3 6-11 Long Instrument

6-11 LONG
Section/Q#
	Sub#	Question/Intro Text	Response Categories	Skip Instructions
A. Your Child’s General Health
		To begin, we would like to ask you about your child’s general health.
1		In general, how would you describe your child’s health?
			Excellent
			Very Good
			Good
			Fair
			Poor
2		How would you describe the condition of your child’s teeth?
			Excellent
			Very Good
			Good
			Fair
			Poor
3		How well does each of these items describe your child?
			Definitely true
			Somewhat true
			Not true
	3a	Your child has difficulty with feeling anxious or depressed
	3b	Your child has difficulty with behavior problems, such as acting out, fighting, or arguing
	3c	Your child bullies or is cruel and mean to others
	3d	Your child argues too much
	3e	Your child is bullied, picked on, or excluded by other children
	3f	Your child has difficulty making and keeping friends
	3g	Your child shows interest and curiosity in learning new things
	3h	Your child works to finish tasks he or she starts.
	3i	Your child stays calm and in control when faced with a challenge
	3j	Your child cares about doing well in school
	3k	Your child does all required homework
4		During the past 12 months, has your child had difficulty with or experienced any of the following?
			Yes
			No
	4a	Breathing or other respiratory problems (such as wheezing or shortness of breath)
	4b	Eating or swallowing because of a health condition
	4c	Digesting food, including stomach/intestinal problems, constipation, or diarrhea
	4d	Repeated or chronic physical pain, including headaches or other back or body pain
	4e	Concentrating, remembering, or making decisions because of a physical, mental or emotional condition
	4f	Walking or climbing stairs
	4g	Dressing or bathing
	4h	Deafness or problems with hearing
	4i	Blindness or problems with seeing, even when wearing glasses
	4j	Toothaches
	4k	Bleeding gums
	4l	Decayed teeth or cavities
5		Chronic Conditions
		Has a doctor or other health care provider ever told you that your child has…
	5a1	Allergies (including food, drug, insect, or other)?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5a2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5a3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	5b1	Arthritis?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5b2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5b3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	5c1	Asthma?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5c2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5c3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	5d1	Blood Disorders (such as sickle cell disease, thalassemia, or hemophilia)?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5d2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5d3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	5e1	Brain injury, concussion or head injury?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5e2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5e3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	5f1	Cerebral Palsy?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5f2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5f3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	5g1	Cystic Fibrosis?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5g2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5g3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	5h1	Diabetes?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5h2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5h3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	5i1	Down Syndrome?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5i2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5i3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	5j1	Epilepsy or seizure disorder?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5j2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5j3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	5k1	Genetic or inherited condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5k2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5k3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	5l1	Heart condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5l2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5l3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	5m1	Frequent or severe headaches, including migraine?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5m2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	5m3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	5n1	Tourette Syndrome?		If Yes, skip to next sub question. Else, skip to next section.
			Yes
			No
	5n2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next section.
			Yes
			No
	5n3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
6		Emotional, Behavioral, and Developmental Conditions/Problems
		Has a doctor or other health care provider ever told you that your child has…
	6a1	Anxiety Problems?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	6a2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	6a3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	6b1	Depression?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	6b2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	6b3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	6c1	Behavioral or Conduct Problems?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	6c2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	6c3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	6d1	Substance Abuse Disorder?
			Yes
			No
	6d2	If yes, does the child currently have the condition?
			Yes
			No
	6d3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	6e1	Developmental Delay?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	6e2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	6e3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	6f1	Intellectual Disability (also known as Mental Retardation)?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	6f2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	6f3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	6g1	Speech or other language disorder?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	6g2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	6g3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	6h1	Learning Disability?		If Yes, skip to next sub question. Else, skip to next section.
			Yes
			No
	6h2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next section.
