2015 Sample Child Core Questionnaire

National Health Interview Survey

Attachment 3c - Sample Child Questionnaire

Sample Child Core Questionnaire

OMB: 0920-0214

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Download: pdf | pdf
Attachment 3c - Sample Child Core

2015 Q1 NHIS Instrument Spec Report
Section name: Child Identification and Verification
Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.001

Variable Name

CURRES

Universe

HHSTAT4 = 'C' and (CSTAT = empty or CSTAT = '2')

Universe-text

Sample child section not started or not completed

Question Text

* Enter the line number of the person to whom you are speaking.

Answer Codes

01-25

Question Type

Integer

Field Pane Description

Line Number of Current Respondent

Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Allowable entries are all non-deleted persons in the family with AGE ge '18' or with
HHSTAT4 = 'E'. Allow only the line numbers of these persons to be acceptable entries.

Skip Instructions

if CSTAT ne empty and CSTAT ne '2' THEN
if ASTAT = empty or ASTAT = '2' THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG ne '1' THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif
goto back.OUTCOMEB1 procedure
endif
<01-25> if this is NOT an allowable line number
goto ERR_CURRES
elseif CURRES = a line number entered in KNOWSC2
store CURRES in CSPAVAIL and CSRESP
goto CSRELTIV
elseif KNOWSC2 = 'Don't know' or 'Refused' or empty (no line numbers in
KNOWSC2)
goto KNOAVAIL
else
goto CSPAVAIL
endif

Hard Edits

ERR_CURRES
* You have selected a non-selectable person.

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* Please correct.

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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.009

Variable Name

CSRESP

Universe
Universe-text
Question Text
Answer Codes

01-25, 96

Question Type

Integer

Field Pane Description
Fill Instructions
Special Instructions Storage variable for the line number of the Sample Child section respondent.
Skip Instructions
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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.010

Variable Name

CSPAVAIL

Universe

KNOWSC2 ne empty and KNOWSC2 ne 'Don't know' and KNOWSC2 ne 'Refused'
and CURRES ne empty and CURRES ne any line number in KNOWSC2

Universe-text

Someone identified as knowledgeable about child's health and knowledgeable
person(s) not entered in CURRES

Question Text

The next questions are about [fill1: ALIAS of Sample Child].
Is [fill2:KNOWSC2 names] available to answer some questions about [fill3: HISHER]
health?
* Enter line number of available respondent from list or enter '96' if no one is available.
* If refused enter CTRL_R.

Answer Codes

display roster of line numbers and names for all persons listed on KNOWSC2
96. No one available
Refused

Question Type

Pick One - answer list pane

Field Pane Description
Fill Instructions

Line Number of Available Respondent

fill2 = [all names for line numbers entered in KNOWSC2]
display up to three names with the word "or" between each name in the question text

Special Instructions Do not allow "Don't Know" as an answer.
Skip Instructions

<01-25> if line number not equal one of the line numbers in KNOWSC2
goto child.cid.ERR_CSPAVAIL
else
store child.cid.CSPAVAIL in child.cid.CSRESP
goto child.cid.CSRELTIV
endif
<96> store child.cid.CSPAVAIL in child.cid.CSRESP
goto cbk.CCALLBK1
 store '4' in CSTAT(FAMINT)
if ASTAT = empty or ASTAT = '2' THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG ne '1' THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif

Hard Edits

ERR_CSPAVAIL
* You have selected a non-selectable person.
* Please correct.

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Soft Edits
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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.015

Variable Name

KNOAVAIL

Universe

(KNOWSC2 = empty or KNOWSC2 = 'Don't know' or KNOWSC2 = 'Refused') and
CURRES ne empty

Universe-text

No line numbers entered in KNOWSC2 and some person's line number entered in
CURRES

Question Text

The next questions are about [fill1: ALIAS of Sample Child]. Is there any family
member available who can answer questions about [fill2: HISHER] health?
* Enter line number of available respondent from list or enter "96" if no one is available.
* If refused enter CTRL_R.

Answer Codes

display roster of line numbers and names of all non-deleted adults (AGE ge '18') and
emancipated minors (HHSTAT4 = 'E') in the family
96. No one available
Refused

Question Type

Pick One - answer list pane

Field Pane Description

Line Number of Any Respondent Available

Fill Instructions
Special Instructions Do not allow "Don't Know" as an answer.
Skip Instructions

<01-25> if line number is not an adult or emancipated minor
goto child.cid.ERR_KNOAVAIL
else
store child.cid.KNOAVAIL in child.cid.CSRESP
goto child.cid.CSRELTIV
endif
<96> store child.cid.KNOAVAIL in child.cid.CSRESP
goto cbk.CCALLBK1
 store '4' in CSTAT(FAMINT)
if ASTAT = empty or ASTAT = '2' THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG ne '1' THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif

Hard Edits

ERR_KNOAVAIL
* You have selected a non-selectable person.
* Please correct.

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AssocHelp
Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.030

Variable Name

CSRELTIV

Universe

(CURRES ne empty and CURRES = line number entered in KNOWSC2) or
(CSPAVAIL ne empty and CSPAVAIL ne '96' and CSPAVAIL ne 'Refused') or
(KNOAVAIL ne empty and KNOAVAIL ne '96' and KNOAVAIL ne 'Refused')

Universe-text

Someone identified as knowledgeable about child's health

Question Text

(book) C1
[fill1: The next questions are about [fill2: ALIAS of Sample Child].]
What is your relationship to [fill2: ALIAS of Sample Child]?

Answer Codes

1. Parent (Biological, adoptive, or step)
2. Grandparent
3. Aunt/Uncle
4. Brother/Sister
5. Other relative
6. Legal guardian
7. Foster parent
8. Other non-relative
Refused
Don't know

Question Type

Pick One - answer list pane

Field Pane Description
Fill Instructions

Child Respondent's Relationship to Child

[fill1: The next questions are about [fill2: ALIAS of Sample Child].] is a fill of the lead-in
statement for situations where CSRELTIV is the next question asked after CURRES
{i.e., CURRES = a line number entered in KNOWSC2).

Special Instructions if CURRES = a line number entered in KNOWSC2 then
display [fill1:] before the question text on this screen
else
display only the question text
endif

Skip Instructions

<1-8,R,D> If CSRESP = demographics.hhc.RELRESP_A
goto child.chs.BWGT_LB
elseif CSRESP = demographics.hhc.HHRESP
goto child.chs.BWGT_LB
else]
goto CSPVERF_S
endif]

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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.035

Variable Name

SCDATE

Universe

CSRELTIV = response

Universe-text

Sample Child section has been started and child respondent's relationship given.

Question Text
Answer Codes
Question Type

Instrument Out Variable

Field Pane Description
Fill Instructions
Special Instructions Set only if SCDATE = empty
If CSRELTIV ne empty
set SCDATE = CDATE (current date) (now called ComputationDate)
endif
This is an output variable that should be in the format 'MMDDYYYY'

Skip Instructions
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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.036

Variable Name

SCTIME

Universe

CSRELTIV = response

Universe-text

Sample Child section has been started and child respondent's relationship given.

Question Text
Answer Codes
Question Type

Instrument Out Variable

Field Pane Description
Fill Instructions
Special Instructions Set only if SCTIME = empty
If CSRELTIV ne empty
set SCTIME = current time
endif
This is an output variable that should be in the format "HH:MM [fill: a.m./p.m.]

Skip Instructions
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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.040

Variable Name

CSPVERF_S

Universe

RELRESP_A ne CSRESP and HHRESP ne CSRESP

Universe-text

Respondent is not the person entered in HHRESP or RELRESP_A.

Question Text

* Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]'s sex as [fill2: Sex of Sample Child]. Is
this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".

Answer Codes

1. Yes
2. No

Question Type

Yes/No

Field Pane Description

Verified Child's Sex

Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Skip Instructions

<1> goto CSPVERF_A
<2> goto NEWSEX

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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.041

Variable Name

NEWSEX

Universe

CSPVERF_S = '2' (No)

Universe-text

Respondent said child's sex is not correct.

Question Text

Is [fill: ALIAS of Sample Child] Male or Female?
*If don't know or refused enter your best guess.

Answer Codes

1. Male
2. Female

Question Type

Pick One - answer list pane

Field Pane Description

Child's Revised Sex

Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Skip Instructions

<1,2> store NEWSEX in SEX
goto ERR_NEWSEX
reset CSPVERF_S
goto CSPVERF_S

Hard Edits

ERR_NEWSEX
* The gender will now be changed to [fill: NEWSEX].
goto CSPVERF_S (as the default goto)

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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.042

Variable Name

CSPVERF_A

Universe

CSPVERF_S ne empty

Universe-text

Respondent verified child's sex

Question Text

* Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]'s age as [fill2: Age of Sample Child] old.
Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".

Answer Codes

1. Yes
2. No

Question Type

Yes/No

Field Pane Description
Fill Instructions

Verified Child's Age

If Sample Child's age in AGE is > "0"
[fill2:  years]
else
[fill2: less than a year]
endif

Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Display the most recently updated age in years to the right of the answer box in the field
pane, e.g., if the age is '15' display '15 years old'. For the case where the age is '0'
years, display 'less than a year old'.

Skip Instructions

<1> goto CSPVERF_D
<2> goto NEWAGE

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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.043

Variable Name

NEWAGE

Universe

CSPVERF_A = ''2' (No)

Universe-text

Respondent said child's age is not correct

Question Text

How old is [fill1: ALIAS of Sample Child]?
* If age given in months, weeks, or days, convert age to appropriate year. If less than
one year old, enter "0".

Answer Codes
Question Type

Integer

Field Pane Description

Child's Revised Age

Fill Instructions
Special Instructions
Skip Instructions

<0-120, Refused, Don't know>
if NEWAGE = 'Refused' or NEWAGE = 'Don't know' or NEWAGE = AGE
reset CSPVERF_A
goto ERR_NEWAGE
else
store NEWAGE in AGE
goto NEWDOB_M

Hard Edits

ERR_NEWAGE
*Age of [fill1: ALIAS of Sample Child] remains [fill2: Age of Sample Child] years old.
goto CSPVERF_A (whether suppressed or not)

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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.044

Variable Name

CSPVERF_D

Universe

CSPVERF_S ne empty

Universe-text

Respondent verified child's sex

Question Text

* Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]'s birthday as [fill2: Birthday of Sample
Child]. Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".

Answer Codes

1. Yes
2. No

Question Type

Yes/No

Field Pane Description
Fill Instructions

Verified Child's Date of Birth

[fill2:  , ] = date of birth, where  should be filled
with the name of the month, not the number. For any part of the birth date that is
"refused", "don't know", or otherwise "blank", put a "?" for that field.

Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Skip Instructions

<1> if AGE of Sample Child ge '18'
goto CNO_MORE
else
goto child.chs.BWGT_LB
endif
<2> goto NEWDOB_M

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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.046_1

Variable Name

NEWDOB_M

Universe

CSPVERF_D = '2' (No) or CSPVERF_A = '2' (No)

Universe-text

Respondent said child's date of birth is not correct or child's age is not correct

Question Text

1 of 3
What is [fill: ALIAS of Sample Child]'s birthday?
*Enter month of birth.

Answer Codes

1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
Refused
Don't know

Question Type

Pick One - answer list pane

Field Pane Description

Child's Revised Month of Birth

Fill Instructions
Special Instructions Display the name of the month for the answer entered in this question to the right of the
answer box in the field pane, e.g., if '10' is entered, display 'October'. If 'Refused' or
'Don't know' is entered, do not display anything to the right of the answer box.

Skip Instructions

<01-12, Refused, Don't know> goto NEWDOB_D

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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.046_2

Variable Name

NEWDOB_D

Universe

CSPVERF_D = '2' (No) or CSPVERF_A = '2' (No)

Universe-text

Respondent said child's date of birth is not correct or child's age is not correct

Question Text

2 of 3
* Enter day of birth.

Answer Codes
Question Type

Integer

Field Pane Description
Fill Instructions

Child's Revised Day of Birth

[fill3: NEWDOB_M] = month of birth, where  should be filled with the
name of the month, not the number.

Special Instructions Only allow valid days for month entered.
Skip Instructions

<01-31,Refused,Don't know> goto NEWDOB_Y
If days not valid, goto ERR_NEWDOB_D

Hard Edits

ERR_NEWDOB_D
* [fill2: NEWDOB_D] is not a valid day for [fill3: NEWDOB_M].
* Please correct.

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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.046_3

Variable Name

NEWDOB_Y

Universe

CSPVERF_D = '2' (No) or CSPVERF_A = '2' (No)

Universe-text

Respondent said child's date of birth is not correct or child's age is not correct

Question Text

3 of 3
* Enter year of birth.

Answer Codes
Question Type

Integer

Field Pane Description
Fill Instructions

Child's Revised Year of Birth

[fill2:  , ] = date of birth, where
 should be filled with the name of the month, not the number. For any
part of the birth date that is "refused", "don't know", or otherwise "blank", put a "?" for
that field.
[fill3:  , ] = date of birth, where  should be filled
with the name of the month, not the number. For any part of the birth date that is
"refused", "don't know", or otherwise "blank", put a "?" for that field.

Special Instructions
Skip Instructions

<1880-2020, Refused, Don't know> if CSPVERF_A = '2' (No) then reset CSPVERF_A
to empty
goto CSPVERF_A
elseif CSPVERF_D = '2' (No) then reset
CSPVERF_D to empty
goto CSPVERF_D
endif
(if year GT current year) or (if year = current year and month GT current month) or (if
year = current year and month = current month and day GT current day)
goto ERR1_NEWDOB_Y
endif
(if birth month = '02' and birth day = '29' and this is not a leap year)
goto ERR2_NEWDOB_Y
endif
(if NEWDOB_M = 'Ref' or 'DK') or (if NEWDOB_D = 'Ref' or 'DK') or (if NEWDOB_Y =
'Ref' or 'DK')
goto ERR3_NEWDOB_Y
else
store NEWDOB_M in DOBM
store NEWDOB_D in DOBD
store NEWDOB_Y in DOBY
if CSPVERF_A = '2' (No) then reset CSPVERF_A to empty
goto CSPVERF_A

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elseif CSPVERF_D = '2' (No) then reset CSPVERF_D to empty
goto CSPVERF_D
endif
endif
Calculate age from NEWDOB_M, NEWDOB_D, and NEWDOB_Y.
if age from NEWDOB items is ne AGE and age from NEWDOB items is valid
reset CSPVERF_A or CSPVERF_D
goto ERR4_NEWDOB_Y
endif

Hard Edits

ERR1_NEWDOB_Y
*Future date invalid: [fill2:  , ]
*Please correct.
goto NEWDOB_M (whether suppressed or not)
ERR2_NEWDOB_Y
*Not a valid day: [fill2:  , ]
*Please correct.
goto NEWDOB_M (whether suppressed or not)
ERR3_NEWDOB_Y
*DOB of [fill1: ALIAS of Sample Child] remains [fill3:  , ]
goto CSPVERF_A
ERR4_NEWDOB_Y
*Data mismatched. Please fix Age or Birthday.

goto CSPVERF_A (whether suppressed or not)

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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.048

Variable Name

CNO_MORE

Universe

[(CSTAT = empty or CSTAT = '2') and HHSTAT4 = 'C' and AGE ge '18']

Universe-text

Sample child whose age is now 18+

Question Text

* [fill: ALIAS of Sample Child] is no longer the sample child for this family.
* You may need to ask additional questions before continuing with the rest of the
interview.

