Form 1 English Screener

26008086

National Survey of Children’s Health
A study by the U.S. Department of Health and Human Services
to better understand the health issues faced by children in the
United States today.

The U.S. Census Bureau is required by law to protect your information and is not permitted to publicly release your responses in
a way that could identify you or your household. The U.S. Census Bureau is conducting the National Survey of Children’s Health
on the behalf of the Department of Health and Human Services (HHS) under Title 13, United States Code, Section 8(b), which allows
the Census Bureau to conduct surveys on behalf of other agencies. Title 42 U.S.C. Section 701(a)(2) allows HHS to collect information
for the purpose of understanding the health and well-being of children in the United States. Federal law protects your privacy and
keeps your answers confidential under 13 U.S.C. Section 9. Per the Federal Cybersecurity Enhancement Act of 2015, your data are
protected from cybersecurity risks through screening of the systems that transmit your data.
Any information you provide will be shared for the work-related purposes identified above and as permitted under the Privacy Act
of 1974 (5 U.S.C. Section 552a) and SORN COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame).
Participation in this survey is voluntary and there are no penalties for refusing to answer questions. However, your cooperation in
obtaining this much needed information is extremely important in order to ensure complete and accurate results.

NSCH-S1
(06/07/2017) Draft 1

§;!qw¤

26008078

Start Here
Thank you for helping us learn about the health and well-being of America’s children.
If your household has children 0 - 17 years old, please have an adult who is familiar with their health and health care
answer all of the questions that apply.
If your household does not have any children, please answer question 1 below AND return the questionnaire.
If you need help or have questions about completing this form, please call 1-800-845-8241.
The telephone call is free.
For Telephone Device for the Deaf (TDD) assistance, please call: 1-800-582-8330.
The telephone call is free.
Si necesita ayuda o tiene preguntas sobre cómo completar este formulario, llame al 1-800-845-8241.
La llamada es gratuita.
Para recibir ayuda relacionada con el Dispositivo Telefónico para Personas Sordas (TDD), llame al 1-800-582-8330.
La llamada es gratuita.

In Your Home
1

Are there any children 0-17 years old who usually live or stay at this address?
Yes
No – STOP HERE after marking “No” and return this survey to us in the enclosed envelope. It is important that we
receive a response from every household selected for this study.

2

How many children 0-17 years old usually live or stay at this address?

Number of children living or staying at this address

3

What is the primary language spoken in the household?
English
Spanish
Other Language, specify:

C

➜ Answer the remaining questions for each of the children 0-17 years old who usually live or stay
at this address.
Start with the YOUNGEST CHILD, who we call “Child 1” and continue with the next youngest
until you have answered the questions for all children who usually live or stay at this address.

NSCH-S1

2

§;!qo¤

26008060

CHILD 1

7

(Youngest)
1

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?
Yes

First name, initials, or nickname of the youngest child

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?

➜ NOTE: Answer BOTH question

Yes

2 about Hispanic
origin and question 3 about race. For this survey,
Hispanic origins are not races.

2

Yes
8

Yes, Mexican, Mexican American, Chicano

No

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Yes, Puerto Rican

No

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin

Yes

White

Vietnamese

Black or
African American

Other Asian

American Indian or
Alaska Native

Native Hawaiian

Asian Indian

Guamanian or
Chamorro

Chinese

Samoan

Filipino

Other Pacific Islander

Japanese

Some other race

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s race? Mark (X) one or more boxes.

Yes
9

No

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?
Yes

No

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

Korean
4

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Is this child of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

3

No

How old is this child? If the child is less than one month
old, round age in months to 1.

No

10 Does this child need or get special therapy, such as
physical, occupational, or speech therapy?
Yes

No

If yes, is this because of ANY medical, behavioral,
or other health condition?
Years OR

Months
Yes

5

Male
6

Female

If this child is YOUNGER THAN 4 YEARS OLD, please
SKIP to question 7 .
How well does this child speak English?

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s sex?

Yes

No

11 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?

Very well

Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

No

Not well
Yes

No

Not at all
NSCH-S1

3

§;!q]¤

26008052

CHILD 2

7

(Next youngest)
1

Yes

First name, initials, or nickname of the next youngest
child

➜ NOTE: Answer BOTH question

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?
Yes

2

about Hispanic
origin and question 3 about race. For this survey,
Hispanic origins are not races.

2

No

Yes

Is this child of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

8

Yes, Mexican, Mexican American, Chicano

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Yes, Puerto Rican

Yes

Yes, another Hispanic, Latino, or Spanish origin

White

Vietnamese

Black or
African American

Other Asian

American Indian or
Alaska Native

Native Hawaiian

Asian Indian

Guamanian or
Chamorro

Chinese

Samoan

Yes
9

No

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?
Yes

No

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

Other Pacific Islander

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Some other race

Japanese

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s race? Mark (X) one or more boxes.

