
DON’T KNOW -2 (HOMEOPATH_TAKE)
PROGRAMMER INSTRUCTIONS:
LIMIT TEXT TO 100 CHARACTERS PER MEDICATION.
IF FIRST LOOP, DISPLAY MED070A.
OTHERWISE, DISPLAY MED070B.
THEN LOOP THROUGH SUPPLMED_TIME FOR EACH SUPPLEMENT IN SUPPLMED FOR UP TO 10 MEDICATIONS.
FOR MED070A, MED070B, AND SUPPLMED_TIME, DISPLAY CORRECT MEDICATION SUPPLMED for appropriate LOOP.
AFTER FINAL LOOP, GO TO HOMEOPATH_TAKE.
MED070A. First, let’s talk about {SUPPLMED_1}.
MED070B. Now let’s talk about {SUPPLMED_2_10}.
MED080/(SUPPLMED_TIME). How long has {C_FNAME/the child} taken these vitamins, minerals, herbals, and other dietary supplements?
0-14 days 1
15-30 days 2
More than 30 days 3
REFUSED -1
DON’T KNOW -2
MED090/(HOMEOPATH_TAKE). In the past 30 days, has {C_FNAME/the child} taken or used any homeopathic medicines or remedies?
YES 1
NO 2 (TIME_STAMP_MED_ET)
REFUSED -1 (TIME_STAMP_MED_ET)
DON’T KNOW -2 (TIME_STAMP_MED_ET)
MED100/(HOMEOPATHMED). Please list the names of all homeopathic medicines or remedies taken by {C_FNAME/the child} in the past 30 days:
INTERVIEWER INSTRUCTIONS:
ENTER ALL HOMEOPATHIC MEDICINES OR REMEDIES IN FIELD SEPARATED BY COMMAS OR “AND”.
ENTER UP TO 10 HOMEOPATHIC MEDICINES OR REMEDIES; IF MORE THAN 10 HOMEOPATHIC MEDICINES OR REMEDIES PROVIDED, ENTER FIRST 10 PROVIDED BY PARENT/CAREGIVER.
________________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
LIMIT TEXT TO 100 CHARACTERS PER MEDICATION.
IF FIRST LOOP, DISPLAY MED110A.
OTHERWISE, DISPLAY MED110B.
THEN LOOP THROUGH HOMEOPATHMED_TIME FOR EACH SUPPLEMENT IN HOMEOPATHMED FOR UP TO 10 MEDICATIONS.
FOR MED110A, MED110B, AND HOMEOPATHMED_TIME, DISPLAY CORRECT MEDICATION HOMEOPATHMED for appropriate LOOP.
AFTER FINAL LOOP, GO TO TIME_STAMP_MED_ET.
MED110A. First, let’s talk about {HOMEOPATHMED_1}.
MED110B. Now let’s talk about {HOMEOPATHMED_2_10}.
MED120/(HOMEOPATHMED_TIME). How long has {C_FNAME/the child} taken this homeopathic medicine or remedy?
0-14 days 1
15-30 days 2
More than 30 days 3
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_MED_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
CONCERN ABOUT CHILD’S DEVELOPMENT
(TIME_STAMP_CD_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
CD001. Now I would like to ask some questions about {C_FNAME/the child}’s development. Sometimes parents have concerns about their children. Are you concerned a lot, a little, or not at all about:
CD002/(CONCERN_SPEECH).
How {C_FNAME/the child} talks and makes speech sounds?
A LOT 1
A LITTLE 2
NOT AT ALL 3
REFUSED -1
DON’T KNOW -2
INTERVIEWER INSTRUCTION:
FOR CONCERN_UNDERSTAND, CONCERN_HANDS, CONCERN_ARMS, AND CONCERN_GETALONG, RE-READ INTRODUCTORY STATEMENT (Sometimes parents have concerns about their children. Sometimes parents have concerns about their children. Are you concerned a lot, a little, or not at all about:) AS NEEDED.
CD004/(CONCERN_UNDERSTAND). How {C_FNAME/the child} understands what you say?
A LOT 1
A LITTLE 2
NOT AT ALL 3
REFUSED -1
DON’T KNOW -2
CD005/(CONCERN_HANDS). How {C_FNAME/the child} uses his or her hands and fingers to do things?
A LOT 1
A LITTLE 2
NOT AT ALL 3
REFUSED -1
DON’T KNOW -2
CD006/(CONCERN_ARMS). How {C_FNAME/the child} uses his or her arms and legs?
A LOT 1
A LITTLE 2
NOT AT ALL 3
REFUSED -1
DON’T KNOW -2
CD007/(CONCERN_GETALONG). How {C_FNAME/the child} gets along with others?
A LOT 1
A LITTLE 2
NOT AT ALL 3
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_CD_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
DISABILITY
(TIME_STAMP_DS_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
DS001. With this next set of questions, we want to learn about people who have physical, mental, or emotional conditions that cause serious difficulties with their daily activities. Though different, these questions may sound similar to ones I asked earlier.
DS002/(DIS_DEAF). Is {C_FNAME/the child} deaf or does {C_FNAME/the child} have serious difficulty hearing?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
DS003/(DIS_BLIND). Is {C_FNAME/the child} blind or does {C_FNAME/the child} have serious difficulty seeing even when wearing glasses?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_DS_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
Public reporting burden for this collection of information is estimated to average 30 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |
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