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OMB No. 0607-0990: Approval Expires 05/31/2019
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.
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Start Here
A3
How true are each of the following statements about
this child?
Definitely Somewhat
true
true
Recently, you completed a survey that asked about the
children usually living or staying at this address.
Thank you for taking the time to complete that survey.
a. This child is affectionate
and tender with you
We now have some follow-up questions to ask about:
b. This child bounces back
quickly when things do not
go his or her way
Not
true
c. This child shows interest
and curiosity in learning
new things
If the name listed above is not correct or does not
correspond to a child living in this household, please
call 1-800-845-8241 for assistance.
We have selected only one child per household in an
effort to minimize the amount of time you will need to
complete the follow-up questions.
d. This child smiles and
laughs a lot
A4
The survey should be completed by an adult who is
familiar with this child’s health and health care.
DURING THE PAST 12 MONTHS, has this child had
FREQUENT or CHRONIC difficulty with any of the
following?
Yes
No
Yes
No
a. Breathing or other respiratory
problems (such as wheezing or
shortness of breath)
Your participation is important. Thank you.
b. Eating or swallowing because of
a health condition
c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea
d. Repeated or chronic physical pain,
including headaches or other back
or body pain
A. This Child’s Health
e. Using his or her hands
A1 In general, how would you describe this child’s health
(the one named above)?
f. Coordination or moving around
Excellent
g. Toothaches
Very good
h. Bleeding gums
Good
i.
Decayed teeth or cavities
Fair
Poor
A5
Does this child have any of the following?
a. Deafness or problems with hearing
A2 How would you describe the condition of this child’s
teeth?
b. Blindness or problems with seeing,
even when wearing glasses
This child does not have any teeth
Excellent
A6
Very good
Has a doctor or other health care provider EVER told
you that this child has...
Allergies (including food, drug, insect, or other)?
Good
Yes
Fair
If yes, does this child CURRENTLY have the
condition?
Poor
No
Yes
No
If yes, is it:
Mild
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Moderate
Severe
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Has a doctor or other health care provider EVER told
you that this child has...
Has a doctor or other health care provider EVER told
you that this child has...
A13 Diabetes?
A7 Arthritis?
Yes
No
Yes
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
Yes
No
Yes
No
If yes, is it:
If yes, is it:
Mild
Moderate
Severe
A8 Asthma?
Mild
Moderate
Severe
A14 Down Syndrome?
Yes
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
Yes
Moderate
Severe
A9 Blood Disorders (such as Sickle Cell Disease,
Mild
Yes
No
Moderate
Mild
Severe
Yes
No
No
If yes, is it:
If yes, is it:
Moderate
Mild
Severe
Moderate
Severe
A17 Frequent or severe headaches, including migraine?
A11 Cerebral Palsy?
Yes
No
Yes
Yes
No
No
If yes, is it:
If yes, is it:
Mild
No
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
Moderate
Mild
Severe
Moderate
Severe
A18 Tourette Syndrome?
A12 Cystic Fibrosis?
Yes
No
Yes
No
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
Yes
No
No
If yes, is it:
If yes, is it:
Mild
No
Yes
No
Yes
Severe
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
Mild
Moderate
A16 Heart Condition?
Brain injury, concussion or head injury?
Yes
No
If yes, is it:
If yes, is it:
Yes
No
Yes
No
Yes
Severe
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
Mild
Moderate
A15 Epilepsy or Seizure Disorder?
Thalassemia, or Hemophilia)?
Yes
No
If yes, is it:
Mild
Yes
No
If yes, does this child CURRENTLY have the
condition?
If yes, is it:
A10
No
Moderate
Mild
Severe
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Moderate
Severe
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Has a doctor or other health care provider EVER told
you that this child has...
Has a doctor, other health care provider, or educator
EVER told you that this child has...
Examples of educators are teachers and school nurses.
A19 Anxiety Problems?
A24 Intellectual Disability (formerly known as Mental
Yes
No
Retardation)?
If yes, does this child CURRENTLY have the
condition?
Yes
Yes
No
If yes, does this child CURRENTLY have the
condition?
No
If yes, is it:
Yes
Mild
Moderate
No
If yes, is it:
Severe
Mild
A20 Depression?
Yes
Yes
If yes, does this child CURRENTLY have the
condition?
No
If yes, does this child CURRENTLY have the
condition?