Answer Codes

1. Enter 1 to Continue

Question Type

Enter 1 to Continue

Field Pane Description

This Person No Longer Sample Child

Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Skip Instructions

<1> store '0' in CSTAT
store empty in HHSTAT4
if there is a sample adult (HHSTAT4 = 'S') and (if ASTAT = empty or ASTAT = '2')
goto adult.aid.SADULT
elseif rec.RCIFLAG ne '1'
goto rec.RCI_BEGIN
else
goto bck.OUTCOMEB1
endif

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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.050

Variable Name

CAGECHG

Universe

HHSTAT4 = 'C' and NEWAGE ne empty and NEWAGE ne original age

Universe-text
Question Text

* Because you changed the Sample child's age, you may need to ask additional
questions before continuing with the rest of the interview.

Answer Codes

1. Enter 1 to Continue

Question Type

Enter 1 to Continue

Field Pane Description
Fill Instructions
Special Instructions
Skip Instructions
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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.052

Variable Name

SCSSN4

Universe

HHSTAT4 = 'C' and AGE <18

Universe-text

All sample children less than 18 years old

Question Text

?[F1]
Finally, we would like the last four digits of [fill 1: ALIAS]’s Social Security Number. This
information will help us link [fill 1: ALIAS]’s survey data with other health-related
records, and allow us to conduct additional research without taking up your time with
more questions. The National Center for Health Statistics uses this information for
research purposes only. Providing this information is voluntary. Federal laws authorize
us to ask for this information and require us to keep it strictly private. There will be no
effect on [fill 1: ALIAS]’s benefits if you do not provide this information.]
* Read if necessary: The specific federal laws are the Public Health Service Act (Title
42, United States Code, Section 242K) and the Confidential Information Protection and
Statistical Efficiency Act (Title V of Public Law 107-347).
What are the last four digits of [fill 1: ALIAS]’s Social Security Number?
* Enter 'N' if no Social Security Number.

Answer Codes
Question Type

Integer

Field Pane Description
Fill Instructions

SSN

[fill 1: Alias] is the sample child's name

Special Instructions Allow 4 digits. QUESTION SHOULD APPEAR AT THE END OF SAMPLE CHILD
QUESTIONNAIRE.

Skip Instructions

<0001-9999> goto SCSSNRP4
<0-999> goto ERR1_SCSSN4
<0000> goto ERR2_SCSSN4
[goto SCRLINK]

Hard Edits

ERR1_SCSSN4
* You must enter all four of the last four digits of the Social Security Number.
* Please correct.

ERR2_SCSSN4
* The last 4 digits of a SSN may be between 0001-9999.
* Please correct.
* For a respondent who does not want to provide the SSN, enter 'Ctrl D' or 'Ctrl R' for

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'Don't Know' or 'Refused.'

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H_LNKINTRO

Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.053

Variable Name

SCSSNRP4

Universe

SCSSN4 ne blank, 'N', 'Refused', or 'Don't know'

Universe-text

Last four digits of the SSN were given at SCSSN4

Question Text

* Enter how the last four digits of the Social Security Number were reported.

Answer Codes

1. From memory
2. From records

Question Type

Pick One - answer list pane

Field Pane Description

SSN memory or records

Fill Instructions
Special Instructions Do not allow 'Refused' or 'Don't know'. QUESTION SHOULD BE ASKED AT THE END
OF MODULE 37.

Skip Instructions

<1,2> goto SCSSNTL4

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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.054

Variable Name

SCSSNTL4

Universe

All from SCSSNRP4

Universe-text

Recorded how last four digits of the SSN were reported

Question Text

* Select one category below to indicate reporting of the last four digits of the Social
Security Number.

Answer Codes

1. In person
2. Telephone

Question Type

Pick One - answer list pane

Field Pane Description

SSN in person or phone

Fill Instructions
Special Instructions Do not allow 'Refused' or 'Don't know'. QUESTION SHOULD BE ASKED AT THE END
OF MODULE 37.

Skip Instructions

<1,2> goto beginning of Sample Adult, Recontact, or Back section

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Module

10

Section Name

Child Identification and Verification

Part
Question ID

CID.055

Variable Name

SCRLINK

Universe

HHSTAT4 = 'C' and SCSSN4='N', refused, don't know

Universe-text

Sample child less than 18 where the response to SCSSN4 was no SSN, refused, or
don't know

Question Text

?[F1]
May we try to link [fill 1: ALIAS]’s survey data without a Social Security Number?
* Read if necessary: Any data obtained will be kept strictly private as required by law
(Public Health Service Act, which is Title 42, United States Code, Section 242K; and
the Confidential Information Protection and Statistical Efficiency Act, which is Title V of
Public Law 107-347).

Answer Codes

1. Yes
2. No
Refused
Don’t know

Question Type

Yes/No

Field Pane Description
Fill Instructions

Linkage

fill 1: fill the sample child's name

Special Instructions QUESTION SHOULD BE ASKED AT THE END OF MODULE 37.
Skip Instructions

<1,2,R,D> [goto beginning of Sample Adult, Recontact or Back section]

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H_LNKINTRO

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2015 Q1 NHIS Instrument Spec Report
Section name: Child Conditions, Limitations, Health Behaviors
Module

11

Section Name

Child Conditions, Limitations, Health Behaviors

Part

A

Question ID

CHS.010_01.000

Variable Name

BWGT_LB

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

?[F1]
What was [fill: S.C.name]'s birth weight?
* Enter 'M' to record metric measurements.

Answer Codes
Question Type

Integer

Field Pane Description

Pounds

Fill Instructions
Special Instructions Formpane = variable description "pounds" on right; label "Birth weight" on left; column
heading = "US Customary"

Skip Instructions

<1-12> [goto BWGT_OZ]
<13-15> [goto ERR1_BWGT_LB]
 [goto CHGT_FT]
 [goto BWGT_GR]
[If NE <1-15, M, D, R> goto ERR2_BWGT_LB]

Hard Edits

ERR2_BWGT_LB
* Only "1-15" or "M" or "Don't know/Refused" allowed in this field.
* Please correct.

Soft Edits

ERR1_BWGT_LB
* [fill: BWGT_LB] is an unusually high number.
* Please verify.

AssocHelp

H_BWGT

Monday, August 25, 2014

Page 1 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.010_02.000

Variable Name

BWGT_OZ

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and BWGT_LB = <1-15>

Universe-text

Sample children <18 who have a value entered for weight in pounds.

Question Text

* Enter ounces.

Answer Codes
Question Type

Integer

Field Pane Description

Ounces

Fill Instructions
Special Instructions Formpane = variable description "ounces" on right
Skip Instructions

<0-15,R,D> [goto CHGT_FT]
[if BWGT_LB = <0-15, D, R> and BWGT_OZ =  go to CHGT_FT]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 2 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Behaviors

Part

A

Question ID

CHS.010_H

Variable Name

H_BWGT

Universe
Universe-text
Question Text

If respondent insists weight is more than 15 pounds and 15 ounces, enter "15" for each
category and continue with next question. Enter a "Control D" or "Control R" for an
answer of "Don't Know" or "Refused."

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
BWGT_LB

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 3 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.011_00.000

Variable Name

BWGT_GR

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and BWGT_LB = M

Universe-text

Sample children <18 whose birth weight will be entered in metric.

Question Text

* Enter weight in grams.

Answer Codes
Question Type

Integer

Field Pane Description
Fill Instructions

Grams

fill2 and fill3 = BWGT_GR converted to pounds and ounces, round ounces to nearest
whole number

Special Instructions Formpane = variable description "grams" on right; label "Birth weight" on left; column
heading "Metric"

Skip Instructions

<500-5485, R,D> [goto CHGT_FT]
<5486-6900> [goto ERR_BWGT_GR]

Hard Edits
Soft Edits

ERR_BWGT_GR
* [fill1: BWGT_GR] is an unusually high number (equal to [fill2] pounds, [fill3] ounces).
* Please verify.

AssocHelp

Monday, August 25, 2014

Page 4 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.020_01.000

Variable Name

CHGT_FT

Universe

HHSTAT4='C' and (AGE GE '012' and AGE NE ' ')

Universe-text

Sample children GE 12

Question Text

?[F1]
How tall is [fill: S.C. name] now (without shoes)?
* If the child's height is given in inches, press 'ENTER' at feet and enter the measure in
inches (36 inches maximum).
* Enter 'M' to record metric measurements.

Answer Codes
Question Type

Integer

Field Pane Description

Feet

Fill Instructions
Special Instructions Formpane = variable description "feet" on right; label "Current height" on left
Don't allow a '.' (a period) after a number. This is a 2 character field and will be picked
up in output

Skip Instructions

 [goto CHGT_IN]
<0-7> [goto CHGT_IN]
 [goto CWGT_LB]
 [goto CHGT_M]
[If NE <0-7, M, D, R> go to ERR_CHGT_FT]

Hard Edits

ERR_CHGT_FT
* Only "0-7" or "M" or "Don't know/Refused" allowed in this field.
* Please correct.

Soft Edits
AssocHelp

H_CHGT

Monday, August 25, 2014

Page 5 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.020_02.000

Variable Name

CHGT_IN

Universe

HHSTAT4='C' and (AGE GE '012' and AGE NE ' ') and CHGT_FT = <0-7, empty>

Universe-text

Sample children GE 12 whose height in feet is 0-7 or is left empty.

Question Text

* Enter inches.

Answer Codes
Question Type

Integer

Field Pane Description

Inches

Fill Instructions
Special Instructions Formpane = variable description "inches" on right
If CHGT_FT = M, Refused, or Don’t know, do not calculate a value for CHTINCH
If CHGT_FT = ‘0’ and CHGT_IN = Refused or Don’t know, do not calculate a value for
CHTINCH
Create variable CHTINCH as follows: (CHGT_FT * 12) + CHGT_IN = CHTINCH
If CHGT_FT = ‘1-7’ and CHGT_IN = Refused or Don’t know use ‘0’ for CHGT_IN when
calculating CHTINCH
If ERR3_CHGT_IN is displayed, set CHGT_FLG = ‘1’
If ERR3_CHGT_IN is closed or you goto another screen from it, leave CHGT_FLG = ‘1’
If ERR3_CHGT_IN is suppressed, reset CHGT_FLG = ‘2’

Skip Instructions

<0-36,R,D> If (CHGT_FT = ‘0’, ’empty’) and (CHGT_IN = ‘0’, ‘empty’)
goto ERR1_CHGT_IN
elseif CHGT_FT = ‘1-7’ and CHGT_IN ge ‘12’
goto ERR2_CHGT_IN
elseif (SEX = ‘1’ and
AGE = ‘12’ and (CHTINCH lt ‘53’ or CHTINCH gt ‘68’)) or
AGE = ‘13’ and (CHTINCH lt ‘55’ or CHTINCH gt ‘72’)) or
AGE = ‘14’ and (CHTINCH lt ‘58’ or CHTINCH gt ‘73’)) or
AGE = ‘15’ and (CHTINCH lt ‘60’ or CHTINCH gt ‘74’)) or
AGE = ‘16’ and (CHTINCH lt ‘61’ or CHTINCH gt ‘74’)) or
AGE = ‘17’ and (CHTINCH lt ‘62’ or CHTINCH gt ‘75’)) or
(SEX = ‘2’ and
AGE = ‘12’ and (CHTINCH lt ‘54’ or CHTINCH gt ‘68’)) or
AGE = ‘13’ and (CHTINCH lt ‘55’ or CHTINCH gt ‘69’)) or
AGE = ‘14’ and (CHTINCH lt ‘57’ or CHTINCH gt ‘69’)) or
AGE = ‘15’ and (CHTINCH lt ‘57’ or CHTINCH gt ‘69’)) or
AGE = ‘16’ and (CHTINCH lt ‘57’ or CHTINCH gt ‘70’)) or
AGE = ‘17’ and (CHTINCH lt ‘57’ or CHTINCH gt ‘69’))
goto ERR3_CHGT_IN
else
goto CWGT_LB

Hard Edits

ERR1_CHGT_IN

Monday, August 25, 2014

Page 6 of 81

* Must enter an answer in at least the inches item.
* Please correct.
ERR2_CHGT_IN
* Number of inches exceeds maximum allowed.
* Please correct.

Soft Edits

ERR3_CHGT_IN
* Please verify that the height was entered correctly. Probe only if necessary.

AssocHelp

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.020_03.000

Variable Name

CHTINCH

Universe
Universe-text
Question Text

**OUT VARIABLE**

Answer Codes
Question Type

Instrument Out Variable

Field Pane Description
Fill Instructions
Special Instructions If CHGT_FT = M, Refused, or Don’t know, do not calculate a value for CHTINCH

If CHGT_FT = ‘0’ and CHGT_IN = Refused or Don’t know, do not calculate a value for
CHTINCH
Create variable CHTINCH as follows: (CHGT_FT * 12) + CHGT_IN = CHTINCH
If CHGT_FT = ‘1-7’ and CHGT_IN = Refused or Don’t know use ‘0’ for CHGT_IN when
calculating CHTINCH

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 7 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Behaviors

Part

A

Question ID

CHS.020_H

Variable Name

H_CHGT

Universe
Universe-text
Question Text

If the child's height is reported in inches only, enter "0" in the feet field and then enter
the inches. Round the number of inches up to the next whole number.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHGT_FT

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 8 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.021_01.000

Variable Name

CHGT_M

Universe

HHSTAT4='C' and (AGE GE '012' and AGE NE ' ') and CHGT_FT = M

Universe-text

Sample children GE 12 whose current height will be entered in metric.

Question Text

* Enter height in metric.
* If the child's height is given in centimeters, press 'ENTER' at meters and enter the
measure in centimeters (241 centimeters maximum).

Answer Codes
Question Type

Integer

Field Pane Description

Meters

Fill Instructions
Special Instructions Formpane = variable description "meters" on right; label "Current height" on left
Skip Instructions

<0-2,empty> [goto CHGT_CM]
 [goto CWGT_LB]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 9 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.021_02.000

Variable Name

CHGT_CM

Universe

HHSTAT4='C' and (AGE GE '012' and AGE NE ' ') and CHGT_FT = M and CHGT_M =


Universe-text

Sample Children GE 12 whose height will be entered in metric, and who entered "0-2"
for height in meters or left it empty.

Question Text

* Enter centimeters.