			Yes
			No
	6h3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	6i1	Any Other Mental Health Condition? If yes, please specify.		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	6i2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	6i3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
7	7a	Has a doctor or other health care provider ever told you that your child had Autism or Autism Spectrum Disorder (ASD)? Please include diagnoses of Asperger’s Disorder or Pervasive Developmental Disorder (PDD))?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	7b	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to subpart c.
			Yes
			No
	7b1	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	7c	How old was your child when a doctor or other health care provider first told you that he or she had Autism, ASD or PDD?
			[AGE]
			Don't Know
	7d	What type of doctor or other health care provider was the first to tell you that your child had Autism, ASD or PDD? (Please check only one)
			Primary Care Provider
			Specialist
			School Psychologist/Counselor
			Other Psychologist (Non-School)
			Psychiatrist
			Other, Specify
			Don't Know
	7e	Is your child currently taking medication for Autism, ASD or PDD?
			Yes
			No
	7f	At any time during the past 12 months, did your child receive behavioral treatment for Autism, ASD or PDD, such as training or an intervention that you or your child received to help with his/her behavior?
			Yes
			No
8	8a	Has a doctor or other health care provider ever told you that your child had Attention Deficit Disorder or Attention-Deficit/Hyperactivity Disorder, that is, ADD or ADHD?		If Yes, skip to next sub question. Else, skip to next section.
			Yes
			No
	8b	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to subpart c.
			Yes
			No
	8b1	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	8b2	Is your child currently taking medication for ADD or ADHD?
			Yes
			No
	8c	At any time during the past 12 months, did your child receive behavioral treatment for ADD or ADHD, such as training or an intervention that you or your child received to help with his/her behavior?
		Please answer the following questions only if your child currently has any health conditions or problems. Otherwise, skip to Section B (Infant Health).
9		During the past 12 months, how often have your child’s health conditions or problems affected his or her ability to do things other children his/her age do?		If Never, skip to next section. Else, skip to Q10.
			Never
			Sometimes
			Usually
			Always
10		To what extent do your child’s health conditions or problems affect his/her ability to do things?
			A great deal
			Some
			Very little
B. Infant Health
1		Was your child born more than 3 weeks before his or her due date?
			Yes
			No
2		How much did he or she weigh when born? Please provide your best estimate.
			[POUNDS]
			[OUNCES]
			[GRAMS]
C. Health Care Services
		Next, we would like to ask you about your child’s use of health care and services.
1		During the past 12 months, did your child see a doctor, nurse, or other health care professional for sick-child care, well-child check-ups, physical exams, hospitalizations or any other kind of medical care?
			Yes
			No	Skip to Q4.
2		During the past 12 months, how many times did your child visit a doctor, nurse, or other health care professional to receive a preventive check-up? A preventive check-up is when your child was not sick or injured, such as an annual or sports physical, or well-child visit.
			0 visits	Skip to Q4.
			1 visit
			2 or more visits
3		Thinking about the last time you took your child for a preventive check-up, about how long was the doctor or healthcare provider who examined your child in the room with you? Your best estimate is fine.
			Less than 10 minutes
			10-20 minutes
			More than 20 minutes
4		What is your child’s current height?
			[FEET]
			[INCHES]
			[METERS]
			[CENTIMETERS]
5		How much does your child currently weigh?
			[POUNDS]
			[KILOGRAMS]
6		Are you concerned about your child’s weight?
			Yes, too high
			Yes, too low
			No, I am not concerned
7		Is there a place that your child usually goes when he or she is sick or you need advice about his or her health?
			Yes, there is a usual place
			No, there is no usual place	Skip to Q8
	7a	Where does your child usually go? Please check one box below:
			Doctor’s Office
			Hospital Emergency Department
			Hospital Outpatient Department
			Clinic or Health Center
			Retail Store Clinic or “Minute Clinic”
			School (Nurse’s Office, Athletic Trainer’s Office)
			Some other place
8		Is there a place that your child usually goes when he or she needs routine preventive care, such as a physical examination or well-child check-up?
			Yes
			No	Skip to Q9.
	8a	Is that the same place where your child goes when he or she is sick?