No
If yes, is it:
Yes
Mild
Moderate
Severe
Mild
Moderate
Severe
A26 Learning Disability?
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, is it:
A21 Other genetic or inherited condition?
Yes
Severe
A25 Speech or other language disorder?
No
Yes
Moderate
No
If yes, does this child CURRENTLY have the
condition?
No
Yes
If yes, is it:
No
If yes, is it:
Mild
Moderate
Severe
Mild
A22 Has a doctor, other health care provider, or educator
EVER told you that this child has...
Examples of educators are teachers and school nurses.
you that this child has...
Any other mental health condition?
Yes
No
No
If yes, specify: C
If yes, does this child CURRENTLY have the
condition?
Yes
Severe
A27 Has a doctor or other health care provider EVER told
Behavioral or Conduct Problems?
Yes
Moderate
No
If yes, does this child CURRENTLY have the
condition?
If yes, is it:
Mild
Moderate
Severe
Yes
A23 Developmental Delay?
Yes
Mild
No
If yes, does this child CURRENTLY have the
condition?
Yes
Severe
you that this child has Autism or Autism Spectrum
Disorder (ASD)? Include diagnoses of Asperger’s Disorder
or Pervasive Developmental Disorder (PDD).
No
No ➔ SKIP to question A33
Yes
Moderate
Moderate
A28 Has a doctor or other health care provider EVER told
If yes, is it:
Mild
No
If yes, is it:
Severe
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, is it:
Mild
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Moderate
Severe
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A29 How old was this child when a doctor or other health
A36 DURING THE PAST 12 MONTHS, how often have this
child’s health conditions or problems affected his or her
ability to do things other children his or her age do?
care provider FIRST told you that he or she had Autism,
ASD, Asperger’s Disorder or PDD?
This child does not have any
health conditions ➔ SKIP to question B1
Don’t know
Age in years
Never
A30 What type of doctor or other health care provider was
the FIRST to tell you that this child had Autism, ASD,
Asperger’s Disorder or PDD? Mark (X) ONE box.
Sometimes
Primary Care Provider
Usually
Specialist
Always
A37 To what extent do this child’s health conditions or
School Psychologist/Counselor
problems affect his or her ability to do things?
Other Psychologist (Non-School)
Very little
Psychiatrist
Other, specify:
Somewhat
C
A great deal
B. This Child as an Infant
Don’t know
A31 Is this child CURRENTLY taking medication for Autism,
B1
ASD, Asperger’s Disorder or PDD?
Yes
Yes
No
No
A32 At any time DURING THE PAST 12 MONTHS, did this
child receive behavioral treatment for Autism, ASD,
Asperger’s Disorder or PDD, such as training or an
intervention that you or this child received to help
with his or her behavior?
Yes
Was this child born more than 3 weeks before his or
her due date?
B2
How much did he or she weigh when born?
Answer in pounds and ounces OR kilograms and grams.
Provide your best estimate.
No
pounds AND
A33 Has a doctor or other health care provider EVER told
OR
you that this child has Attention Deficit Disorder or
Attention Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?
No ➔ SKIP to question A36
Yes
kilograms AND
B3
If yes, does this child CURRENTLY have the
condition?
Yes
grams
What was the age of the mother when this child was
born?
Age in years
No
B4
If yes, is it:
Mild
ounces
Moderate
Severe
Was this child EVER breastfed or fed breast milk?
Yes
No ➔ SKIP to question B6
A34 Is this child CURRENTLY taking medication for ADD or
ADHD?
Yes
No
A35 At any time DURING THE PAST 12 MONTHS, did this
child receive behavioral treatment for ADD or ADHD,
such as training or an intervention that you or this
child received to help with his or her behavior?
Yes
No
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B5
C. Health Care Services
If yes, how old was this child when he or she
COMPLETELY stopped breastfeeding or being fed
breast milk?
C1
days
DURING THE PAST 12 MONTHS, did this child see a
doctor, nurse, or other health care professional for
sick-child care, well-child check-ups, physical exams,
hospitalizations or any other kind of medical care?
OR
Yes
weeks
OR
No ➔ SKIP to question C4
C2
months
OR
If yes, DURING THE PAST 12 MONTHS, how many times
did this child visit a doctor, nurse, or other health care
professional to receive a PREVENTIVE check-up?
A preventive check-up is when this child was not sick or
injured, such as an annual or sports physical, or well-child
visit.