Answer Codes
Question Type

Integer

Field Pane Description

Centimeters

Fill Instructions
Special Instructions Formpane = variable description "centimeters" on right
If CHGT_M = Refused or Don’t know, do not calculate a value for CHTCM
If CHGT_M = ‘0’ and CHGT_CM = Refused or Don’t know, do not calculate a value for
CHTCM
Create variable CHTCM as follows: (CHGT_M * 100) + CHGT_CM = CHTCM
If CHGT_CM = Refused or Don’t know use ‘0’ for CHGT_CM when checking if height
exceeds maximum allowed or when calculating CHTCM
If ERR3_CHGT_CM is displayed, set CHGT_FLG = ‘1’
If ERR3_CHGT_CM is closed or you goto another screen from it, leave CHGT_FLG =
‘1’
If ERR3_CHGT_CM is suppressed, reset CHGT_FLG = ‘2’

Skip Instructions

<0-241,R,D> If (CHGT_M = ‘0’, ’empty’) and (CHGT_CM = ‘0’, ‘empty’)
goto ERR1_CHGT_CM
elseif (CHGT_M eq ‘2’ and CHGT_CM gt ‘41’) or (CHGT_M eq ‘1’ and
CHGT_CM gt ‘141’)
goto ERR2_CHGT_CM
elseif (SEX = ‘1’ and
AGE = ‘12’ and (CHTCM lt ‘137’ or CHTCM gt ‘174’)) or
AGE = ‘13’ and (CHTCM lt ‘140’ or CHTCM gt ‘184’)) or
AGE = ‘14’ and (CHTCM lt ‘148’ or CHTCM gt ‘186’)) or
AGE = ‘15’ and (CHTCM lt ‘152’ or CHTCM gt ‘189’)) or
AGE = ‘16’ and (CHTCM lt ‘156’ or CHTCM gt ‘189’)) or
AGE = ‘17’ and (CHTCM lt ‘157’ or CHTCM gt ‘192’)) or
(SEX = ‘2’ and
AGE = ‘12’ and (CHTCM lt ‘138’ or CHTCM gt ‘173’)) or
AGE = ‘13’ and (CHTCM lt ‘141’ or CHTCM gt ‘176’)) or
AGE = ‘14’ and (CHTCM lt ‘145’ or CHTCM gt ‘176’)) or
AGE = ‘15’ and (CHTCM lt ‘145’ or CHTCM gt ‘177’)) or
AGE = ‘16’ and (CHTCM lt ‘145’ or CHTCM gt ‘177’)) or
AGE = ‘17’ and (CHTCM lt ‘145’ or CHTCM gt ‘176’))
goto ERR3_CHGT_CM
else

Monday, August 25, 2014

Page 10 of 81

goto CWGT_LB

Hard Edits

ERR1_CHGT_CM
* Must enter an answer at least in the centimeters item.
* Please correct.
ERR2_CHGT_CM
* Total height exceeds maximum allowed.
* Please correct.

Soft Edits

ERR3_CHGT_CM
* Please verify that the height was entered correctly. Probe only if necessary.

AssocHelp
Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.021_03.000

Variable Name

CHTCM

Universe
Universe-text
Question Text

**OUT VARIABLE**

Answer Codes
Question Type

Instrument Out Variable

Field Pane Description
Fill Instructions
Special Instructions If CHGT_M = Refused or Don’t know, do not calculate a value for CHTCM

If CHGT_M = ‘0’ and CHGT_CM = Refused or Don’t know, do not calculate a value for
CHTCM
Create variable CHTCM as follows: (CHGT_M * 100) + CHGT_CM = CHTCM
If CHGT_CM = Refused or Don’t know use ‘0’ for CHGT_CM when checking if height
exceeds maximum allowed or when calculating CHTCM

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 11 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.021_04.000

Variable Name

CHGT_FLG

Universe
Universe-text
Question Text

**OUT VARIABLE**

Answer Codes

blank,1,2

Question Type

Instrument Out Variable

Field Pane Description
Fill Instructions
Special Instructions If ERR3_CHGT_IN or ERR3_CHGT_CM is displayed, set CHGT_FLG = ‘1’
If ERR3_CHGT_IN or ERR3_CHGT_CM is closed or you goto another screen from it,
leave CHGT_FLG = ‘1’
If ERR3_CHGT_IN or ERR3_CHGT_CM is suppressed, reset CHGT_FLG = ‘2’

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 12 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.021_05.000

Variable Name

CMETERS

Universe
Universe-text
Question Text

**OUT VARIABLE**

Answer Codes
Question Type

Instrument Out Variable

Field Pane Description
Fill Instructions
Special Instructions Create variable CMETERS as follows:

if CHTINCH ne ‘empty’
set CMETERS = CHTINCH/39.37008
elseif CHTCM ne ‘empty’
set CMETERS = CHTCM/100

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 13 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.022_00.000

Variable Name

CWGT_LB

Universe

HHSTAT4='C' and (AGE GE '012' and AGE NE ' ')

Universe-text

Sample children GE 12

Question Text

How much does [fill: S.C. name] weigh now (without shoes)?
* Enter 'M' to record metric measurements.
* Enter '500' if 500 pounds or more.

Answer Codes
Question Type

Integer

Field Pane Description

Pounds

Fill Instructions
Special Instructions Formpane = variable description "pounds" on right; label "Current weight" on left
If ERR2_CWGT_LB is displayed, set CWGT_FLG = ‘1’
If ERR2_CWGT_LB is closed or you goto another screen from it, leave CWGT_FLG =
‘1’
If ERR2_CWGT_LB is suppressed, reset CWGT_FLG = ‘2’

Skip Instructions

<1-500> if CWGT_LB lt ‘1’ or CWGT_LB gt ‘500’
goto ERR1_CWGT_LB
elseif (SEX = ‘1’ and
AGE = ‘12’ and (CWGT_LB lt ‘62’ or CWGT_LB gt ‘209’)) or
AGE = ‘13’ and (CWGT_LB lt ‘70’ or CWGT_LB gt ‘247’)) or
AGE = ‘14’ and (CWGT_LB lt ‘83’ or CWGT_LB gt ‘266’)) or
AGE = ‘15’ and (CWGT_LB lt ‘94’ or CWGT_LB gt ‘267’)) or
AGE = ‘16’ and (CWGT_LB lt ‘98’ or CWGT_LB gt ‘306’)) or
AGE = ‘17’ and (CWGT_LB lt ‘106’ or CWGT_LB gt ‘317’)) or
(SEX = ‘2’ and
AGE = ‘12’ and (CWGT_LB lt ‘62’ or CWGT_LB gt ‘212’)) or
AGE = ‘13’ and (CWGT_LB lt ‘73’ or CWGT_LB gt ‘238’)) or
AGE = ‘14’ and (CWGT_LB lt ‘84’ or CWGT_LB gt ‘252’)) or
AGE = ‘15’ and (CWGT_LB lt ‘84’ or CWGT_LB gt ‘238’)) or
AGE = ‘16’ and (CWGT_LB lt ‘87’ or CWGT_LB gt ‘257’)) or
AGE = ‘17’ and (CWGT_LB lt ‘90’ or CWGT_LB gt ‘292’))
goto ERR2_CWGT_LB
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE ge ‘2’
goto ADD_1
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE lt ‘2’
goto ADD1_2
else
calculate the BMI (Body Mass Index) – See CBMI spec page
 if AGE ge ‘2’
goto ADD_1
else

Monday, August 25, 2014

Page 14 of 81

goto ADD1_2
 goto CWGT_KG

Hard Edits

ERR1_CWGT_LB
* Weight is out of range (1-500).
* Please correct.

Soft Edits

ERR2_CWGT_LB
* Please verify that the weight was entered correctly. Probe only if necessary.

AssocHelp

Monday, August 25, 2014

Page 15 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.023_00.000

Variable Name

CWGT_KG

Universe

HHSTAT4='C' and (AGE GE '012' and AGE NE ' ') and CWGT_LB = M

Universe-text

Sample children GE 12 whose weight will be entered in metric.

Question Text

* Enter weight in kilograms.

Answer Codes
Question Type

Integer

Field Pane Description

Kilograms

Fill Instructions
Special Instructions Formpane = variable description "kilograms" on right; label "Current weight" on left;
column heading "Metric"
If ERR2_CWGT_KG is displayed, set CWGT_FLG = ‘1’
If ERR2_CWGT_KG is closed or you goto another screen from it, leave CWGT_FLG =
‘1’
If ERR2_CWGT_KG is suppressed, reset CWGT_FLG = ‘2’

Skip Instructions

<2-226> if CWGT_KG lt ‘2’ or CWGT_KG gt ‘226’
goto ERR1_CWGT_KG
elseif (SEX = ‘1’ and
AGE = ‘12’ and (CWGT_KG = ‘28’ or CWGT_KG = ‘95’)) or
AGE = ‘13’ and (CWGT_KG = ‘32’ or CWGT_KG = ‘112’)) or
AGE = ‘14’ and (CWGT_KG = ‘38’ or CWGT_KG = ‘121’)) or
AGE = ‘15’ and (CWGT_KG = ‘42’ or CWGT_KG = ‘121’)) or
AGE = ‘16’ and (CWGT_KG = ‘44’ or CWGT_KG = ‘139’)) or
AGE = ‘17’ and (CWGT_KG = ‘48’ or CWGT_KG = ‘144’)) or
(SEX = ‘2’ and
AGE = ‘12’ and (CWGT_KG = ‘28’ or CWGT_KG = ‘96’)) or
AGE = ‘13’ and (CWGT_KG = ‘33’ or CWGT_KG = ‘108’)) or
AGE = ‘14’ and (CWGT_KG = ‘38’ or CWGT_KG = ‘114’)) or
AGE = ‘15’ and (CWGT_KG = ‘38’ or CWGT_KG = ‘108’)) or
AGE = ‘16’ and (CWGT_KG = ‘39’ or CWGT_KG = ‘117’)) or
AGE = ‘17’ and (CWGT_KG = ‘41’ or CWGT_KG = ‘133’))
goto ERR2_CWGT_KG
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE ge ‘2’
goto ADD_1
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE lt ‘2’
goto ADD1_2
else
calculate the BMI (Body Mass Index) – See CBMI spec page
 if AGE ge ‘2’
goto ADD_1
else
goto ADD1_2

Monday, August 25, 2014

Page 16 of 81

Hard Edits

ERR1_CWGT_KG
* Weight is out of range (2-226).
* Please correct.

Soft Edits

ERR2_CWGT_KG
* Please verify that the weight was entered correctly. Probe only if necessary.

AssocHelp
Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.024_01.000

Variable Name

CWGT_FLG

Universe
Universe-text
Question Text

**OUT VARIABLE**

Answer Codes

blank,1,2

Question Type

Instrument Out Variable

Field Pane Description
Fill Instructions
Special Instructions If ERR2_CWGT_LB or ERR2_CWGT_KG is displayed, set CWGT_FLG = ‘1’
If ERR2_CWGT_LB or ERR2_CWGT_KG is closed or you goto another screen from it,
leave CWGT_FLG = ‘1’
If ERR2_CWGT_LB or ERR2_CWGT_KG is suppressed, reset CWGT_FLG = ‘2’

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 17 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.024_02.000

Variable Name

CKG

Universe
Universe-text
Question Text

**OUT VARIABLE**

Answer Codes
Question Type

Instrument Out Variable

Field Pane Description
Fill Instructions
Special Instructions Create variable CKG as follows:

If CWGT_LB ne ‘M’, ‘Refused’, ‘Don’t know’, or ‘empty’
Set CKG = CWGT_LB/2.20462
elseif CWGT_KG ne ‘Refused’, ‘Don’t know’, or ‘empty’
Set CKG = CWGT_KG

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 18 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.024_03.000

Variable Name

CBMI

Universe
Universe-text
Question Text

**OUT VARIABLE**

Answer Codes
Question Type

Instrument Out Variable

Field Pane Description
Fill Instructions
Special Instructions Create variable CBMI as follows: (CKG/(CMETERS * CMETERS)) = CBMI
If ERR_CBMI is displayed, set CBMI_FLG = ‘1’
If ERR_CBMI is closed or you goto another screen from it, leave CBMI_FLG = ‘1’
If ERR_CBMI is suppressed, reset CBMI_FLG = ‘2’

Skip Instructions

if (SEX = ‘1’ and
AGE = ‘12’ and (CBMI lt ‘14’ or CBMI gt ‘35’)) or
AGE = ‘13’ and (CBMI lt ‘14’ or CBMI gt ‘39’)) or
AGE = ‘14’ and (CBMI lt ‘15’ or CBMI gt ‘40’)) or
AGE = ‘15’ and (CBMI lt ‘15’ or CBMI gt ‘39’)) or
AGE = ‘16’ and (CBMI lt ‘17’ or CBMI gt ‘44’)) or
AGE = ‘17’ and (CBMI lt ‘17’ or CBMI gt ‘43’)) or
(SEX = ‘2’ and
AGE = ‘12’ and (CBMI lt ‘13’ or CBMI gt ‘39’)) or
AGE = ‘13’ and (CBMI lt ‘15’ or CBMI gt ‘41’)) or
AGE = ‘14’ and (CBMI lt ‘16’ or CBMI gt ‘41’)) or
AGE = ‘15’ and (CBMI lt ‘16’ or CBMI gt ‘39’)) or
AGE = ‘16’ and (CBMI lt ‘16’ or CBMI gt ‘45’)) or
AGE = ‘17’ and (CBMI lt ‘16’ or CBMI gt ‘48’))
goto ERR_CBMI
elseif AGE ge ‘2’
goto ADD_1
else
goto ADD1_2

Hard Edits
Soft Edits

ERR_CBMI
* Please verify that the entries for height and weight were entered correctly. Probe only
if necessary.

AssocHelp

Monday, August 25, 2014

Page 19 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.024_04.000

Variable Name

CBMI_FLG

Universe
Universe-text
Question Text

**OUT VARIABLE**

Answer Codes

blank,1,2

Question Type

Instrument Out Variable

Field Pane Description
Fill Instructions
Special Instructions If ERR_CBMI is displayed, set CBMI_FLG = ‘1’

If ERR_CBMI is closed or you goto another screen from it, leave CBMI_FLG = ‘1’
If ERR_CBMI is suppressed, reset CBMI_FLG = ‘2’

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 20 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.031_02.000

Variable Name

ADD1_2

Universe

HHSTAT4='C' and (AGE LE '001' and AGE NE ' ')

Universe-text

Sample children <2

Question Text

?[F1]
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Intellectual disability, also known as mental retardation?

Answer Codes

1. Yes
2. No
Don't Know
Refused

Question Type

Yes/No

Field Pane Description

Intellectual disability

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto ADD1_3]

Hard Edits
Soft Edits
AssocHelp

H_MENTRD

Monday, August 25, 2014

Page 21 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.031_03.000

Variable Name

ADD1_3

Universe

HHSTAT4='C' and (AGE LE '001' and AGE NE ' ')

Universe-text

Sample children <2

Question Text

?[F1]
* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?

Answer Codes

1. Yes
2. No
Don't Know
Refused

Question Type

Yes/No

Field Pane Description

Other developmental delay

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CONDL]

Hard Edits
Soft Edits
AssocHelp

H_DEVDLAY

Monday, August 25, 2014

Page 22 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Behaviors

Part

A

Question ID

CHS.031_2_H

Variable Name

H_MENTRD

Universe
Universe-text
Question Text

Intellectual disability/Mental retardation - This is someone who is significantly below
average in intellectual functioning along with problems in adaptive behavior.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
ADD1_2
ADD_2

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 23 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Behaviors

Part

A

Question ID

CHS.031_3_H

Variable Name

H_DEVDLAY

Universe
Universe-text
Question Text

This is someone who is significantly delayed, as defined by the state and measured by
appropriate diagnostic tests in one of several areas: physical development, cognitive
(mental) development, social or emotional development, or adaptive development.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
ADD1_3
ADD_3

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 24 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.032_01.000

Variable Name

ADD_1

Universe

HHSTAT4='C' and ('002' <= AGE<= '017')

Universe-text

Sample children 2-17

Question Text

?[F1]
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?