			Yes
			No
9		During the past 12 months, did your child see a dentist or other oral health care provider for any kind of dental care?
			Yes
			No	Skip to Q10.
	9a	During the past 12 months, how many times did your child see a dentist or other oral health care provider for preventive dental care, such as check-ups and dental cleanings?
			No preventive visits in past 12 months	Skip to Q10.
			1 visit
			2 or more visits
	9b	During the past 12 months, did your child receive any of the following preventive dental services:
			Checkup
			Cleaning
			Instruction on tooth brushing and oral health care
			X-Rays
			Fluoride treatment
			Sealant (plastic coatings on back teeth)
			Don't Know
10		During the past 12 months, has your child received any treatment or counseling from a mental health professional? Mental health professionals include psychiatrists, psychologists, psychiatric nurses, and clinical social workers.
			Yes
			No, but my child needed to see a mental health professional
			No. My child did not need to see a mental health professional.	Skip to Q11.
	10a	How much of a problem was it to get the mental health treatment or counseling that your child needed?
			Big problem
			Small problem
			Not a problem
12		During the past 12 months, has your child taken any medication because of difficulties with his or her emotions, concentration, or behavior?
			Yes
			No
11		During the past 12 months, did your child see a specialist other than a mental health professional? Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and others who specialize in one area of health care.
			Yes
			No, but my child needed to see a specialist
			No. My child did not need to see a specialist.	Skip to Q12.
	11a	How much of a problem was it to get the specialist care that your child needed?
			Big problem
			Small problem
			Not a problem
13		During the past 12 months, did your child use any type of alternative health care or treatment? Alternative health care can include acupuncture, chiropractic care, relaxation therapies, herbal supplements, and others. Some therapies involve seeing a health care provider, while others can be done on your own.
			Yes
			No
14		Sometimes people have difficulty getting health care when they need it. During the past 12 months, was there any time when your child needed health care but it was not received? By health care, we mean medical care as well as other kinds of care like dental care, vision care, and mental health services.
			Yes
			No	Skip to Q16.
	14a	If yes, which type of care was not received? Check all that apply.
			Medical Care
			Dental Care
			Vision Care
			Hearing Care
			Mental Health Services
			Other (specify)______________________
15		Were these difficulties in getting services for your child because:
			Yes
			No
	15a	Your child was not eligible for the services?
	15b	The services your child needed were not available in your area?
	15c	There were problems getting an appointment when your child needed one?
	15d	There were problems with getting transportation or child care?
	15e	The (clinic/doctor's) office wasn't open when your child needed care?
	15f	There were issues related to cost?
16		During the past 12 months, how often were you frustrated in your efforts to get services for your child?
			Never
			Sometimes
			Usually
			Always
17		During the past 12 months, how many times did your child visit a hospital emergency department?
			1 visit
			2 or more visits
			No visits
18		Does your child receive Special Educational Services? Children receiving these services often have an Individualized Family Service Plan or Individualized Education Plan.
			Yes
			No
19		Has your child ever received therapy services to meet his/her developmental needs, such as occupational therapy, speech therapy, or behavioral therapy?
			Yes
			No	Skip to next section.
	19a	How old was your child when he/she began receiving these therapy services?
			[YEARS OF AGE]
			Don't Know
	19b	Is your child currently receiving these therapy services?
			Yes
			No
D. Experience with Your Child’s Health Care Providers
		Next we would like to ask you about your child’s health care providers and experiences with receiving health care services.
1		Does your child have a primary doctor or nurse? A primary doctor or nurse is the one your child would see if he or she needs a check-up or gets sick or hurt.
			Yes
			No
2		During the past 12 months, did your child need a referral to see any doctors or receive any services?
			Yes
			No	Skip to Q3.
	2a	Was getting referrals a big problem, a small problem, or not a problem?
			Big problem
			Small problem
			Not a problem
		Please answer the following questions only if your child had a health care visit in the past 12 months. Otherwise, skip to Section E (Your Child's Health Insurance Coverage).