Check this box if child is still breastfeeding
0 visits
B6
How old was this child when he or she was FIRST fed
formula?
1 visit
2 or more visits
Check this box if child has never been fed formula
OR
C3
At birth
OR
Thinking about the LAST TIME you took this child for
a preventive check-up, about how long was the doctor
or health care provider who examined this child in the
room with you? Your best estimate is fine.
Less than 10 minutes
days
10-20 minutes
OR
More than 20 minutes
weeks
C4
What is this child’s CURRENT height?
OR
feet AND
months
B7
inches
OR
How old was this child when he or she was FIRST fed
anything other than breast milk or formula? Include
juice, cow’s milk, sugar water, baby food, or anything else
that your child might have been given, even water.
meters AND
C5
centimeters
How much does this child CURRENTLY weigh?
Check this box if child has never been fed anything
other than breast milk or formula
OR
pounds AND
ounces
OR
At birth
OR
kilograms AND
days
C6
grams
Are you concerned about this child’s weight?
OR
Yes, it’s too high
weeks
Yes, it’s too low
OR
No, I am not concerned
months
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C7 DURING THE PAST 12 MONTHS, did this child’s doctors C11 Is there a place that this child USUALLY goes when
or other health care providers ask if you have concerns
about this child’s learning, development, or behavior?
he or she needs routine preventive care, such as a
physical examination or well-child check-up?
Yes
Yes
No
No ➔ SKIP to question C13
C8 If this child is YOUNGER THAN 9 MONTHS, please
SKIP to question C9 .
DURING THE PAST 12 MONTHS, did a doctor or other
health care provider have you or another caregiver fill
out a questionnaire about specific concerns or
observations you may have about this child’s
development, communication, or social behaviors?
Sometimes a child’s doctor or other health care provider
will ask a parent to do this at home or during a child’s visit.
Yes
C12 If yes, is this the same place this child goes when he
or she is sick?
Yes
No
C13 Has this child EVER had his or her vision tested with
pictures, shapes, or letters?
Yes
No
No ➔ SKIP to question C15
If yes, and this child is 9-23 Months:
Did the questionnaire ask about your concerns
or observations about: Mark (X) ALL that apply.
C14 If yes, what kind of place or places did this child have
his or her vision tested? Mark (X) ALL that apply.
How this child talks or makes speech sounds?
Eye doctor or eye specialist (ophthalmologist,
optometrist) office
How this child interacts with you and others?
Pediatrician or other general doctor’s office
If yes, and this child is 2-5 Years:
Clinic or health center
Did the questionnaire ask about your concerns
or observations about: Mark (X) ALL that apply.
School
Words and phrases this child uses and
understands?
Other, specify:
C
How this child behaves and gets along with
you and others?
C9 Is there a place that this child USUALLY goes when
he or she is sick or you or another caregiver needs
advice about his or her health?
C15 DURING THE PAST 12 MONTHS, did this child see a
dentist or other oral health care provider for any kind
of dental or oral health care?
Yes
Yes, saw a dentist
No ➔ SKIP to question C11
Yes, saw other oral health care provider
C10 If yes, where does this child USUALLY go first?
No ➔ SKIP to question C18
Mark (X) ONE box.
Doctor’s Office
C16 If yes, DURING THE PAST 12 MONTHS, did this child
see a dentist or other oral health care provider for
preventive dental care, such as check-ups, dental
cleanings, dental sealants, or fluoride treatments?
Hospital Emergency Room
Hospital Outpatient Department
No preventive visits in
the past 12 months ➔ SKIP to question C18
Clinic or Health Center
Yes, 1 visit
Retail Store Clinic or “Minute Clinic”
Yes, 2 or more visits
School (Nurse’s Office, Athletic Trainer’s Office)
Some other place
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C17 If yes, DURING THE PAST 12 MONTHS, what
C23 DURING THE PAST 12 MONTHS, did this child use any
type of alternative health care or treatment? Alternative
health care can include acupuncture, chiropractic care,
relaxation therapies, herbal supplements, and others.
Some therapies involve seeing a health care provider,
while others can be done on your own.
preventive dental services did this child receive?
Mark (X) ALL that apply.
Check-up
Cleaning
Yes
Instruction on tooth brushing and oral health care
X-Rays
No
C24 DURING THE PAST 12 MONTHS, was there any time
when this child needed health care but it was not
received? By health care, we mean medical care as well
as other kinds of care like dental care, vision care, and
mental health services.