Filipino

Yes

No

10 Does this child need or get special therapy, such as
physical, occupational, or speech therapy?

Korean
4

No

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

Yes, Cuban

3

No

How old is this child? If the child is less than one month
old, round age in months to 1.

Yes

No

If yes, is this because of ANY medical, behavioral,
or other health condition?
Years OR

Months
Yes

5

Male
6

Female

If this child is YOUNGER THAN 4 YEARS OLD, please
SKIP to question 7 .
How well does this child speak English?

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s sex?

Yes

No

11 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?

Very well

Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

No

Not well
Yes

No

Not at all
NSCH-S1

4

§;!qU¤

26008045

CHILD 3

7

(Next youngest)
1

Yes

First name, initials, or nickname of the next youngest
child

➜ NOTE: Answer BOTH question

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?
Yes

2

about Hispanic
origin and question 3 about race. For this survey,
Hispanic origins are not races.

2

No

Is this child of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes
8

Yes, Mexican, Mexican American, Chicano

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Yes, Puerto Rican

Yes, another Hispanic, Latino, or Spanish origin

Yes

White

Vietnamese

Black or
African American

Other Asian

American Indian or
Alaska Native

Native Hawaiian

Asian Indian

Guamanian or
Chamorro

Chinese

Samoan

Filipino

Other Pacific Islander

Japanese

Some other race

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s race? Mark (X) one or more boxes.

Yes
9

No

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?
Yes

No

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

No

10 Does this child need or get special therapy, such as
physical, occupational, or speech therapy?

Korean
4

No

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

Yes, Cuban

3

No

How old is this child? If the child is less than one month
old, round age in months to 1.

Yes

No

If yes, is this because of ANY medical, behavioral,
or other health condition?
Years OR

Months
Yes

5

Male
6

Female

If this child is YOUNGER THAN 4 YEARS OLD, please
SKIP to question 7 .
How well does this child speak English?

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s sex?

Yes

No

11 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?

Very well

Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

No

Not well
Yes

No

Not at all
NSCH-S1

5

§;!qN¤

26008037

CHILD 4

7

(Next youngest)
1

Yes

First name, initials, or nickname of the next youngest
child

➜ NOTE: Answer BOTH question

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?
Yes

2

about Hispanic
origin and question 3 about race. For this survey,
Hispanic origins are not races.

2

No

Is this child of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes
8

Yes, Mexican, Mexican American, Chicano

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Yes, Puerto Rican

Yes, another Hispanic, Latino, or Spanish origin

Yes

White

Vietnamese

Black or
African American

Other Asian

American Indian or
Alaska Native

Native Hawaiian

Asian Indian

Guamanian or
Chamorro

Chinese

Samoan

Yes
9

No

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?
Yes

No

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

Other Pacific Islander

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Some other race

Japanese

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s race? Mark (X) one or more boxes.

Filipino

Yes

No

10 Does this child need or get special therapy, such as
physical, occupational, or speech therapy?

Korean
4

No

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

Yes, Cuban

3

No

How old is this child? If the child is less than one month
old, round age in months to 1.

Yes

No

If yes, is this because of ANY medical, behavioral,
or other health condition?
Years OR

Months
Yes

5

Male
6

Female

If this child is YOUNGER THAN 4 YEARS OLD, please
SKIP to question 7 .
How well does this child speak English?

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

What is this child’s sex?

Yes

No

11 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?

Very well

Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

No

Not well
Yes

No

Not at all
NSCH-S1

6

§;!qF¤

26008029

➜

If there are more than four children 0-17 years old who usually live or stay at this address, list the first name, initials,
or nickname for each child as well as their age and sex.
Do not repeat information for children already included for Child 1 through Child 4.

First name, initials, or nickname

Child 5
▲

(Next youngest)

Age

Years OR

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

First name, initials, or nickname

Child 6
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

Child 7
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

Child 8
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

Child 9
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

Child 10
▲

(Next youngest)

Age

Years OR

NSCH-S1

7

§;!q>¤

26008011

Mailing Instructions
Thank you for your participation.
On behalf of the U.S. Department of Health and Human Services, we would like to thank you for the time and
effort you have spent sharing information about your household and the children of this household.
Your answers are important to us and will help researchers, policymakers and family advocates to better
understand the health and health care needs of children in our diverse population.

➜ Make sure you have:
• Listed all first names, initials, or nicknames of children 0-17 years old in the household
• Answered all questions for each child reported

➜ Place the completed questionnaire in the postage-paid return envelope. If the envelope has been
misplaced, please mail the questionnaire to:
U.S. Census Bureau
ATTN: DCB 60-A
1201 E. 10th Street
Jeffersonville, IN 47132-0001
You may also call 1-800-845-8241 to request a replacement envelope.

NSCH-S1

8

§;!q,¤