3		During the past 12 months, how often did your child’s doctors or other health care providers:
			Never
			Sometimes
			Usually
			Always
	3a	Spend enough time with your child?
	3b	Listen carefully to you?
	3c	Show sensitivity to your family’s values and customs?
	3d	Provide the specific information you needed concerning your child?
	3e	Help you feel like a partner in your child’s care?
4		During the past 12 months, were any decisions needed about your child’s health care services or treatment, such as whether to start or stop a prescription or therapy services, get a referral to a specialist, or have a medical procedure?
			Yes
			No, no health care decisions were needed	Skip to next section.
5		During the past 12 months, how often did your child’s doctors or other healthcare providers:
			Never
			Sometimes
			Usually
			Always
	5a	Discuss with you the range of options to consider for his or her health care or treatment?
	5b	Make it easy for you to raise concerns or disagree with recommendations for your child’s health care?
	5c	Work with you to decide together which health care and treatment choices would be best for your child?
6		Does anyone help you arrange or coordinate your child’s care among the different doctors or services that your child uses?
			Yes
			No
			Did not see more than one health care provider in past 12 months	Skip to Q8.
	6a	During the past 12 months, have you felt that you could have used extra help arranging or coordinating your child’s care among the different health care providers or services?
			Yes
			No	Skip to Q7.
	6b	During the past 12 months, how often did you get as much help as you wanted with arranging or coordinating your child’s health care?
			Never
			Sometimes
			Usually
			Always
7		Overall, how satisfied are you with the communication among your child’s doctors and other health care providers?
			Very satisfied
			Somewhat satisfied
			Somewhat dissatisfied
			Very dissatisfied
8		During the past 12 months, did your child’s health care provider communicate with the child’s school, child care provider, or special education program?
			Yes
			No	Skip to next section.
	8a	Overall, how satisfied are you with that communication?
			Very satisfied
			Somewhat satisfied
			Somewhat dissatisfied
			Very dissatisfied
E. Your Child’s Health Insurance Coverage
1		During the past 12 months, was your child EVER covered by ANY kind of health insurance or health coverage plan?
			Yes, my child was covered all 12 months	Skip to Q3.
			Yes, but my child had a gap in coverage
			No
2		Please indicate whether any of the following is a reason your child was not covered by health insurance during the past 12 months:
			Yes
			No
	2a	Change in employer or employment status
	2b	Cancellation due to overdue premiums
	2c	Dropped coverage because it was unaffordable
	2d	Dropped coverage because benefits were inadequate
	2e	Dropped coverage because choice of health care providers was inadequate
	2f	Problems with application or renewal process
	2g	Other (specify)__________________________
3		Is your child CURRENTLY covered by ANY kind of health insurance or health coverage plan?
			Yes
			No	Skip to next section.
4		Is your child covered by any of the following types of health insurance or health coverage plans?
			Yes
			No
		Insurance through a current or former employer or union
		Insurance purchased directly from an insurance company
		Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability
		TRICARE or other military health care
		Indian Health Service
		Other (specify) __________________
5		How often does your child’s health insurance offer benefits or cover services that meet your child’s needs?
			Never
			Sometimes
			Usually
			Always
6		How often does your child’s health insurance allow him/her to see the health care providers he/she needs?
			Never
			Sometimes
			Usually
			Always
7		Not including health insurance premiums or costs that are covered by insurance, do you pay any money for your child’s health care?
			Yes
			No	Skip to Q8.
	7a	How often are these costs reasonable?
			Never
			Sometimes
			Usually
			Always
		Please answer the next question only if your child uses mental or behavioral health services. Otherwise, skip to Section F (Providing for your child's health).
8		Finally, thinking specifically about your child’s mental or behavioral health needs, does your child’s health insurance offer benefits or cover services that meet these needs?
			No, it never covers these services
			Yes, it sometimes covers these services
			Yes, it usually covers these services
			Yes, it always covers these services
F. Providing for Your Child’s Health
		Now we would like to ask you if your child’s health has any impact on your family.
