3 6-11 Long Instrument

Questionnaire and Data Collection Testing, Evaluation, and Research for the Health Resources and Services Administration (HRSA)

6-11 UNFORMATTED Long_v1.2

Experiments to Support the Redesign of the National Survey of Children's Health

OMB: 0915-0379

Document [docx]
Download: docx | pdf

6-11 LONG

 

 

 

Section/Q#

 

 

 

 

 

Sub#

Question/Intro Text

Response Categories

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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

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMarie Kirsch
File Modified0000-00-00
File Created2021-01-28

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