10 Test-Retest

Test-Retest Instrument

[Administered over the phone for respondents assigned to the test-retest validation condition]

Hello. This is [INTERVIEWER NAME] from NORC at the University of Chicago. We are calling to follow up on the interview you completed with us a few weeks back. We would like to ask you a few more questions to confirm some of the answers you gave during the interview. This should take about 20 minutes to complete.

#		Question	Response Options	Skip Instructions
1		First, we would like to ask some question about Chronic Conditions.
		Has a doctor or other health care provider ever told you that your child has…
	1a1	Allergies (including food, drug, insect, or other)?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1a2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1a3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	1b1	Arthritis?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1b2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1b3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	1c1	Asthma?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1c2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1c3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	1d1	Blood Disorders (such as sickle cell disease, thalassemia, or hemophilia)?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1d2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1d3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	1e1	Brain injury, concussion or head injury?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1e2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1e3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	1f1	Cerebral Palsy?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1f2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1f3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	1g1	Cystic Fibrosis?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1g2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1g3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	1h1	Diabetes?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1h2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1h3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	1i1	Down Syndrome?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1i2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1i3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	1j1	Epilepsy or seizure disorder?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1j2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1j3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	1k1	Genetic or inherited condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1k2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1k3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	1l1	Heart condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1l2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1l3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	1m1	Frequent or severe headaches, including migraine?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1m2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	1m3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	1n1	Tourette Syndrome?		If Yes, skip to next sub question. Else, skip to next section.
			Yes
			No
	1n2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next section.
			Yes
			No
	1n3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
2		Now we would like to ask some questions about Emotional, Behavioral, and Developmental Conditions and Problems.
		Has a doctor or other health care provider ever told you that your child has…
	2a1	Anxiety Problems?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	2a2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	2a3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	2b1	Depression?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	2b2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	2b3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	2c1	Behavioral or Conduct Problems?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	2c2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	2c3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
[INTERVIEWER INSTRUCTION: ONLY ADMINISTER SUBSTANCE ABUSE ITEM FOR CHILDREN AGE 6 OR OLDER]
	2d1	Substance Abuse Disorder?
			Yes
			No
	2d2	If yes, does the child currently have the condition?
			Yes
			No
	2d3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	2d1	Developmental Delay?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	2d2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	2d3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	2e1	Intellectual Disability (also known as Mental Retardation)?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	2e2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	2e3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	2f1	Speech or other language disorder?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	2f2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	2f3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	2g1	Learning Disability?		If Yes, skip to next sub question. Else, skip to next section.
			Yes
			No
	2g2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next section.
			Yes
			No
	2g3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	2h1	Any Other Mental Health Condition? If yes, please specify.		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	2h2	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to next condition.
			Yes
			No
	2h3	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
3	3a	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
	3b	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to subpart c.
			Yes
			No
	3b1	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	3c	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
	3d	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
	3e	Is your child currently taking medication for Autism, ASD or PDD?
			Yes
			No
	3f	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
4	4a	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
	4b	If yes, does the child currently have the condition?		If Yes, skip to next sub question. Else, skip to subpart c.
			Yes
			No
	4b1	If yes, would you describe it as mild, moderate, or severe?
			Mild
			Moderate
			Severe
	4b2	Is your child currently taking medication for ADD or ADHD?
			Yes
			No
	4c	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?
		Next, we would like to ask some questions about your child’s health insurance coverage.
5		Is your child CURRENTLY covered by ANY kind of health insurance or health coverage plan?
			Yes
			No	Skip to next section.
5		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) __________________

Thank you for taking the time to answer these questions.