1		How much money did you pay for this child’s medical and health care during the past 12 months? Please do not include health insurance premiums or costs that were or will be reimbursed by insurance or another source.
			$0 (No medical or health-related expenses)	Skip to Q3.
			$1-$249
			$250-$499
			$500-$999
			$1,000-$5,000
			More than $5,000
2		During the past 12 months, did your family have problems paying for any of your child’s medical or health care bills?
			Yes
			No
3		During the past 12 months, have you or other family members:
			Yes
			No
	3a	Stopped working because of your child’s health status?
	3b	Cut down on the hours you work because of your child’s health or health conditions?
	3c	Avoided changing jobs because of concerns about maintaining health insurance for your child?
4		In an average week, how many hours do you or other family members spend providing health care at home for your child? Care might include changing bandages, or giving medication and therapies when needed.
			Less than 1 hour per week
			1-4 hours per week
			5-10 hours per week
			11 or more hours per week
5		In an average week, how many hours do you or other family members spend arranging or coordinating health or medical care for your child, such as making appointments or locating services?
			Less than 1 hour per week
			1-4 hours per week
			5-10 hours per week
			11 or more hours per week
G. Your Child's Schooling and Activities
		This next set of questions asks about your child's schooling and extracurricular activities.
1		During the past 12 months, about how many days did your child miss school because of illness or injury?
			No missed school days
			1-3 days
			4-6 days
			7-10 days
			11 or more days
2		During the past 12 months, how many times has your child’s school contacted you or another adult in your household about any problems he/she is having with school?
			No calls home
			1 time
			2 or more times
3		Since starting kindergarten, has your child repeated any grades?
			Yes
			No
4		During the past 12 months, did your child participate in:
			Yes
			No
	4a	A sports team or did he/she take sports lessons after school or on weekends?
	4b	Any clubs or organizations after school or on weekends?
	4c	Any other organized activities or lessons, such as music, dance, language, or other arts?
	4d	Any type of community service or volunteer work at school, church, or in the community?
	4e	Any paid work, including regular jobs as well as babysitting, cutting grass, or other occasional work?
5		During the past 12 months, how often did you attend events or activities that your child participated in?
			Never
			Sometimes
			Usually
			Always
6		During the past week, on how many days did your child exercise, play a sport, or participate in physical activity for at least 60 minutes?
			0 days
			1-3 days
			4-6 days
			Every day
H. About Your Child
1		Was your child born in the United States?
			Yes	Skip to Q2.
			No
	1a	How long has your child been in the United States?
			[YEARS]
			[MONTHS]
2		How many times has your child moved to a new address since he or she was born?
			[NUMBER OF TIMES]
		We would now like to ask some questions about your child’s sleeping behaviors.
3		How often does your child go to bed at about the same time on weeknights?
			Never
			Rarely
			Sometimes
			Usually
			Always
4		During the past week, how many hours of sleep did your child get on an average weeknight?
			Less than 6 hours
			6-7 hours
			8-9 hours
			10 or more hours
5		On an average weekday, about how much time does your child usually spend in front of a TV watching TV programs, videos, or playing video games?
			None
			Less than 1hour
			1-2 hours
			3-4 hours
			More than 4 hours
6		On an average weekday, about how much time does your child usually spend with computers, cell phones, handheld video games, and other electronic devices, doing things other than schoolwork?
			None
			Less than 1hour
			1-2 hours
			3-4 hours
			More than 4 hours
7		How well can you and your child share ideas or talk about things that really matter?
			Very well
			Somewhat well
			Not very well
			Not very well at all
8		In general, how well do you feel that you are coping with the day-to-day demands of raising children?
			Very well
			Somewhat well
			Not very well
			Not very well at all
9		During the past month, how often have you felt:
			Never
			Rarely
			Sometimes
			Usually
			Always
	9a	That your child is much harder to care for than most children his/her age?