Answer Codes

1. Yes
2. No
Don't Know
Refused

Question Type

Yes/No

Field Pane Description

ADHD/ADD

Fill Instructions
Special Instructions Formpane = Column heading "Children 2-17 years of age"
Skip Instructions

<1,2,R,D> [go to ADD_2]

Hard Edits
Soft Edits
AssocHelp

H_ADD

Monday, August 25, 2014

Page 25 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.032_02.000

Variable Name

ADD_2

Universe

HHSTAT4='C' and ('002' <= AGE<= '017')

Universe-text

Sample children 2-17

Question Text

?[F1]
* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Intellectual disability, also known as mental retardation?

Answer Codes

1. Yes
2. No
Don't Know
Refused

Question Type

Yes/No

Field Pane Description

Intellectual disability

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to AUTISM]

Hard Edits
Soft Edits
AssocHelp

H_MENTRD

Monday, August 25, 2014

Page 26 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part
Question ID

CHS.032_02.010

Variable Name

AUTISM

Universe

HHSTAT4='C' and ('002' <= AGE<= '017')

Universe-text

Sample children 2-17

Question Text

?[F1]
* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Autism, Asperger’s disorder, pervasive developmental disorder, or autism spectrum
disorder?

Answer Codes

1. Yes
2. No
Don't Know
Refused

Question Type

Yes/No

Field Pane Description

Autism

Fill Instructions
Special Instructions Associated Screens:
H_AUTISM

Skip Instructions

<1,2,R,D> [go to ADD_3]

Hard Edits
Soft Edits
AssocHelp

H_AUTISM

Monday, August 25, 2014

Page 27 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.032_03.000

Variable Name

ADD_3

Universe

HHSTAT4='C' and ('002' <= AGE<= '017')

Universe-text

Sample children 2-17

Question Text

?[F1]
* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?

Answer Codes

1. Yes
2. No
Don't Know
Refused

Question Type

Yes/No

Field Pane Description

Other developmental delay

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CONDL]

Hard Edits
Soft Edits
AssocHelp

H_DEVDLAY

Monday, August 25, 2014

Page 28 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Behaviors

Part

A

Question ID

CHS.032_1_H

Variable Name

H_ADD

Universe
Universe-text
Question Text

Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder is diagnosed by a
health or school professional and is characterized by problems with attention,
impulsiveness, hyperactivity, school problems, and sometimes aggression.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
ADD_1

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 29 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Behaviors

Part
Question ID

CHS.032_2_H

Variable Name

H_AUTISM

Universe
Universe-text
Question Text

Autism is pronounced (Aw-tizm). This is a developmental disability affecting verbal and
nonverbal communication and social interaction.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated Screens:
AUTISM

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 30 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.060_00.000

Variable Name

CONDL

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

(book) C2 ?[F1]
Looking at this list, has a doctor or health professional ever told you that [fill: S.C.
name] had any of these conditions?
*Read if necessary.
Down syndrome
Cerebral palsy
Muscular dystrophy
Cystic fibrosis
Sickle cell anemia
Diabetes
Arthritis
Congenital heart disease
Other heart condition

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Conditions-yes/no

Fill Instructions
Special Instructions Fill grayed out answer categories 1-9 under question text. They are only for reference
in case this question is being answered over the phone, so the FR does not have to
enter "yes" to get to the next question in order to see the condition list. This is similar to
HHC.170 (NATOR).

Skip Instructions

<1> [goto CONDL1] <2,R,D> [goto CPOX]

Hard Edits
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AssocHelp

H_CONDL

Monday, August 25, 2014

Page 31 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Behaviors

Part

A

Question ID

CHS.060_H

Variable Name

H_CONDL

Universe
Universe-text
Question Text

[b] Cerebral palsy [b] is pronounced (ce-Re-bral Pawl-zee)
[b] Muscular dystrophy [b] is pronounced (Dis-tro-fee)
[b] Cystic fibrosis [b] is pronounced (Sis-tic fi-Bro-sis)
Include as heart disease or heart condition any of the following: heart failure, chronic
heart condition, rheumatic heart disease, heart murmurs, atrial or mitral valve
disease/damage, etc.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CONDL

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 32 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.061_00.000

Variable Name

CONDL1

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CONDL(e)='1'

Universe-text

Sample children <18 who have one of the CONDL conditions

Question Text

(book) C2 ?[F1]
Which ones?
* Enter all that apply, separate with commas.

Answer Codes

1. Down syndrome
2. Cerebral palsy
3. Muscular dystrophy
4. Cystic fibrosis
5. Sickle cell anemia
6. Diabetes
7. Arthritis
8. Congenital heart disease
9. Other heart condition
Refused
Don’t know

Question Type

Enter All That Apply

Field Pane Description

Conditions-which

Fill Instructions
Special Instructions
Skip Instructions

<1-9, R,D> [go to CPOX]

Hard Edits
Soft Edits
AssocHelp

H_CONDL

Monday, August 25, 2014

Page 33 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.070_00.000

Variable Name

CPOX

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

Has [fill: S.C. name] EVER had chickenpox?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Chickenpox - ever

Fill Instructions
Special Instructions
Skip Instructions

<1> [go to CPOX12MO]
<2, D, R> [go to CASHMEV]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 34 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.072_00.000

Variable Name

CPOX12MO

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CPOX(e)='1'

Universe-text

Sample children <18 who have had chickenpox

Question Text

Has [fill: S.C. name] had chickenpox DURING THE PAST 12 MONTHS?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Chickenpox - past 12 months

Fill Instructions
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.

Skip Instructions

<1,2,R,D> [goto CASHMEV]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 35 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.080_00.000

Variable Name

CASHMEV

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

? [F1]
Has a doctor or other health professional EVER told you that [fill: S.C. name] had
asthma?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Asthma - ever

Fill Instructions
Special Instructions
Skip Instructions

<1> [go to CASSTILL]
<2,R,D> if AGE LE 2 [go to CCONDT1_1];
else [go to CCONDT_1]

Hard Edits
Soft Edits
AssocHelp

H_CASHMEV

Monday, August 25, 2014

Page 36 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Behaviors

Part

A

Question ID

CHS.080_H

Variable Name

H_CASHMEV

Universe
Universe-text
Question Text

Accept asthma of any kind such as smoker's asthma, bronchial asthma, allergic
asthma, and the like. Do not accept self-diagnosed lung problems or conditions
reported by a person who is not a doctor and not working with or for a doctor.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CASHMEV

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 37 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.085_00.000

Variable Name

CASSTILL

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CASHMEV(e)='1'

Universe-text

Sample child <18 and doctor has informed that child had asthma

Question Text

Does [fill: S.C. name] still have asthma?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Asthma - still

Fill Instructions
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.

Skip Instructions

<1,2,R,D> [go to CASHYR]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 38 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.090_00.000

Variable Name

CASHYR

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CASHMEV(e) ='1'

Universe-text

Sample child <18 and doctor has informed that child had asthma

Question Text

The following questions are about [fill: S.C. name]'s asthma DURING THE PAST 12
MONTHS.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had an episode of asthma or
an asthma attack?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Asthma - past 12 months

Fill Instructions
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.

Skip Instructions

<1,2,R,D> [goto CASMERYR]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 39 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.100_00.000

Variable Name

CASMERYR

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CASHMEV(e) ='1'

Universe-text

Sample child <18 and doctor has informed that child had asthma

Question Text

DURING THE PAST 12 MONTHS, did [fill1: S.C. name] have to visit an emergency
room or urgent care center because of [fill2: his/her] asthma?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Asthma - ER past 12 months

Fill Instructions
Special Instructions Double indent field pane description to indicate that question is a follow-up to a
previous question (which, itself, was a follow-up question).

Skip Instructions

<1,2,R,D> if AGE LE 2 [go to CCONDT1_1];
else [go to CCONDT_1]

Hard Edits
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AssocHelp

Monday, August 25, 2014

Page 40 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.111_01.000

Variable Name

CCONDT1_1

Universe

HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')

Universe-text

Sample children LE 2

Question Text

DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Hay fever?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Hay fever

Fill Instructions
Special Instructions Formpane = column heading "Children under 3 years of age"
Skip Instructions

<1,2,R,D> [go to CCONDT1_2]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 41 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.111_02.000

Variable Name

CCONDT1_2

Universe

HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')

Universe-text

Sample children LE 2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Any kind of respiratory allergy?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Respiratory allergy

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CCONDT1_3]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 42 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.111_03.000

Variable Name

CCONDT1_3

Universe

HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')

Universe-text

Sample children LE 2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Any kind of food or digestive allergy?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Food/digestive allergy

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CCONDT1_4]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 43 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.111_04.000

Variable Name

CCONDT1_4

Universe

HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')

Universe-text

Sample children LE 2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Eczema or any kind of skin allergy?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Eczema/skin allergy

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CCONDT1_5]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 44 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.111_05.000

Variable Name

CCONDT1_5

Universe

HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')

Universe-text

Sample children LE 2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Frequent or repeated diarrhea or colitis?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Frequent diarrhea/colitis

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CCONDT1_6]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 45 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.111_06.000

Variable Name

CCONDT1_6

Universe

HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')

Universe-text

Sample children LE 2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Anemia?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Anemia

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CCONDT1_8]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 46 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.111_08.000

Variable Name

CCONDT1_8

Universe

HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')

Universe-text

Sample children LE 2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Three or more ear infections?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Ear infections

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CCONDT1_9]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 47 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.111_09.000

Variable Name

CCONDT1_9

Universe

HHSTAT4='C' and (AGE LE '002' and AGE NE ' ')

Universe-text

Sample children LE 2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Seizures?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Seizures

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CHSTATYR]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 48 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.115_01.000

Variable Name

CCONDT_1

Universe

HHSTAT4='C' and ('003' <= AGE <= '017')

Universe-text

Sample children = 3-17

Question Text

DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Hay fever?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Hay fever

Fill Instructions
Special Instructions Formpane = column heading "Children 3-17 years of age"
Skip Instructions

<1,2,R,D> [go to CCONDT_2]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 49 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.115_02.000

Variable Name

CCONDT_2

Universe

HHSTAT4='C' and ('003' <= AGE <= '017')

Universe-text

Sample children = 3-17

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Any kind of respiratory allergy?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Respiratory allergy

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CCONDT_3]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 50 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.115_03.000

Variable Name

CCONDT_3

Universe

HHSTAT4='C' and ('003' <= AGE <= '017')

Universe-text

Sample children = 3-17

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Any kind of food or digestive allergy?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Food/digestive allergy

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CCONDT_4]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 51 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.115_04.000

Variable Name

CCONDT_4

Universe

HHSTAT4='C' and ('003' <= AGE <= '017')

Universe-text

Sample children = 3-17

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Eczema or any kind of skin allergy?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Eczema/skin allergy

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CCONDT_5]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 52 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.115_05.000

Variable Name

CCONDT_5

Universe

HHSTAT4='C' and ('003' <= AGE <= '017')

Universe-text

Sample children = 3-17

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Frequent or repeated diarrhea or colitis?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Frequent diarrhea/colitis

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CCONDT_6]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 53 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.115_06.000

Variable Name

CCONDT_6

Universe

HHSTAT4='C' and ('003' <= AGE <= '017')

Universe-text

Sample children = 3-17

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Anemia?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Anemia

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CCONDT_7]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 54 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.115_07.000

Variable Name

CCONDT_7

Universe

HHSTAT4='C' and ('003' <= AGE <= '017')

Universe-text

Sample children = 3-17

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Frequent or severe headaches, including migraines?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Frequent headaches/migraines

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CCONDT_8]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 55 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.115_08.000

Variable Name

CCONDT_8

Universe

HHSTAT4='C' and ('003' <= AGE <= '017')

Universe-text

Sample children = 3-17

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Three or more ear infections?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Ear infections

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CCONDT_9]

Hard Edits
Soft Edits
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Monday, August 25, 2014

Page 56 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.115_09.000

Variable Name

CCONDT_9

Universe

HHSTAT4='C' and ('003' <= AGE <= '017')

Universe-text

Sample children = 3-17

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Seizures?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Seizures

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CCONDT_10]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 57 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.115_10.000

Variable Name

CCONDT_10

Universe

HHSTAT4='C' and ('003' <= AGE <= '017')

Universe-text

Sample children = 3-17

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following
conditions...
Stuttering or stammering?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Stuttering/Stammering

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CHSTATYR]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 58 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.210_00.000

Variable Name

CHSTATYR

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

Compared with 12 months ago, would you say [fill: S.C. name]'s health is now better,
worse, or about the same?

Answer Codes

1. Better
2. Worse
3. About the same
Refused
Don't know

Question Type

Pick One - answer list pane

Field Pane Description

Health now vs. 12 months ago

Fill Instructions
Special Instructions
Skip Instructions

<1-3,R,D> [if AGE le <4> goto CCOLD2W; else goto SCHDAYR]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 59 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.220_00.000

Variable Name

SCHDAYR

Universe

HHSTAT4='C' and ('005' <= AGE <= '017')

Universe-text

Sample children 5-17

Question Text

DURING THE PAST 12 MONTHS about how many days did [fill2: S.C. name] miss
school because of illness or injury?
* Enter '996' if child did not go to school in the past 12 months.

Answer Codes
Question Type

Integer

Field Pane Description

Missed days

Fill Instructions
Special Instructions Note that first part of soft edit is to be spoken, and written in the same font as question
text.

Skip Instructions

<0-99,996,R,D> [goto CCOLD2W]
<100-240> [go to ERR1_SCHDAYR]
<241-995> [goto ERR2_SCHDAYR]

Hard Edits

ERR2_SCHDAYR
* "241-995" days not allowed in this field.
* Please correct.

Soft Edits

ERR1_SCHDAYR
[fill4: SCHDAYR] is an unusually large number. Did [fill2: SC name] miss [fill:
SCHDAYR] days of school because of illness or injury?
* Please verify.

AssocHelp

Monday, August 25, 2014

Page 60 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.230_00.000

Variable Name

CCOLD2W

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

These next questions are about [fill: S.C. name]'s recent health DURING THE LAST 2
WEEKS.
Did [fill: S.C. name] have a head cold or chest cold that started DURING THE LAST 2
WEEKS?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Cold - past 2 weeks

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CINTIL2W]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 61 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.240_00.000

Variable Name

CINTIL2W

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

Did [fill: S.C. name] have a stomach or intestinal illness with vomiting or diarrhea that
started DURING THE LAST 2 WEEKS?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Stomach illness - past 2 weeks

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CHEARST1]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 62 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.250_00.000

Variable Name

CHEARST1

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

Which statement best describes [fill: S.C. name]'s hearing without a hearing aid:
Excellent, good, a little trouble hearing, moderate trouble, a lot of trouble, or is [fill: SC's
name] deaf?