Fluoride treatment
Sealant (plastic coatings on back teeth)
Yes
Don’t know
No ➔ SKIP to question C27
C18 DURING THE PAST 12 MONTHS, has this child
received any treatment or counseling from a mental
health professional? Mental health professionals include
psychiatrists, psychologists, psychiatric nurses, and clinical
social workers.
C25 If yes, which types of care were not received?
Mark (X) ALL that apply.
Medical Care
Yes
Dental Care
No, but this child needed to see a mental health
professional
Vision Care
No, this child did not need to see a
mental health professional ➔ SKIP to question C20
Hearing Care
C19 How difficult was it to get the mental health treatment or
Mental Health Services
counseling that this child needed?
Very difficult
Other, specify:
C
Somewhat difficult
Not difficult
C26 Did any of the following reasons contribute to this child
not receiving needed health services? Mark (X) Yes or No
for each item.
C20 DURING THE PAST 12 MONTHS, has this child taken
Yes
any medication because of difficulties with his or her
emotions, concentration, or behavior?
Yes
b. The services this child needed were
not available in your area
No
c. There were problems getting an
appointment when this child needed
one
C21 DURING THE PAST 12 MONTHS, did this child see a
specialist other than a mental health professional?
Specialists are doctors like surgeons, heart doctors, allergy
doctors, skin doctors, and others who specialize in one
area of health care.
d. There were problems with getting
transportation or child care
Yes
e. The (clinic/doctor’s) office wasn’t
open when this child needed care
No, but this child needed to see a specialist
f. There were issues related to cost
No, this child did not need to
see a specialist ➔ SKIP to question C23
No
a. This child was not eligible for the
services
C27 DURING THE PAST 12 MONTHS, how often were you
frustrated in your efforts to get services for this child?
C22 How difficult was it to get the specialist care that this
Never
child needed?
Very difficult
Sometimes
Somewhat difficult
Usually
Not difficult
Always
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D. Experience with This
Child’s Health Care
Providers
C28 DURING THE PAST 12 MONTHS, how many times did
this child visit a hospital emergency room?
None
1 time
D1
2 or more times
C29 Has this child EVER had a special education or early
intervention plan? Children receiving these services often
have an Individualized Family Service Plan (IFSP) or
Individualized Education Plan (IEP).
Do you have one or more persons you think of as this
child’s personal doctor or nurse? A personal doctor or
nurse is a health professional who knows this child well
and is familiar with this child’s health history. This can be
a general doctor, a pediatrician, a specialist doctor, a
nurse practitioner, or a physician’s assistant.
Yes, one person
Yes
Yes, more than one person
No ➔ SKIP to question C32
No
C30 If yes, how old was this child at the time of the FIRST
D2
plan?
DURING THE PAST 12 MONTHS, did this child need a
referral to see any doctors or receive any services?
Yes
Years AND
Months
No ➔ SKIP to question D4
C31 Is this child CURRENTLY receiving services under one
of these plans?
D3
If yes, how difficult was it to get referrals?
Yes
Very difficult
No
Somewhat difficult
Not difficult
C32 Has this child EVER received special services to meet
his or her developmental needs such as speech,
occupational, or behavioral therapy?
D4
Yes
Answer the following questions only if this child had a
health care visit IN THE PAST 12 MONTHS.
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers:
No ➔ SKIP to question D1
Always
Usually Sometimes
Never
a. Spend enough time
with this child?
C33 If yes, how old was this child when he or she began
receiving these special services?
b. Listen carefully to
you?
Years AND
Months
c. Show sensitivity to
your family’s values
and customs?
C34 Is this child CURRENTLY receiving these special
services?
d. Provide the specific
information you
needed concerning
this child?
Yes
No
e. Help you feel like a
partner in this
child’s care?
D5
DURING THE PAST 12 MONTHS, did this child need
any decisions to be made regarding his or her health
care, such as whether to get prescriptions, referrals,
or procedures?
Yes
No ➔ SKIP to question D7
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D6 If yes, DURING THE PAST 12 MONTHS, how often did
D11 DURING THE PAST 12 MONTHS, did this child’s health
care provider communicate with the child’s school, child
care provider, or special education program?
this child’s doctors or other health care providers:
Always
Usually Sometimes Never
Yes
a. Discuss with you
the range of options
to consider for his
or her health care or
treatment?
b. Make it easy for you
to raise concerns or
disagree with
recommendations
for this child’s health
care?