	9b	That your child does things that really bother you a lot?
	9c	Angry with your child?
10		During the past 12 months, was there someone that you could turn to for day-to-day emotional support  with parenting or raising children?
			Yes
			No	Go to next section.
11		If yes, did you receive this emotional support from:
			Yes
			No
	11a	Healthcare provider?
	11b	Family member or close friend?
	11c	Place of worship or religious leader?
	11d	Support or advocacy group related to specific health condition?
	11e	Peer support group?
	11f	Counselor or other mental health professional?
	11g	Other (specify)
I. About Your Family and Household
1		During the past week, on how many days did all the family members who live in the household eat a meal together?
			0 days
			1-3 days
			4-6 days
			Every day
2		Does anyone living in your household use cigarettes, cigars, or pipe tobacco?
			Yes
			No	Skip to Q3.
	1a	Does anyone smoke inside your home?
			Yes
			No
3		When your family faces problems, how often are you likely to do each of the following?
			None of the time
			Some of the time
			Most of the time
			All of the time
	3a	Talk together about what to do
	3b	Work together to solve our problems
	3c	Know we have strengths to draw on
	3d	Stay hopeful even in difficult times
4		Since your child was born, how often has it been very hard to get by on your family’s income – hard to cover the basics like food or housing?
			Very often
			Somewhat often
			Rarely
			Never
5		The next question is about whether you were able to afford the food you need. Which of these statements best describes the food situation in your household in the last 12 months:
			We could always afford to eat good nutritious meals
			We could always afford enough to eat but not always the kinds of food we should eat
			Sometimes we could not afford enough to eat
			Often we could not afford enough to eat
6		At any time during the past 12 months, even for one month, did anyone in this household receive:
			Yes
			No
	6a	Cash assistance from a government welfare program?
	6b	Food Stamps or Supplemental Nutrition Assistance Program benefits?
	6c	Free or reduced-cost breakfasts or lunches at school?
	6d	Benefits from the Women, Infants, and Children (WIC) Program?
7		In your neighborhood, are there:
			Yes
			No
	7a	Sidewalks or walking paths?
	7b	A park or playground?
	7c	A recreation center, community center, or boys’ and girls’ club?
	7d	A library or bookmobile?
	7e	Litter or garbage on the street or sidewalk?
	7f	Poorly kept or rundown housing?
	7g	Vandalism such as broken windows or graffiti?
8		To what extent do you agree with these statements about your neighborhood or community:
			Definitely agree
			Somewhat agree
			Somewhat disagree
			Definitely disagree
	8a	People in this neighborhood help each other out.
	8b	We watch out for each other’s children in this neighborhood.
	8c	My child is safe in our neighborhood.
	8d	When we encounter difficulties, we know where to go for help in our community.
	8e	My child is safe at school.
9		Other than you or other adults in your home, is there at least one other adult in your child’s school, neighborhood, or community who knows your child well and who he/she can rely on for advice or guidance?
			Yes
			No
		Families must sometimes face hardships such as divorce or separation, the loss of a loved one, or drug and alcohol addiction. The next question asks about experiences and events that may have occurred during your child’s life. We understand the sensitive nature of this question so we ask that you answer to the best of your ability.
10		To the best of your knowledge, has your child ever experienced any of the following?
			Yes
			No
	10a	Parent/guardian divorced or separated
	10b	Parent/guardian died
	10c	Parent/guardian served time in jail
	10d	Saw or heard parents or adults slap, hit, kick, punch one another in the home
	10e	Was a victim of violence or witnessed violence in neighborhood
	10f	Lived with anyone who was mentally ill, suicidal, or severely depressed
	10g	Lived with anyone who had a problem with alcohol or drugs
	10h	Was ever discriminated against
J. Adult Demographics
		Please fill out a column for each of the two adults in the household who are the child’s primary caregivers. If there is just one adult, please provide answer for that adult.