Answer Codes

1. Excellent
2. Good
3. A little trouble hearing
4. Moderate trouble
5. A lot of trouble
6. Deaf
Refused
Don't know

Question Type

Pick One - answer list pane

Field Pane Description

Hearing

Fill Instructions
Special Instructions
Skip Instructions

<1-6,R,D> [go to CVISION]

Hard Edits
Soft Edits
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Monday, August 25, 2014

Page 63 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.260_00.000

Variable Name

CVISION

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

Does [fill1: S.C. name] have any trouble seeing [fill2: , even when wearing glasses or
contact lenses]?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description
Fill Instructions

Trouble seeing

fill2 = [if AGE ge <2> = "Even when wearing glasses or contact lenses?"]

Special Instructions
Skip Instructions

<1> [goto CBLIND]
<2,R,D> [goto IHSPEQ]

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Soft Edits
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Monday, August 25, 2014

Page 64 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.270_00.000

Variable Name

CBLIND

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CVISION(e)='1'

Universe-text

Sample children <18 who have trouble seeing

Question Text

Is [fill: S.C. name] blind or unable to see at all?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Blind

Fill Instructions
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.

Skip Instructions

<1,2,R,D> [goto IHSPEQ]

Hard Edits
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Monday, August 25, 2014

Page 65 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.290_00.000

Variable Name

IHSPEQ

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

Does [fill1: S.C. name] have any impairment or health problem that requires [fill2:
him/her] to use special equipment, such as a brace, a wheelchair, or a hearing aid
(excluding ordinary eyeglasses or corrective shoes)?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Special equipment

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto IHMOB]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 66 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.300_00.000

Variable Name

IHMOB

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

Does [fill1: S.C. name] have an impairment or health problem that limits [fill2: his/her]
ability to (crawl), walk, run, or play?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Limited ability to walk/play

Fill Instructions
Special Instructions
Skip Instructions

<1> [goto IHMOBYR]
<2,R,D> [goto PROBRX]

Hard Edits
Soft Edits
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Monday, August 25, 2014

Page 67 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.310_00.000

Variable Name

IHMOBYR

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and IHMOB(e)='1'

Universe-text

Sample children <18 that have limited ability to crawl, walk, run, or play

Question Text

Is this an impairment or health problem that has lasted, or is expected to last, 12
months or longer?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Lasted or will last 12 months

Fill Instructions
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.

Skip Instructions

<1,2,R,D> [goto PROBRX]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 68 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.311_00.000

Variable Name

PROBRX

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

?[F1]
Does [fill1: S.C. name] NOW have a problem for which [fill2: he/she] has regularly
taken prescription medication for at least three months?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Prescription meds for 3 months

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [if AGE LE <1> go to CAU.CUSUALPL;
else if AGE GE 3 go to LEARND;
else if AGE = 2 and SEX = 1 go to CMHAGM11_1;
if AGE = 2 and SEX = 2 go to CMHAGF11_1]

Hard Edits
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AssocHelp

H_PROBRX

Monday, August 25, 2014

Page 69 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Behaviors

Part

A

Question ID

CHS.311_H

Variable Name

H_PROBRX

Universe
Universe-text
Question Text

Prescription medication is:
[blt] any medicine obtained on a licensed health care professional's written
prescription,
[blt] any medicine prepared on the basis of a doctor's telephone call to a pharmacist,
[blt] any medicine including injections given by the doctor (or nurse) to the person to
take at home
or administered in the office, hospital or clinic.
Do not include medicine only recommended by a doctor if no prescription is necessary.
[b] Regularly taken [b] - Do not count medicine that the sample child is taking for a
short term illness, such as taking antibiotics for 10 days for an infection.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
PROBRX

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 70 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

A

Question ID

CHS.312_00.000

Variable Name

LEARND

Universe

HHSTAT4='C' and ('003' <= AGE <= '017')

Universe-text

Sample children 3-17

Question Text

?[F1]
Has a representative from a school or a health professional ever told you that [fill: S.C.
name] had a learning disability?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Learning disability

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [if AGE > 3 go to CUSUALPL;
if AGE = 3 and SEX = 1 go to CMHAGM11_1;
if AGE = 3 and SEX = 2 go to CMHAGF11_1]

Hard Edits
Soft Edits
AssocHelp

H_LEARND

Monday, August 25, 2014

Page 71 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Behaviors

Part

A

Question ID

CHS.312_H

Variable Name

H_LEARND

Universe
Universe-text
Question Text

A learning disability is a disorder in one or more of the basic psychological processes
involved in understanding or in using language, spoken or written. It may be evident by
an inability to listen, think, speak, read, write, spell or do mathematical calculations. It
includes conditions such as brain injury, minimal brain dysfunction, dyslexia or
aphasia. It does not apply to children who have difficulty learning as a result of visual,
hearing, motor, mental retardation, or emotional disturbance.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
LEARND

Skip Instructions
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Monday, August 25, 2014

Page 72 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

B

Question ID

CHS.321_01.000

Variable Name

CMHAGM11_1

Universe

HHSTAT4='C' and AGE IN('002','003') and SEX='1'

Universe-text

Male sample children 2-3

Question Text

(book) C3 ?[F1]
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
He:
Has been uncooperative?

Answer Codes

0. Not true
1. Sometimes true
2. Often true
Don't know
Refused

Question Type

Pick One - answer list pane

Field Pane Description

Uncooperative

Fill Instructions
Special Instructions
Skip Instructions

<0-2,R,D> [go to CMHAGM11_2]

Hard Edits
Soft Edits
AssocHelp

H_CMHAG

Monday, August 25, 2014

Page 73 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

B

Question ID

CHS.321_02.000

Variable Name

CMHAGM11_2

Universe

HHSTAT4='C' and AGE IN('002','003') and SEX='1'

Universe-text

Male sample children 2-3

Question Text

(book) C3 ?[F1]
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
He:
Has trouble getting to sleep?

Answer Codes

0. Not true
1. Sometimes true
2. Often true
Don't know
Refused

Question Type

Pick One - answer list pane

Field Pane Description

Trouble getting sleep

Fill Instructions
Special Instructions
Skip Instructions

<0-2,R,D> [go to CMHAGM11_3]

Hard Edits

*****Author, please make sure that the reference period is the same in Spanish as it is
in English. There was a slight discrepancy that I think is now fixed. Please double
check. Thanks. AG

Soft Edits
AssocHelp

H_CMHAG

Monday, August 25, 2014

Page 74 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

B

Question ID

CHS.321_03.000

Variable Name

CMHAGM11_3

Universe

HHSTAT4='C' and AGE IN('002','003') and SEX='1'

Universe-text

Male sample children 2-3

Question Text

(book) C3 ?[F1]
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
He:
Has speech problems?

Answer Codes

0. Not true
1. Sometimes true
2. Often true
Don't know
Refused

Question Type

Pick One - answer list pane

Field Pane Description

Speech problems

Fill Instructions
Special Instructions
Skip Instructions

<0-2,R,D> [go to CMHAGM11_4]

Hard Edits
Soft Edits
AssocHelp

H_CMHAG

Monday, August 25, 2014

Page 75 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

B

Question ID

CHS.321_04.000

Variable Name

CMHAGM11_4

Universe

HHSTAT4='C' and AGE IN('002','003') and SEX='1'

Universe-text

Male sample children 2-3

Question Text

(book) C3 ?[F1]
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
He:
Has been unhappy, sad, or depressed?

Answer Codes

0. Not true
1. Sometimes true
2. Often true
Don't know
Refused

Question Type

Pick One - answer list pane

Field Pane Description

Unhappy/depressed

Fill Instructions
Special Instructions
Skip Instructions

<0-2,R,D> [go to CAU.CUSUALPL]

Hard Edits
Soft Edits
AssocHelp

H_CMHAG

Monday, August 25, 2014

Page 76 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Behaviors

Part

B

Question ID

CHS.321_H

Variable Name

H_CMHAG

Universe
Universe-text
Question Text

If respondent gives an answer which does not match the categories read in the
question, reread the question emphasizing the wording of the answer categories.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CMHAGM11_1
CMHAGM11_2
CMHAGM11_3
CMHAGM11_4
CMHAGF11_1
CMHAGF11_2
CMHAGF11_3
CMHAGF11_4

Skip Instructions
Hard Edits
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Monday, August 25, 2014

Page 77 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

B

Question ID

CHS.361_01.000

Variable Name

CMHAGF11_1

Universe

HHSTAT4='C' and AGE IN('002','003') and SEX = '2'

Universe-text

Female sample children 2-3

Question Text

(book) C3 ?[F1]
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
She:
Has temper tantrums or a hot temper?

Answer Codes

0. Not true
1. Sometimes true
2. Often true
Don't know
Refused

Question Type

Pick One - answer list pane

Field Pane Description

Temper tantrums

Fill Instructions
Special Instructions
Skip Instructions

<0-2,R,D> [go to CMHAGF11_2]

Hard Edits
Soft Edits
AssocHelp

H_CMHAG

Monday, August 25, 2014

Page 78 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

B

Question ID

CHS.361_02.000

Variable Name

CMHAGF11_2

Universe

HHSTAT4='C' and AGE IN('002','003') and SEX = '2'

Universe-text

Female sample children 2-3

Question Text

(book) C3 ?[F1]
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
She:
Has speech problems?

Answer Codes

0. Not true
1. Sometimes true
2. Often true
Don't know
Refused

Question Type

Pick One - answer list pane

Field Pane Description

Speech problems

Fill Instructions
Special Instructions
Skip Instructions

<0-2,R,D> [go to CMHAGF11_3]

Hard Edits
Soft Edits
AssocHelp

H_CMHAG

Monday, August 25, 2014

Page 79 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

B

Question ID

CHS.361_03.000

Variable Name

CMHAGF11_3

Universe

HHSTAT4='C' and AGE IN('002','003') and SEX = '2'

Universe-text

Female sample children 2-3

Question Text

(book) C3 ?[F1]
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
She:
Has been nervous or high-strung?

Answer Codes

0. Not true
1. Sometimes true
2. Often true
Don't know
Refused

Question Type

Pick One - answer list pane

Field Pane Description

Nervous/high-strung

Fill Instructions
Special Instructions
Skip Instructions

<0-2,R,D> [go to CMHAGF11_4]

Hard Edits
Soft Edits
AssocHelp

H_CMHAG

Monday, August 25, 2014

Page 80 of 81

Module

11

Section Name

Child Conditions, Limitations, Health Status

Part

B

Question ID

CHS.361_04.000

Variable Name

CMHAGF11_4

Universe

HHSTAT4='C' and AGE IN('002','003') and SEX = '2'

Universe-text

Female sample children 2-3

Question Text

(book) C3 ?[F1]
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has
been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING
THE PAST TWO MONTHS.
She:
Has been unhappy, sad, or depressed?

Answer Codes

0. Not true
1. Sometimes true
2. Often true
Don't know
Refused

Question Type

Pick One - answer list pane

Field Pane Description

Unhappy/depressed

Fill Instructions
Special Instructions
Skip Instructions

<0-2,R,D> [go to CAU.CUSUALPL]

Hard Edits
Soft Edits
AssocHelp

H_CMHAG

Monday, August 25, 2014

Page 81 of 81

2015 Q1 NHIS Instrument Spec Report
Section name: Child Health Care Access and Utilization
Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.020

Variable Name

CUSUALPL

Universe

HHSTAT4 = 'C' and AGE <18

Universe-text

Sample Children <18

Question Text

?[F1]
The next questions are about health care.
Is there a place that [fill1: alias] USUALLY goes when [fill2: he/she] is sick or you need
advice
about [fill3: his/her] health?

Answer Codes

1. Yes
2. There is NO place
3. There is MORE THAN ONE place
Don't know
Refused

Question Type

Pick One - answer list pane

Field Pane Description

Usually go when sick

Fill Instructions
Special Instructions
Skip Instructions

<1,3> [go to CPLKIND]
<2,D,R> [go to CHCPLKND]

Hard Edits
Soft Edits
AssocHelp

H_CUSUALPL

Monday, August 25, 2014

Page 1 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.020_H

Variable Name

H_CUSUALPL

Universe
Universe-text
Question Text

A place to USUALLY go when a child is sick or in need of advice about his/her health
includes:
[blt]Walk-in clinic
[blt]Doctor's office
[blt]Clinic
[blt]Health Center
[blt]Health Maintenance Organization
[blt]Hospital - Emergency Room or Outpatient Clinic
[blt]Military or VA Health Care Facility

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CUSUALPL

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 2 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.030

Variable Name

CPLKIND

Universe

HHSTAT4 = 'C' and AGE <18 and CUSUALPL = 1,3

Universe-text

Sample children <18 with one or more usual places to go when sick or need health
advice

Question Text

?[F1]
[fill1: What kind of place is it / What kind of place does [fill2: alias] go to most often] - a
clinic, doctor's office, emergency room, or some other place?

Answer Codes

1. Clinic or health center
2. Doctor's office or HMO
3. Hospital emergency room
4. Hospital outpatient department
5. Some other place
6. Doesn't go to one place most often
Don't know
Refused

Question Type

Pick One - answer list pane

Field Pane Description
Fill Instructions

Go to most often

fill1: [if CUSUALPL/CAU.020 = 1 then "What kind of place is it...";
if CUSUALPL/CAU.020 = 3 then "What kind of place does [fill2: alias] go to most
often..."

Special Instructions
Skip Instructions

<1-5> [go to CHCPLROU]
<6,D,R> [go to CHCPLKND]

Hard Edits
Soft Edits
AssocHelp

H_CPLKIND

Monday, August 25, 2014

Page 3 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.030_H

Variable Name

H_CPLKIND

Universe
Universe-text
Question Text

[b]Doctor[b] includes medical doctors, as well as other health care professionals, such
as: general practitioners, psychologists, chiropractors, etc.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CPLKIND

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 4 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.035

Variable Name

CHCPLROU

Universe

HHSTAT4 = 'C' and AGE <18 and CPLKIND =1-5

Universe-text

Sample children <18 with one or more usual places to go when sick or need health
advice who reported that place as a clinic or health center, doctor's office or HMO,
hospital emergency room, hospital outpatient department, or some other place

Question Text

?[F1]
Is that [fill1: CPLKIND/CAU.030] the same place [fill2: alias] USUALLY goes when [fill3:
he/she] needs routine or preventive care, such as a physical examination or (well
baby/child) check-up?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description
Fill Instructions

Routine / prev. care place

fill1 = CPLKIND answer text

Special Instructions
Skip Instructions

<1> [go to CHCCHGYR]
<2,D,R> [go to CHCPLKND]

Hard Edits
Soft Edits
AssocHelp

H_CHCPLROU

Monday, August 25, 2014

Page 5 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.035_H

Variable Name

H_CHCPLROU

Universe
Universe-text
Question Text

[b]Routine or preventive care[b] is a health procedure or series of health procedures
done to help a person avoid illness or to detect problems early.
A [b]general physical exam or check-up [b] is an examination not for a specific
condition or problem. This may include the following: a periodic health examination, a
complete medical examination, an annual health check-up, or a comprehensive
physical examination. It does NOT include dental exams and vision tests.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCPLROU

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 6 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.037

Variable Name

CHCPLKND

Universe

HHSTAT4 = 'C' and AGE <18 and [CUSUALPL=2,D,R or CPLKIND =6,D,R, or
CHCPLROU =2,D,R]

Universe-text

Sample Children <18 who do not have a usual source of sick care; who Ref/NA/DK if
have a usual source of sick care; who have a usual source of sick care but does not go
to one place most often; who have a usual source of sick care but Ref/NA/DK what
kind of place; who have a usual source of sick care, but it is not same place as usual
source of routine/preventive care; who have a usual source of sick care but Ref/NA/DK
if it is same place as usual source of routine/preventive care.