No ➔ SKIP to question E1
Did not need health care
provider to communicate
with these providers ➔ SKIP to question E1
D12 If yes, during this time, how satisfied were you with the
health care provider’s communication with the school,
child care provider, or special education program?
Very satisfied
c. Work with you to
decide together
which health care
and treatment
choices would be
best for this child?
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
D7 DURING THE PAST 12 MONTHS, did anyone help you
arrange or coordinate this child’s care among the
different doctors or services that this child uses?
E. This Child’s Health
Insurance Coverage
No
Yes
E1
Did not see more than one health care provider
in PAST 12 MONTHS
DURING THE PAST 12 MONTHS, was this child EVER
covered by ANY kind of health insurance or health
coverage plan?
Yes, this child was covered
all 12 months ➔ SKIP to question E4
D8 DURING THE PAST 12 MONTHS, have you felt that you
could have used extra help arranging or coordinating
this child’s care among the different health care
providers or services?
Yes, but this child had a gap in coverage
No
Yes
E2
No ➔ SKIP to question D10
Indicate whether any of the following is a reason this
child was not covered by health insurance at any time
DURING THE PAST 12 MONTHS:
Yes
D9 If yes, DURING THE PAST 12 MONTHS, how often
a. Change in employer or employment
status
did you get as much help as you wanted with
arranging or coordinating this child’s health care?
Usually
b. Cancellation due to overdue
premiums
Sometimes
c. Dropped coverage because it was
unaffordable
Never
d. Dropped coverage because benefits
were inadequate
e. Dropped coverage because choice
of health care providers was
inadequate
D10 DURING THE PAST 12 MONTHS, how satisfied were
you with the communication among this child’s doctors
and other health care providers?
Very satisfied
f. Problems with application or
renewal process
Somewhat satisfied
g. Other, specify: C
Somewhat dissatisfied
Very dissatisfied
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E3
F. Providing for This
Child’s Health
Is this child CURRENTLY covered by ANY kind of
health insurance or health coverage plan?
Yes
F1
No ➔ SKIP to question F1
E4
Is this child covered by any of the following types of
health insurance or health coverage plans?
Mark (X) Yes or No for EACH item.
Yes
No
a. Insurance through a current or
former employer or union
Including co-pays and amounts from Health Savings
Accounts (HSA) and Flexible Spending Accounts
(FSA), how much money did you pay for this child’s
medical, health, dental, and vision care DURING THE
PAST 12 MONTHS? Do not include health insurance
premiums or costs that were or will be reimbursed by
insurance or another source.
$0 (No medical or health-related
expenses) ➔ SKIP to question F4
b. Insurance purchased directly
from an insurance company
c. Medicaid, Medical Assistance,
or any kind of government
assistance plan for those with
low incomes or a disability
$500-$999
d. TRICARE or other military
health care
$1,000-$5,000
e. Indian Health Service
More than $5,000
f. Other, specify: C
$1-$249
$250-$499
F2
How often are these costs reasonable?
Always
Usually
E5
How often does this child’s health insurance offer
benefits or cover services that meet this child’s needs?
Sometimes
Always
Usually
Never
F3
Sometimes
Yes
Never
E6
DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?
No
How often does this child’s health insurance allow him
or her to see the health care providers he or she needs?
F4
Always
DURING THE PAST 12 MONTHS, have you or other
family members:
Yes
Usually
a. Stopped working because of this
child’s health or health conditions?
Sometimes
b. Cut down on the hours you work
because of this child’s health or
health conditions?
Never
E7
c. Avoided changing jobs because of
concerns about maintaining health
insurance for this child?
Thinking specifically about this child’s mental or
behavioral health needs, how often does this child’s
health insurance offer benefits or cover services that
meet these needs?
This child does not use mental or behavioral
health services
Always
Usually
Sometimes
Never
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26018093
F5
IN AN AVERAGE WEEK, how many hours do you or
G4 How confident are you that this child is ready to be in
school?
other family members spend providing health care at
home for this child? Care might include changing
Completely confident
bandages, or giving medication and therapies when needed.
This child does not need health care provided
on a weekly basis
Mostly confident
Somewhat confident
No at home care is provided by me or other family
members
Not at all confident
Less than 1 hour per week
G5 How often can this child recognize the beginning
sound of a word? For example, can this child tell you
that the word “ball” starts with the “buh” sound?