		ADULT 1 (Respondent)
1		How are you related to the selected child?
			Biological or Adoptive Parent
			Step-parent
			Grandparent
			Foster Parent
			Aunt or Uncle
			Other: Relative
			Other: Non-Relative
2		What is your sex?
			Male
			Female
3		What is your age?
			[AGE IN YEARS]
4		Where were you born?
			In the United States	Go to Q5.
			Outside of the United States
	4a	When did you come to the United States?
			[YEAR]
5		What is the highest grade or year of school you have completed?
			8th grade or less
			9th-12th grade; No diploma
			High School Graduate or GED Completed
			Completed a vocational, trade, or business school program
			Some College Credit, but No Degree
			Associate Degree (AA, AS)
			Bachelor’s Degree (BA, BS, AB)
			Master’s Degree (MA, MS, MSW, MBA)
			Doctorate (PhD, EdD) or Professional Degree (MD, DDS, DVM, JD)
6		What is your marital status?
			Married
			Not married, but living with a partner
			Never Married
			Divorced
			Separated
			Widowed
7		In general, what is your physical health status?
			Excellent
			Very Good
			Good
			Fair
			Poor
8		In general, what is your mental or emotional health status?
			Excellent
			Very Good
			Good
			Fair
			Poor
		ADULT 2
1		How is Adult 2 related to the selected child?
			Biological or Adoptive Parent
			Step-parent
			Grandparent
			Foster Parent
			Aunt or Uncle
			Other: Relative
			Other: Non-Relative
2		What is Adult 2's sex?
			Male
			Female
3		What is Adult 2's age?
			[AGE IN YEARS]
4		Where was Adult 2 born?
			In the United States	Go to Q5.
			Outside of the United States
	4a	When did Adult 2 come to the United States?
			[YEAR]
5		What is the highest grade or year of school Adult 2 has completed?
			8th grade or less
			9th-12th grade; No diploma
			High School Graduate or GED Completed
			Completed a vocational, trade, or business school program
			Some College Credit, but No Degree
			Associate Degree (AA, AS)
			Bachelor’s Degree (BA, BS, AB)
			Master’s Degree (MA, MS, MSW, MBA)
			Doctorate (PhD, EdD) or Professional Degree (MD, DDS, DVM, JD)
6		In general, what is Adult 2's physical health status?
			Excellent
			Very Good
			Good
			Fair
			Poor
7		In general, what is Adult 2's mental or emotional health status?
			Excellent
			Very Good
			Good
			Fair
			Poor
1		Was anyone in the household employed at least 50 weeks out of the past 52 weeks?
			Yes
			No
2		The following question is about your income and is very important for our research. Think about your total combined family income during last year for all members of the family. Can you please tell us that amount before taxes? Include money from jobs, child support, social security, retirement income, unemployment payments, public assistance, and so forth. Also, include income from interest, dividends, net income from business, farm, or rent, and any other money income received.
			[INCOME AMOUNT]
			Don't Know/Don't Remember
3		For the purposes of this survey, it is important to get at least a range for the total income received by all members of your household last year. To the best of your knowledge, please select the range that best applies to your household.
			No income
			Less than $20,000
			$20,000 - $29,999
			$30,000 - $49,999
			$50,000 - $69,999
			$70,000 - $99,999
			$100,000 - $124,999
			$125,000 - $149,999
			$150,000 or more
4		How many people are living or staying at this address? Please include everyone who is living or staying here for more than two months. Include yourself if you are living here for more than two months. Include anyone else staying here how does not have another place to stay, even if they are here for two months or less. Do NOT include anyone who is living somewhere else for more than two months, such as a college student living away or someone in the Armed Forces on deployment.
			[NUMBER]
END QUESTIONNAIRE

Color	Code
	All age groups (0-5, 6-11, 12-17)
	0-5 Only
	6-11 Only
	12-17 Only
	Older age groups (6-11, 12-17)
	Not Applicable
RED	Test/Retest Item
GRAY	Item excluded from Short version

6-11 LONG v1.2