Question Text

?[F1]
What kind of place does [fill1: alias] USUALLY go to when [fill2: he/she] needs routine
or preventive care, such as a physical examination or (well baby/child) check-up?

Answer Codes

0. Doesn't get preventive care anywhere
1. Clinic or health center
2. Doctor's office or HMO
3. Hospital emergency room
4. Hospital outpatient department
5. Some other place
6. Doesn't go to one place most often
Don't know
Refused

Question Type

Pick One - answer list pane

Field Pane Description

Usually go for routine / prev. care

Fill Instructions
Special Instructions
Skip Instructions

<0-6,R,D> if CUSUALPL=2 [goto CNOUSLPL];
else if CUSUALPL=,R,D [goto CPRVTRYR];
else [goto CHCCHGYR]

Hard Edits
Soft Edits
AssocHelp

H_CHCPLKND

Monday, August 25, 2014

Page 7 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part
Question ID

CAU.037_H

Variable Name

H_CHCPLKND

Universe
Universe-text
Question Text

Accept whatever the respondent reports.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCPLKND

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 8 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.040

Variable Name

CHCCHGYR

Universe

HHSTAT4 = 'C' and AGE <18 and [CUSUALPL=1,3 or CHCPLROU = 1]

Universe-text

Sample children <18 with one or more place to go when sick/need advice [or who
reported same place as usual source of routine/preventive care]

Question Text

?[F1]
At any time IN THE PAST 12 MONTHS did you CHANGE the place(s) to which [fill:
alias] USUALLY goes for health care?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Change health care place

Fill Instructions
Special Instructions
Skip Instructions

<1> [go to CHCCHGHI]
<2,D,R> to CPRVTRYR]

Hard Edits
Soft Edits
AssocHelp

H_CHCCHGYR

Monday, August 25, 2014

Page 9 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.040_H

Variable Name

H_CHCCHGYR

Universe
Universe-text
Question Text

[b]Change the place[b] refers to a change in health care providers, not a change of
address for a current provider.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCCHGYR

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 10 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.050

Variable Name

CHCCHGHI

Universe

HHSTAT4 = 'C' and AGE <18 and CHCCHGYR=1

Universe-text

All sample children <18 that have changed their usual place of health care in the past
12 months

Question Text

Was this change for a reason related to health insurance?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Change due to health ins.

Fill Instructions
Special Instructions
Skip Instructions

<1,2,D,R> [goto CPRVTRYR]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 11 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.050_00.010

Variable Name

CNOUSLPL

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CUSUALPL(e)='2'

Universe-text

Sample children <18 who don't have a usual place of care

Question Text

Why doesn’t [fill: alias] have a usual source of medical care?
*Enter all that apply, separate with commas.

Answer Codes

1. Doesn’t need a doctor/Haven't had any problems
2. Doesn’t like/trust/believe in doctors
3. Doesn’t know where to go
4. Previous doctor is not available/moved
5. Too expensive/no insurance/cost
6. Speak a different language
7. No care available/Care too far away, not convenient
8. Put it off/Didn't get around to it
9.Other
Refused
Don't know

Question Type

Enter all that apply

Field Pane Description

No usual source

Fill Instructions
Special Instructions
Skip Instructions

<1-9,R,D>[goto CPRVTRYR]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 12 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.052_00.010

Variable Name

CPRVTRYR

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

DURING THE PAST 12 MONTHS, did you have any trouble finding a general doctor or
provider who would see [fill: alias]?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Trouble finding doctor

Fill Instructions
Special Instructions
Skip Instructions

<1> [goto CPRVTRFD ] <2,R,D> [goto CDRNANP]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 13 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.053_00.010

Variable Name

CPRVTRFD

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CPRVTRYR(e)='1'

Universe-text

Sample children <18 who had trouble finding a provider in the last year

Question Text

Were you able to find a general doctor or provider who could see [fill: alias]?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Able to find doctor

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CDRNANP]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 14 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.055_00.010

Variable Name

CDRNANP

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they
would not accept [fill: alias] as a new patient?

Answer Codes

1. Yes
2. No
Refused
Don’t know

Question Type

Yes/No

Field Pane Description

Not accept patient

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D>[goto CDRNAI]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 15 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.056_00.010

Variable Name

CDRNAI

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample children <18

Question Text

DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they
did not accept [fill: alias]'s health care coverage?

Answer Codes

1. Yes
2. No
Refused
Don’t know

Question Type

Yes/No

Field Pane Description

Not accept health care

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D>[goto CHCDLYR_1]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 16 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part
Question ID

CAU.080_1

Variable Name

CHCDLYR1_1

Universe

HHSTAT4 = 'C' and AGE <18

Universe-text

All sample children <18

Question Text

?[F1]
There are many reasons people delay getting medical care. Have you delayed getting
care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
You couldn't get through on the telephone.

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Couldn't get through on phone

Fill Instructions
Special Instructions Formpane: column heading = "Past 12 months"
Skip Instructions

<1,2,D,R> [goto CHCDLYR1_2]

Hard Edits
Soft Edits
AssocHelp

H_CHCDLYR1_1

Monday, August 25, 2014

Page 17 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.080_1_H

Variable Name

H_CHCDLYR1_1

Universe
Universe-text
Question Text

Delayed assumes that medical care has been or will eventually be received.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCDLYR1_1

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 18 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.080_2

Variable Name

CHCDLYR1_2

Universe

HHSTAT4 = 'C' and AGE <18

Universe-text

All sample children <18

Question Text

?[F1]
* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting
care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
You couldn't get an appointment for [fill: alias] soon enough.

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

No appt. soon enough

Fill Instructions
Special Instructions
Skip Instructions

<1,2,D,R> [goto CHCDLYR1_3]

Hard Edits
Soft Edits
AssocHelp

H_CHCDLYR1_2

Monday, August 25, 2014

Page 19 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.080_2_H

Variable Name

H_CHCDLYR1_2

Universe
Universe-text
Question Text

[b]Delayed[b] assumes that medical care has been or will eventually be received.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCDLYR1_2

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 20 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.080_3

Variable Name

CHCDLYR1_3

Universe

HHSTAT4 = 'C' and AGE <18

Universe-text

All sample children <18

Question Text

?[F1]
* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting
care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
Once you get there, [fill: alias] has to wait too long to see the doctor.

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Wait too long to see Dr.

Fill Instructions
Special Instructions
Skip Instructions

<1,2,D,R> [goto CHCDLYR1_4]

Hard Edits
Soft Edits
AssocHelp

H_CHCDLYR1_3

Monday, August 25, 2014

Page 21 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.080_3_H

Variable Name

H_CHCDLYR1_3

Universe
Universe-text
Question Text

[b]Delayed[b] assumes that medical care has been or will eventually be received.
[b]Waiting time to see the doctor[b] includes only time from arrival until the health care
provider is seen.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCDLYR1_3

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 22 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.080_4

Variable Name

CHCDLYR1_4

Universe

HHSTAT4 = 'C' and AGE <18

Universe-text

All sample children <18

Question Text

?[F1]
* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting
care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
The (clinic/doctor's office) wasn't open when you could get there.

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Clinic / office not open

Fill Instructions
Special Instructions
Skip Instructions

<1,2,D,R> [goto CHCDLYR1_5]

Hard Edits
Soft Edits
AssocHelp

H_CHCDLYR1_4

Monday, August 25, 2014

Page 23 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.080_4_H

Variable Name

H_CHCDLYR1_4

Universe
Universe-text
Question Text

[b]Delayed[b] assumes that medical care has been or will eventually be received.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCDLYR1_4

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 24 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.080_5

Variable Name

CHCDLYR1_5

Universe

HHSTAT4 = 'C' and AGE <18

Universe-text

All sample children <18

Question Text

?[F1]
* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting
care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
You didn’t have transportation.

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

No transportation

Fill Instructions
Special Instructions
Skip Instructions

<1,2,D,R> [if AGE GE <2> goto CHCAFYR1_1; else goto CHCAFYR]

Hard Edits
Soft Edits
AssocHelp

H_CHCDLYR1_5

Monday, August 25, 2014

Page 25 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.080_5_H

Variable Name

H_CHCDLYR1_5

Universe
Universe-text
Question Text

[b]Delayed[b] assumes that medical care has been or will eventually be received.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCDLYR1_5

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 26 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.130

Variable Name

CHCAFYR

Universe

HHSTAT4 = 'C' and AGE <2

Universe-text

Sample children <2

Question Text

?[F1]
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of
the following, but didn't get it because you couldn't afford it...
Prescription medicines?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Prescription medicines

Fill Instructions
Special Instructions Formpane: column heading: "Children under 2 years old - past 12 months"
Skip Instructions

<1, 2, D, R> [CHCAFYRN]

Hard Edits
Soft Edits
AssocHelp

H_CHCAFYR

Monday, August 25, 2014

Page 27 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.130_H

Variable Name

H_CHCAFYR

Universe
Universe-text
Question Text

[b]Prescription Medicines[b] are medication which can only be obtained with the
approval of a licensed health care professional. The medication is usually obtained
through a pharmacy using a written note or telephoned instructions from the health care
professional to the pharmacy.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCAFYR
CHCAFYR1_1

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 28 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.133_00.010

Variable Name

CHCAFYRN

Universe

HHSTAT4='C' and (AGE LE '001' and AGE NE ' ')

Universe-text

Sample children <2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of
the following, but didn't get it because you couldn't afford it...
To see a specialist?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Specialist

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CHCAFYRF]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 29 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.133_00.020

Variable Name

CHCAFYRF

Universe

HHSTAT4='C' and (AGE LE '001' and AGE NE ' ')

Universe-text

Sample children <2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of
the following, but didn't get it because you couldn't afford it...
Follow-up care?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Follow-up

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [if AGE <1 goto CHCSYR1_2; else goto CDENLONG]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 30 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.135_1

Variable Name

CHCAFYR1_1

Universe

HHSTAT4 = 'C' and AGE GE 2

Universe-text

Sample children GE 2

Question Text

?[F1]
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of
the following, but didn't get it because you couldn't afford it...
Prescription medicines?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Prescription medicines

Fill Instructions
Special Instructions Formpane: column heading: "Children 2-17 years old - past 12 months"
Skip Instructions

<1, 2, D, R> [goto CHCAFYR1_2]

Hard Edits
Soft Edits
AssocHelp

H_CHCAFYR

Monday, August 25, 2014

Page 31 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.135_2

Variable Name

CHCAFYR1_2

Universe

HHSTAT4 = 'C' and AGE GE 2

Universe-text

Sample children GE 2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of
the following, but didn't get it because you couldn't afford it...
Mental health care or counseling?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Mental health care / counseling

Fill Instructions
Special Instructions
Skip Instructions

<1, 2, D, R> [goto CHCAFYR1_3]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 32 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.135_3

Variable Name

CHCAFYR1_3

Universe

HHSTAT4 = 'C' and AGE GE 2

Universe-text

Sample children GE 2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of
the following, but didn't get it because you couldn't afford it...
Dental care (including check-ups)?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Dental care

Fill Instructions
Special Instructions
Skip Instructions

<1, 2, D, R> [goto CHCAFYR1_4]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 33 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.135_4

Variable Name

CHCAFYR1_4

Universe

HHSTAT4 = 'C' and AGE GE 2

Universe-text

Sample children GE 2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of
the following, but didn't get it because you couldn't afford it...
Eyeglasses?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Eyeglasses

Fill Instructions
Special Instructions
Skip Instructions

<1, 2, D, R> [goto CHCAFYR1_6]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 34 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.135_5.010

Variable Name

CHCAFYR1_5

Universe

HHSTAT4='C' and ('002' <= AGE<= '017')

Universe-text

Sample children GE 2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of
the following, but didn't get it because you couldn't afford it...
To see a specialist?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Specialist

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CHCAFYR1_6]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 35 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.135_6.010

Variable Name

CHCAFYR1_6

Universe

HHSTAT4='C' and ('002' <= AGE<= '017')

Universe-text

Sample children GE 2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of
the following, but didn't get it because you couldn't afford it...
Follow-up care?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Follow-up

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CDENLONG]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 36 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

B

Question ID

CAU.160

Variable Name

CDENLONG

Universe

HHSTAT4 = 'C' and AGE GE 1

Universe-text

Sample children GE 1

Question Text

(book) C4 ?[F1]
About how long has it been since [fill: alias] last saw a dentist? Include all types of
dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well
as dental hygienists.

Answer Codes

0. Never
1. 6 months or less
2. More than 6 months, but not more than 1 year ago
3. More than 1 year, but not more than 2 years ago
4. More than 2 years, but not more than 5 years ago
5. More than 5 years ago
Don't know
Refused

Question Type

Pick One - answer list pane

Field Pane Description

Last saw dentist

Fill Instructions
Special Instructions
Skip Instructions

<0-5, D,R> [if AGE GE <2> goto CHCSYR_1; else go to CHCSYR1_2]

Hard Edits
Soft Edits
AssocHelp

H_CDENLONG

Monday, August 25, 2014

Page 37 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.160_H

Variable Name

H_CDENLONG

Universe
Universe-text
Question Text

Always probe for an exact number.
If the respondent reports a range or interval, assist the respondent in making an
estimate by probing. For example, you might ask "Could you give me a more exact
number?"