1-4 hours per week
F6
5-10 hours per week
Always
11 or more hours per week
Most of the time
About half the time
IN AN AVERAGE WEEK, how many hours do you or
other family members spend arranging or coordinating
health or medical care for this child, such as making
appointments or locating services?
This child does not need health care coordinated
on a weekly basis
Sometimes
Never
G6 About how many letters of the alphabet can this child
recognize?
No health or medical care is arranged or coordinated
by me or other family members
All of them
Less than 1 hour per week
Most of them
1-4 hours per week
About half of them
5-10 hours per week
Some of them
11 or more hours per week
None of them
G7 Can this child rhyme words?
G. This Child’s Learning
Yes
No
G1 Is this child 3 years old or older?
Yes
G8
No ➔ SKIP to question H1
How often can this child explain things he or she has seen
or done so that you get a very good idea what happened?
Always
G2 Has this child started school? Include any formal
Most of the time
home schooling.
About half the time
Yes, preschool
Sometimes
Yes, kindergarten
Never
Yes, first grade
G9
No
How often can this child write his or her first name, even
if some of the letters aren’t quite right or are backwards?
Always
G3 Are you concerned about how this child is learning to
do things for him or herself?
Most of the time
Yes, somewhat concerned
About half the time
Yes, very concerned
Sometimes
No
Never
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G10 How high can this child count?
G15 When this child is paying attention, how often can he
or she follow instructions to complete a simple task?
This child cannot count
Always
Up to five
Most of the time
Up to ten
About half the time
Up to 20
Sometimes
Up to 50
Never
Up to 100 or more
G16 How does this child usually hold a pencil?
G11 How often can this child identify basic shapes such as
a triangle, circle, or square?
Uses fingers to hold the pencil
Always
Grips the pencil in his or her fist
Most of the time
This child cannot hold a pencil
About half the time
G17 How often does this child play well with others?
Sometimes
Always
Never
Most of the time
About half the time
G12 Can this child identify the colors red, yellow, blue,
and green by name?
Sometimes
Yes, all of them
Never
Yes, some of them
G18 How often does this child become angry or anxious
when going from one activity to another?
No, none of them
G13 How often is this child easily distracted?
Always
Always
Most of the time
Most of the time
About half the time
About half the time
Sometimes
Sometimes
Never
Never
G19 How often does this child show concern when others
are hurt or unhappy?
G14 How often does this child keep working at something
until he or she is finished?
Always
Always
Most of the time
Most of the time
About half the time
About half the time
Sometimes
Sometimes
Never
Never
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G20 When excited or all wound up, how often can this child
H3 How many times has this child moved to a new address
calm down quickly?
since he or she was born?
Always
Number of times
Most of the time
H4 How often does this child go to bed at about the same
time on weeknights?
About half the time
Sometimes
Always
Never
Usually
Sometimes
G21 How often does this child lose control of his or her
temper when things do not go his or her way?
Rarely
Always
Never
Most of the time
H5 DURING THE PAST WEEK, how many hours of sleep
did this child get during an average day (count both
nighttime sleep and naps)?
About half the time
Sometimes
Less than 7 hours
Never
7 hours
G22 Compared to other children his or her age, how much
8 hours
difficulty does this child have making or keeping
friends?
9 hours
A lot of difficulty
10 hours
A little difficulty
11 hours
No difficulty
12 or more hours
G23 Compared to other children his or her age, how often
is this child able to sit still?
H6
Answer the next question only if this child is LESS THAN
12 MONTHS OLD. Otherwise, SKIP to question H7 .
In which position do you most often lay this baby down
to sleep now? Mark (X) ONE box.
Always
Most of the time
On his or her side
About half the time
On his or her back
Sometimes
On his or her stomach
Never
H7
H. About You and This
Child
ON AN AVERAGE WEEKDAY, about how much time
does this child usually spend in front of a TV watching
TV programs, videos, or playing video games?
None
Less than 1 hour
H1 Was this child born in the United States?
Yes ➔ SKIP to question H3
1 hour
No
2 hours
3 hours
H2 If no, how long has this child been living in the
United States?
Years AND
4 or more hours
Months
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H8
ON AN AVERAGE WEEKDAY, about how much time
does this child usually spend with computers, cell
phones, handheld video games, and other electronic
devices, doing things other than schoolwork?