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CDENLONG
CHCHNOYR
CSRGNOYR

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 38 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.170_1

Variable Name

CHCSYR1_2

Universe

HHSTAT4 = 'C' and AGE <2

Universe-text

Sample children <2

Question Text
DURING THE PAST 12 MONTHS has anyone in the family seen or talked to any of the
following health care providers about [fill2: alias]'s health?
An optometrist, ophthamologist, or eye doctor (someone who prescribes eyeglasses)?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Eye doctor

Fill Instructions
Special Instructions Formpane: column heading = "Children under 2 years old - past 12 months"
Skip Instructions

<1, 2, D, R> [goto CHCSYR1_3]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 39 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.170_2

Variable Name

CHCSYR1_3

Universe

HHSTAT4 = 'C' and AGE <2

Universe-text

Sample children <2

Question Text

?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS has anyone in the family seen or talked to any of the
following health care providers about [fill2: alias]'s health?
A foot doctor?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Foot doctor

Fill Instructions
Special Instructions
Skip Instructions

<1,2, D, R> [goto CHCSYR1_5]

Hard Edits
Soft Edits
AssocHelp

H_CHCSYR1_3

Monday, August 25, 2014

Page 40 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.170_2_H

Variable Name

H_CHCSYR1_3

Universe
Universe-text
Question Text

A foot doctor is someone who treats diseases of the foot and is commonly known as a
podiatrist.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCSYR1_3
CHCSYR_3

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 41 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.170_3

Variable Name

CHCSYR1_5

Universe

HHSTAT4 = 'C' and AGE <2

Universe-text

Sample children <2

Question Text

?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS has anyone in the family seen or talked to any of the
following health care providers about [fill2: alias]'s health?
A physical therapist, speech therapist, respiratory therapist, audiologist, or occupational
therapist?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Physical / speech / resp. therapist

Fill Instructions
Special Instructions
Skip Instructions

<1,2, D, R> [goto CHCSYR1_6]

Hard Edits
Soft Edits
AssocHelp

H_CHCSYR1_5

Monday, August 25, 2014

Page 42 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.170_3_H

Variable Name

H_CHCSYR1_5

Universe
Universe-text
Question Text

A [b] physical therapist [b] is a health care professional skilled in working with persons
with health problems resulting from injury, disease, or developmental problems. A
physical therapist diagnoses muscle and joint problems and provides exercises and
treatments.
A [b] speech therapist [b] is a health care professional skilled in working with
communication and language disorders. Speech pathologists diagnose speech and
language problems and provide therapy including treatment for stuttering, impaired
articulation, or language or voice impairment.
A [b] respiratory therapist [b] is a health care professional skilled in working with
persons with respiratory difficulties. Respiratory therapists treat and manage the care
of persons with respiratory diseases. This may include administration of breathing
treatments, oxygen, and education of patients in regards to respiratory treatment
procedures.
An [b] audiologist [b] is a health care professional skilled in working with hearing
problems. An audiologist diagnoses hearing problems and their nature, and
determines if a person can benefit from using hearing aids.
An [b] occupational therapist [b] is a health care professional skilled in working with
health problems resulting from injury, disease, or developmental problems.
Occupational therapy involves working on functional activities such as dressing,
feeding, and writing.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCSYR1_5
CHCSYR_5

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 43 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.170_4

Variable Name

CHCSYR1_6

Universe

HHSTAT4 = 'C' and AGE <2

Universe-text

Sample children <2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS has anyone in the family seen or talked to any of the
following health care providers about [fill2: alias]'s health?
A nurse practitioner, physician assistant or midwife?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Nurse prac. / physician asst.

Fill Instructions
Special Instructions
Skip Instructions

<1, 2, D, R> [goto CHCSYR8_1]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 44 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.175_1

Variable Name

CHCSYR_1

Universe

HHSTAT4 = 'C' and AGE GE 2

Universe-text

Sample children GE 2

Question Text
DURING THE PAST 12 MONTHS have you seen or talked to any of the following
health care providers about [fill2: alias]'s health...
A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or
clinical social worker?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Mental health professional

Fill Instructions
Special Instructions Formpane: column heading: "Children 2-17 years old - past 12 months"
Skip Instructions

<1, 2, D, R> [goto CHCSYR_2]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 45 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.175_2

Variable Name

CHCSYR_2

Universe

HHSTAT4 = 'C' and AGE GE 2

Universe-text

Sample children GE 2

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS have you seen or talked to any of the following
health care providers about [fill2: alias]'s health...
An optometrist, ophthalmologist (AHF-thal-MOL-oh-jist), or eye doctor (someone who
prescribes eyeglasses)?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Eye doctor

Fill Instructions
Special Instructions
Skip Instructions

<1, 2, D, R> [goto CHCSYR_3]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 46 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.175_3

Variable Name

CHCSYR_3

Universe

HHSTAT4 = 'C' and AGE GE 2

Universe-text

Sample children GE 2

Question Text

?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS have you seen or talked to any of the following
health care providers about [fill2: alias]'s health...
A foot doctor?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Foot doctor

Fill Instructions
Special Instructions
Skip Instructions

<1, 2, D, R> [goto CHCSYR_4]

Hard Edits
Soft Edits
AssocHelp

H_CHCSYR1_3

Monday, August 25, 2014

Page 47 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.175_4

Variable Name

CHCSYR_4

Universe

HHSTAT4 = 'C' and AGE GE 2

Universe-text

Sample children GE 2

Question Text

?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS have you seen or talked to any of the following
health care providers about [fill2: alias]'s health...
A chiropractor?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Chiropractor

Fill Instructions
Special Instructions
Skip Instructions

<1, 2, D, R> [goto CHCSYR_5]

Hard Edits
Soft Edits
AssocHelp

H_CHCSYR_4

Monday, August 25, 2014

Page 48 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.175_4_H

Variable Name

H_CHCSYR_4

Universe
Universe-text
Question Text

A chiropractor is a licensed professional, but not a medical doctor, who uses
manipulation of the body joints, especially the spine, to restore normal nerve function.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCSYR_4

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 49 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.175_5

Variable Name

CHCSYR_5

Universe

HHSTAT4 = 'C' and AGE GE 2

Universe-text

Sample children GE 2

Question Text

?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS have you seen or talked to any of the following
health care providers about [fill2: alias]'s health...
A physical therapist, speech therapist, respiratory therapist, audiologist, or occupational
therapist?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Physical / speech / resp. therapist

Fill Instructions
Special Instructions
Skip Instructions

<1, 2, D, R> [goto CHCSYR_6]

Hard Edits
Soft Edits
AssocHelp

H_CHCSYR1_5

Monday, August 25, 2014

Page 50 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.175_6

Variable Name

CHCSYR_6

Universe

HHSTAT4 = 'C' and AGE GE 2

Universe-text

Sample children GE 2

Question Text

?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS have you seen or talked to any of the following
health care providers about [fill2: alias]'s health...
A nurse practitioner, physician assistant or midwife?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Nurse prac. / phys. asst. / midwife

Fill Instructions
Special Instructions
Skip Instructions

<1, 2, D, R> [if SEX eq <2> and AGE GE 15 goto CHCSYR7; else goto CHCSYR8]

Hard Edits
Soft Edits
AssocHelp

H_CHCSYR_6

Monday, August 25, 2014

Page 51 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.175_6_H

Variable Name

H_CHCSYR_6

Universe
Universe-text
Question Text

A [b] nurse practitioner [b] is a registered nurse who has completed an advanced
program of study leading to an expanded role in health care. Nurse practitioners are
able to take health histories, perform physical examinations, order tests, and prescribe
treatments including medications. Nurse practitioners work under the supervision of a
doctor, but not necessarily in the presence of the doctor.
A [b] nurse midwife [b] is a registered nurse who has completed an advanced program
of study leading to an expanded role in health care for women. Nurse midwives
provide gynecological, pregnancy and delivery care to women. Nurse midwives work
under the supervision of a doctor, but not necessarily in the presence of the doctor.
A [b] physician assistant [b] works under the supervision of a physician to provide
diagnostic, preventative, and therapeutic health care services. Duties may include
examining patients, interpreting and ordering x-rays and lab tests, and the diagnosis
and treatment of minor injuries.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCSYR_6

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 52 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.230

Variable Name

CHCSYR7

Universe

HHSTAT4 = 'C' and AGE GE 15 and SEX=2

Universe-text

Sample children GE 15 who are female

Question Text

?[F1]
DURING THE PAST 12 MONTHS have you seen or talked to a doctor who specializes
in women's health (an obstetrician/gynecologist) about [fill2: alias]'s health?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Women's health doctor

Fill Instructions
Special Instructions Form pane: column heading = "Past 12 months"
Skip Instructions

<1, 2, R, D> [goto CHCSYR8_1]

Hard Edits
Soft Edits
AssocHelp

H_CHCSYR7

Monday, August 25, 2014

Page 53 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.230_H

Variable Name

H_CHCSYR7

Universe
Universe-text
Question Text

An Obstetrician/Gynecologist is a medical doctor who treats women, pregnancy, and
diseases of the female reproductive system, including the breasts.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCSYR7

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 54 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.240_1

Variable Name

CHCSYR8_1

Universe

HHSTAT4 = 'C' and AGE <18

Universe-text

All sample children <18

Question Text

DURING THE PAST 12 MONTHS have you seen or talked to the following about [fill2:
alias]'s health?
A medical doctor who specializes in a particular medical disease or problem [fill3:other
than obstetrician/ gynecologist, psychiatrist or ophthalmologist (AHF-thal-MOL-oh-jist)?
/fill4: other than psychiatrist or ophthalmologist (AHF-thal-MOL-oh-jist)]?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description
Fill Instructions

Specialist doctor

Fill 3: If [SEX = Female (2) ] Fill 4: If [SEX = Male (1) ]

Special Instructions Formpane: column heading = "Past 12 months"
Skip Instructions

<1, 2, D, R> [goto CHCSYR8_2]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 55 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.240_2

Variable Name

CHCSYR8_2

Universe

HHSTAT4 = 'C' and AGE <18

Universe-text

All sample children <18

Question Text

* Read if necessary.
DURING THE PAST 12 MONTHS have you seen or talked to the following about [fill2:
alias]'s health?
A general doctor who treats a variety of illnesses (a doctor in general practice,
pediatrics, family medicine, or internal medicine)?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

General doctor

Fill Instructions
Special Instructions
Skip Instructions

<1> [goto CHCSYR10]
<2, D, R> [goto CHPEXYR]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 56 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.260

Variable Name

CHCSYR10

Universe

HHSTAT4 = 'C' and AGE <18 and CHCSYR8_2=1

Universe-text

Sample children <18 who have seen or talked to a general doctor during the past 12
months

Question Text

Does that doctor treat children and adults (a doctor in general practice or family
medicine)?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Doctor treats children and adults

Fill Instructions
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.

Skip Instructions

<1, 2, D, R> [goto CHCSYREM]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 57 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.265

Variable Name

CHCSYREM

Universe

HHSTAT4 = 'C' and AGE <18 and CHCSYR8_2=1

Universe-text

Sample children <18 who have seen a general doctor in the past 12 months

Question Text

Did you see or talk to this general doctor because of an emotional or behavioral
problem that [fill1: alias] may have?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

General doctor for emotional problem

Fill Instructions
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.

Skip Instructions

<1, 2, D, R> [goto CHPEXYR]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 58 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.270

Variable Name

CHPEXYR

Universe

HHSTAT4 = 'C' and AGE <18

Universe-text

Sample children <18

Question Text

?[F1]
DURING THE PAST 12 MONTHS, did [fill1: alias] receive a well-child check-up, that is
a general check-up, when [fill2: he/she] was not sick or injured?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Check-up

Fill Instructions
Special Instructions
Skip Instructions

<1, 2, D, R> [goto CHERNOYR]

Hard Edits
Soft Edits
AssocHelp

H_CHPEXYR

Monday, August 25, 2014

Page 59 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.270_H

Variable Name

H_CHPEXYR

Universe
Universe-text
Question Text

A general physical exam or check-up is an examination not for a specific condition or
problem. This may include the following: a periodic health examination, a complete
medical examination, an annual health check-up, or a comprehensive physical
examination. It does NOT include dental exams and vision tests.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHPEXYR

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 60 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part
Question ID

CAU.280

Variable Name

CHERNOYR

Universe

HHSTAT4 = 'C' and AGE<18

Universe-text

Sample children <18

Question Text

(book) C5 ?[F1]
DURING THE PAST 12 MONTHS, HOW MANY TIMES has [fill1: alias] gone to a
HOSPITAL EMERGENCY ROOM about [fill2: his/her] health? (This includes
emergency room visits that resulted in a hospital admission.)

Answer Codes

0.
1.
2.
3.
4.
5.
6.
7.
8.

Question Type

Integer

Field Pane Description

None
1
2-3
4-5
6-7
8-9
10 - 12
13 - 15
16 or more

Emergency room

Fill Instructions
Special Instructions
Skip Instructions

<0,R,D> [goto CHCHYR] <1-8> [goto CERVISND]

Hard Edits
Soft Edits
AssocHelp

H_CHERNOYR

Monday, August 25, 2014

Page 61 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.280_H

Variable Name

H_CHERNOYR

Universe
Universe-text
Question Text

[b] Hospital Emergency Room [b] is an emergency care facility at a hospital. Do NOT
include emergency care received at a clinic or HMO. Include emergency room visits
which resulted in admission for inpatient care.
Do not include visits to outpatient clinics, urgent care facilities and the like.
Always probe for an exact number. If the respondent reports a range or interval, assist
the respondent in making an estimate by probing. For example, you might ask "Could
you give me a more exact number?"

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHERNOYR

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 62 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.281_00.010

Variable Name

CERVISND

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and ('01' <= CHERNOYR(e) <='08')

Universe-text

Sample children <18 who had at least one ER visit in the past year

Question Text

Thinking about [fill: S.C. name]'s most recent emergency room visit, did [fill: he/she ] go
to the emergency room either at night or on the weekend?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

ER night

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CERHOS]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 63 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.282_00.010

Variable Name

CERHOS

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and ('01' <= CHERNOYR(e) <='08')

Universe-text

Sample children <18 who had at least one ER visit in the past year

Question Text

Did this emergency room visit result in a hospital admission?

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

ER hospital

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [go to CERREAS1]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 64 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.283_01.010

Variable Name

CERREAS1

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and ('01' <= CHERNOY2(e) <='08')

Universe-text

Sample children <18 who had at least one ER visit in the past year

Question Text

Tell me which of these apply to [fill: alias]'s last emergency room visit?
… [fill: He/She] didn’t have another place to go

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Another place

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CERREAS2]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 65 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.283_02.020

Variable Name

CERREAS2

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and ('01' <= CHERNOY2(e) <='08')

Universe-text

Sample children <18 who had at least one ER visit in the past year

Question Text

*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
… [fill: alias]'s doctor’s office or clinic was not open

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Dr. not open

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CERREAS3]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 66 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.283_03.030

Variable Name

CERREAS3

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and ('01' <= CHERNOY2(e) <='08')

Universe-text

Sample children <18 who had at least one ER visit in the past year

Question Text

*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
… [fill: alias]'s health provider advised that [fill: he/she] go

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Provider advised to go

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CERREAS4]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 67 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.283_04.040

Variable Name

CERREAS4

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and ('01' <= CHERNOY2(e) <='08')

Universe-text

Sample children <18 who had at least one ER visit in the past year

Question Text

*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
… The problem was too serious for the doctor’s office or clinic

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Problem serious

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CERREAS5]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 68 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.283_05.050

Variable Name

CERREAS5

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and ('01' <= CHERNOY2(e) <='08')

Universe-text

Sample children <18 who had at least one ER visit in the past year

Question Text

*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
… Only a hospital could help [fill: alias]

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Only hospital

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CERREAS6]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 69 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.283_06.060

Variable Name

CERREAS6

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and ('01' <= CHERNOY2(e) <='08')

Universe-text

Sample children <18 who had at least one ER visit in the past year

Question Text

*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
… The emergency room is [fill: alias]'s closest provider

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

ER closest

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CERREAS7]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 70 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.283_07.070

Variable Name

CERREAS7

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and ('01' <= CHERNOY2(e) <='08')

Universe-text

Sample children <18 who had at least one ER visit in the past year

Question Text

*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
…[fill: alias] gets most of [fill: his/her] care at the emergency room

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Care at ER

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CERREAS8]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 71 of 83

Module

12

Section Name

Child Access to Health Care & Utilization

Part
Question ID

CAU.283_08.080

Variable Name

CERREAS8

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and ('01' <= CHERNOY2(e) <='08')

Universe-text

Sample children <18 who had at least one ER visit in the past year

Question Text

*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
…[fill: alias] arrived by ambulance or other emergency vehicle

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Ambulance

Fill Instructions
Special Instructions
Skip Instructions

<1,2,R,D> [goto CHCHYR]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 72 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.290

Variable Name

CHCHYR

Universe

HHSTAT4 = 'C' and AGE <18

Universe-text

Sample children <18

Question Text

?[F1]
DURING THE PAST 12 MONTHS, did [fill1: alias] receive care AT HOME from a nurse
or other health care professional?

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Home care - nurse / hlth. prof.

Fill Instructions
Special Instructions Formpane: column heading = "Past 12 months"
Skip Instructions

<1> [goto CHCHMOYR]
<2, D, R> [goto CHCNOYR]

Hard Edits
Soft Edits
AssocHelp

H_CHCHYR

Monday, August 25, 2014

Page 73 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.290_H

Variable Name

H_CHCHYR

Universe
Universe-text
Question Text

At HOME refers to the child's own home and everyone else's home in which the child
was staying at the time. This could be a house, apartment, motor home, houseboat,
trailer, or other dwelling. Do not include visits by a doctor while the child was in a
hospital or institutionalized.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCHYR

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 74 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.300

Variable Name

CHCHMOYR

Universe

HHSTAT4 = 'C' and AGE <18 and CHCHYR=1

Universe-text

Sample children <18 that have received home care from health professional during the
past 12 months

Question Text

?[F1]
DURING THE PAST 12 MONTHS, how many months did [fill: alias] receive care AT
HOME from a health care professional?

Answer Codes
Question Type

Integer

Field Pane Description

Number of months

Fill Instructions
Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.

Skip Instructions

<01-12, D, R> [goto CHCHNOYR]

Hard Edits
Soft Edits
AssocHelp

H_CHCHMOYR

Monday, August 25, 2014

Page 75 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.300_H

Variable Name

H_CHCHMOYR

Universe
Universe-text
Question Text

At HOME refers to the child's own home and everyone else's home in which the child
was staying at the time. This could be a house, apartment, motor home, houseboat,
trailer, or other dwelling. Do not include visits by a doctor while the child was in a
hospital or institutionalized.
Always probe for an exact number.
If the respondent reports a range or interval, assist the respondent in making an
estimate by probing. For example, you might ask "Could you give me a more exact
number?"

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCHMOYR

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 76 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.310

Variable Name

CHCHNOYR

Universe

HHSTAT4 = 'C' and AGE <18 and CHCHYR=1

Universe-text

Sample children <18 that have received home care from health professional during the
past 12 months

Question Text

(book) C6 ?[F1]
What was the total number of home visits received for [fill1: alias] during [fill2: that
month/those months]?

Answer Codes

1.
2.
3.
4.
5.
6.
7.
8.

Question Type

Integer

Field Pane Description
Fill Instructions

1
2-3
4-5
6-7
8-9
10 - 12
13 - 15
16 or more

Number of visits

fill2 = if CHCHMOYR = 1 then "that"; else then "those"

Special Instructions Indent field pane description to indicate that question is a follow-up to a previous
question.

Skip Instructions

<1-8, D, R> [goto CHCNOYR]

Hard Edits
Soft Edits
AssocHelp

H_CDENLONG

Monday, August 25, 2014

Page 77 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.320

Variable Name

CHCNOYR

Universe

HHSTAT4 = 'C' and AGE <18

Universe-text

Sample children <18

Question Text

(book) C5 ?[F1]
DURING THE PAST 12 MONTHS, HOW MANY TIMES has [fill1: alias] seen a doctor
or other health care professional about [fill2: his/her] health at A DOCTOR’S OFFICE,
A CLINIC, OR SOME OTHER PLACE? Do not include times [fill1: alias] was
hospitalized overnight, visits to hospital emergency rooms, home visits, dental visits or
telephone calls.

Answer Codes

0. None
1. 1
2. 2 - 3
3. 4 - 5
4. 6 - 7
5. 8 - 9
6. 10 - 12
7. 13 - 15
8. 16 or more

Question Type

Integer

Field Pane Description

Number of office visits

Fill Instructions
Special Instructions
Skip Instructions

<0-8, D, R> [goto CSRGYR]

Hard Edits
Soft Edits
AssocHelp

H_CHCNOYR

Monday, August 25, 2014

Page 78 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.320_H

Variable Name

H_CHCNOYR

Universe
Universe-text
Question Text

[b] Doctor [b] includes medical doctors, as well as other health care professionals, such
as general practitioners, psychologists, chiropractors, etc. Do not include dentists.
Always probe for an exact number. If the respondent reports a range or interval, assist
the respondent in making an estimate by probing. For example, you might ask 'Could
you give me a more exact number?'

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CHCNOYR

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 79 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.330

Variable Name

CSRGYR

Universe

HHSTAT4 = 'C' and AGE <18

Universe-text

Sample children <18

Question Text

DURING THE PAST 12 MONTHS has [fill1: alias] had SURGERY or other surgical
procedures either as an inpatient or outpatient?
* Read if necessary.
This includes both major surgery and minor procedures such as setting bones or
removing growths.

Answer Codes

1. Yes
2. No
Don't know
Refused

Question Type

Yes/No

Field Pane Description

Surgery / surgical procedures

Fill Instructions
Special Instructions
Skip Instructions

<1> [goto CSRGNOYR]
<2, D, R> [goto CMDLONG]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 80 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.340

Variable Name

CSRGNOYR

Universe

HHSTAT4 = 'C' and AGE <18 and CSRGYR=1

Universe-text

All sample children <18 that have undergone surgery during the past 12 months

Question Text

?[F1]
Including any times you may have already told me about, HOW MANY DIFFERENT
TIMES has [fill1: alias] had surgery DURING THE PAST 12 MONTHS?
* Enter '95' for 95 or more times.

Answer Codes
Question Type

Integer

Field Pane Description

Number of surgeries

Fill Instructions
Special Instructions
Skip Instructions

<1-10, D, R> [goto CMDLONG]
<11-95> [goto ERR_CMDLONG]

Hard Edits
Soft Edits

ERR_CMDLONG
[fill2: CSRGNOYR] is an unusually large number. Did [fill1: alias] have [fill2:
CSRGNOYR] surgical procedures?
*Please verify.

AssocHelp

H_CDENLONG

Monday, August 25, 2014

Page 81 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

C

Question ID

CAU.345

Variable Name

CMDLONG

Universe

HHSTAT4 = 'C' and AGE <18

Universe-text

Sample children <18

Question Text

(book) C4 ?[F1]
About how long has it been since anyone in the family last saw or talked to a doctor or
other health care professional about [fill1: SC name]'s health? Include doctors seen
while [fill2: he/she] was a patient in a hospital.

Answer Codes

0. Never
1. 6 months or less
2. More than 6 months, but not more than 1 year ago
3. More than 1 year, but not more than 2 years ago
4. More than 2 years, but not more than 5 years ago
5. More than 5 years ago
Refused
Don't Know

Question Type

Pick One - answer list pane

Field Pane Description

Last saw / talked with doctor / hlth. prof.

Fill Instructions
Special Instructions
Skip Instructions

<0-5, D, R> [goto CVSLWRD]

Hard Edits
Soft Edits
AssocHelp

H_CMDLONG

Monday, August 25, 2014

Page 82 of 83

Module

12

Section Name

Child Health Care Access and Utilization

Part

A

Question ID

CAU.345_H

Variable Name

H_CMDLONG

Universe
Universe-text
Question Text

Always probe for an exact number. If the respondent reports a range or interval, assist
the respondent in making an estimate by probing. For example, you might ask 'Could
you give me a more exact number?'
[b] Medical doctor [b] refers to both medical doctors (M.D.s) and osteopathic physicians
(D.O.s), including general practitioners and all types of specialists; and their assistants.
Do not include persons who do not have an M.D. or D.O. degree, such as dentists, oral
surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science
healers, opticians, optometrists, psychologists, etc., unless they assist an M.D. or D.O.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated screens:
CMDLONG

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 83 of 83

2015 Q1 NHIS Instrument Spec Report
Section name: Child Influenza Immunization
Module

33

Section Name

Child Influenza Immunization

Part
Question ID

CFI.005_00.010

Variable Name

CH1N1_1

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ')

Universe-text

Sample Child LE 17 years

Question Text

?[F1]
DURING THE PAST 12 MONTHS, has {SC name} had a flu vaccination? A flu
vaccination is usually given in the fall and protects against influenza for the flu season.

Answer Codes

1. Yes
2. No
Refused
Don't know

Question Type

Yes/No

Field Pane Description

Flu Vaccine

Fill Instructions
Special Instructions
Skip Instructions

<1> [goto CH1N1_2]
<2,R,D> [goto SCSSN4]

Hard Edits
Soft Edits
AssocHelp

CFI.005_00.010_H

Monday, August 25, 2014

Page 1 of 9

Module

33

Section Name

Child Influenza Immunization

Part
Question ID

CFI.005_00.010_H

Variable Name

H_CH1N1_1

Universe
Universe-text
Question Text

This includes a new type of flu shot called the Fluzone Intradermal vaccine that
features an ultra-fine needle that is 90 percent shorter than the typical needle used for
flu injections.

Answer Codes
Question Type

Help Screen

Field Pane Description
Fill Instructions
Special Instructions Associated Screen:
CH1N1_1

Skip Instructions
Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 2 of 9

Module

33

Section Name

Child Influenza Immunization

Part
Question ID

CFI.005_00.020

Variable Name

CH1N1_2

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CH1N1(e)='1'

Universe-text

Sample Child LE 17 years who have had an vaccine dose

Question Text

How many vaccinations has {S.C. name} received?

Answer Codes

1. 1 vaccination or dose
2. 2 or more vaccination doses
Refused
Don't know

Question Type

Pick One - answer list pane

Field Pane Description

How many

Fill Instructions
Special Instructions
Skip Instructions

<1,2> [goto CH1N1_3M]
 [goto SCSSN4]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 3 of 9

Module

33

Section Name

Child Influenza Immunization

Part
Question ID

CFI.005_00.030

Variable Name

CH1N1_3M

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CH1N1_2(e) IN ('1','2')

Universe-text

Sample Child LE 17 who have had one or more vaccine doses

Question Text

1 of 2
During what month and year did {S.C. name} receive {fill: his/her} most recent flu
vaccine?

Answer Codes

1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
Refused
Don't know

Question Type

Pick One - answer list pane

Field Pane Description
Fill Instructions

Month

Fill1: IFCH1N1_2=1 and SEX=1 then fill "his";
IFCH1N1_2=1 and SEX=2 then fill "her"

Special Instructions
Skip Instructions

<1-12,D> [ goto CH1N1_4Y]  [goto CH1N1_5]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 4 of 9

Module

33

Section Name

Child Influenza Immunization

Part
Question ID

CFI.005_00.040

Variable Name

CH1N1_4Y

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (('01' <= CH1N1_3M(e) <= '12')
or (CH1N1_3M(e)=‘99’))

Universe-text

Sample Child LE 17 years who have had one or more vaccine doses and gave
month/don't know month of vaccine dose

Question Text

2 of 2
*Enter year of most recent flu vaccine.

Answer Codes
Question Type

Integer

Field Pane Description

Year

Fill Instructions
Special Instructions
Skip Instructions

 [goto CH1N1_5]
[If CH1N1_3M and CH1N1_4Y = a future date] goto ERR1_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to birth] goto ERR2_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to 12 months ago] goto ERR3_
CH1N1_4Y]

Hard Edits

ERR1_ CH1N1_4Y
*Future date invalid.
ERR2_ CH1N1_4Y
*Date before birth.
ERR3_ CH1N1_4Y
*Date before 12 months ago.

Soft Edits
AssocHelp

Monday, August 25, 2014

Page 5 of 9

Module

33

Section Name

Child Influenza Immunization

Part
Question ID

CFI.005_00.050

Variable Name

CH1N1_5

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CH1N1_2 IN ('1','2')

Universe-text

Sample Child LE 17 years who have had one or more vaccine doses

Question Text

Was this a shot, or was it a vaccine sprayed in the nose?
*Read if necessary: The flu nasal spray is called FluMist(trademark).

Answer Codes

1. Flu shot
2. Flu nasal spray (Spray, mist or drop in nose)
Refused
Don't know

Question Type

Pick One - answer list pane

Field Pane Description

Type

Fill Instructions
Special Instructions
Skip Instructions

<1-2,R,D> IF CH1N1_2=1 [go to SCSSN4];
else if CH1N1_2=2 [goto CH1N1_6M]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 6 of 9

Module

33

Section Name

Child Influenza Immunization

Part
Question ID

CFI.005_00.060

Variable Name

CH1N1_6M

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CH1N1_2(e)='2'

Universe-text

Sample Child LE 17 years who have had more than one vaccine doses

Question Text

1 of 2
During what month and year did {S.C. name} receive {fill: his/her} next most recent flu
vaccine?

Answer Codes

1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
Refused
Don't know

Question Type

Pick One - answer list pane

Field Pane Description

Month - 2nd

Fill Instructions
Special Instructions
Skip Instructions

<1-12,D> [ goto CH1N1_7Y]  [goto CH1N1_8]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 7 of 9

Module

33

Section Name

Child Influenza Immunization

Part
Question ID

CFI.005_00.070

Variable Name

CH1N1_7Y

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and (('01' <= CH1N1_6M(e) <= '12')
or (CH1N1_6M(e)=‘99’))

Universe-text

Sample Child LE 17 years who have had more than one vaccine doses and gave
month/don't know month of vaccine dose

Question Text

2 of 2
*Enter year of next most recent flu vaccine.

Answer Codes
Question Type

Integer

Field Pane Description

Year - 2nd

Fill Instructions
Special Instructions
Skip Instructions

 [goto CH1N1_8]
[If CH1N1_6M and CH1N1_7Y = a future date] goto ERR1_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to birth] goto ERR2_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to 12 months ago] goto ERR3_
CH1N1_7Y]

Hard Edits

ERR1_ CH1N1_7Y
*Future date invalid.
ERR2_ CH1N1_7Y
*Date before birth.
ERR3_ CH1N1_7Y
*Date before 12 months ago.

Soft Edits
AssocHelp

Monday, August 25, 2014

Page 8 of 9

Module

33

Section Name

Child Influenza Immunization

Part
Question ID

CFI.005_00.080

Variable Name

CH1N1_8

Universe

HHSTAT4='C' and (AGE LE '017' and AGE NE ' ') and CH1N1_2='2'

Universe-text

Sample Child LE 17 years who have more than one vaccine dose

Question Text

Was this a shot, or was it a vaccine sprayed in the nose?
*Read if necessary: The flu nasal spray is called FluMist(trademark).

Answer Codes

1. Flu shot
2. Flu nasal spray (spray, mist or drop in nose)
Refused
Don't know

Question Type

Pick One - answer list pane

Field Pane Description

Type - 2nd

Fill Instructions
Special Instructions
Skip Instructions

<1-2,R,D> [go to SCSSN4]

Hard Edits
Soft Edits
AssocHelp

Monday, August 25, 2014

Page 9 of 9


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File Modified2014-08-27
File Created2014-08-25

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