H13 DURING THE PAST 12 MONTHS, was there someone
that you could turn to for day-to-day emotional support
with parenting or raising children?
Yes
None
No ➔ SKIP to question H15
Less than 1 hour
H14 If yes, did you receive emotional support from:
Yes
1 hour
H9
2 hours
a. Spouse?
3 hours
b. Other family member or close friend?
4 or more hours
c. Health care provider?
No
d. Place of worship or religious leader?
DURING THE PAST WEEK, how many days did you or
other family members read to this child?
0 days
e. Support or advocacy group related
to specific health condition?
1-3 days
f. Peer support group?
4-6 days
g. Counselor or other mental health
professional?
Every day
h. Other person, specify:
C
H10 DURING THE PAST WEEK, how many days did you or
other family members tell stories or sing songs to this
child?
H15 Does this child receive care for at least 10 hours per
week from someone other than his or her parent or
guardian? This could be a day care center, preschool,
Head Start program, family child care home, nanny,
au pair, babysitter or relative.
0 days
1-3 days
4-6 days
Yes
Every day
No
H11 How well do you think you are handling the day-to-day
demands of raising children?
H16 DURING THE PAST 12 MONTHS, did you or anyone in
the family have to quit a job, not take a job, or greatly
change your job because of problems with child care
for this child?
Very well
Somewhat well
Yes
Not very well
No
Not at all
I. About Your Family and
Household
H12 DURING THE PAST MONTH, how often have you felt:
Never
a. That this
child is much
harder to care
for than most
children his
or her age?
Rarely Sometimes Usually Always
I1
DURING THE PAST WEEK, on how many days did all
the family members who live in the household eat a
meal together?
0 days
b. That this
child does
things that
really bother
you a lot?
1-3 days
4-6 days
Every day
c. Angry with
this child?
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I2
Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?
I8
Which of these statements best describes your
household’s ability to afford the food you need
DURING THE PAST 12 MONTHS?
Yes
We could always afford to eat good nutritious meals.
No ➔ SKIP to question I4
I3
I4
We could always afford enough to eat but not always
the kinds of food we should eat.
If yes, does anyone smoke inside your home?
Yes
Sometimes we could not afford enough to eat.
No
Often we could not afford enough to eat.
DURING THE PAST 12 MONTHS, how often were
pesticides used inside your residence to control for
insects? If the frequency changed throughout the year,
report the highest frequency.
I9
More than once a week
a. Cash assistance from a government
welfare program?
Once a week
b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?
Once a month
Once every 2-5 months
c. Free or reduced-cost breakfasts or
lunches at school?
Once every 6 months
d. Benefits from the Woman, Infants,
and Children (WIC) Program?
Yes
No
Yes
No
I10 In your neighborhood, is/are there:
Once during the past 12 months
Never
a. Sidewalks or walking paths?
Don’t know
I5
At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive:
b. A park or playground?
DURING THE PAST 12 MONTHS, other than in a shower
or bathtub, have you seen any mold, mildew or other
signs of water damage on walls or other surfaces inside
your home?
c. A recreation center, community
center, or boys’ and girls’ club?
d. A library or bookmobile?
Yes
e. Litter or garbage on the street
or sidewalk?
No
I6
f. Poorly kept or rundown housing?
When your family faces problems, how often are you
likely to do each of the following?
All of
the time
Most of
the time
Some of
the time
g. Vandalism such as broken
windows or graffiti?
None of
the time
a. Talk together
about what to do
I11 To what extent do you agree with these statements
about your neighborhood or community?
b. Work together to
solve our problems
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree
a. People in this
neighborhood
help each other
out
b. We watch out for
each other’s
children in this
neighborhood
c. Know we have
strengths to draw on
d. Stay hopeful
even in difficult
times
I7
SINCE THIS CHILD WAS BORN, how often has it been
very hard to cover the basics, like food and housing,
on your family’s income?
c. This child is
safe in our
neighborhood
Never
Rarely
d. When we
encounter
difficulties, we
know where to
go for help in
our community
Somewhat often
Very often
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26018044
I12 The next questions are about events that may have
J4
Where were you born?
happened during this child’s life. These things can
happen in any family, but some people may feel
uncomfortable with these questions. You may skip
any questions you do not want to answer.
To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated
In the United States ➔ SKIP to question J6
Outside of the United States
J5
When did you come to live in the United States?
Year
b. Parent or guardian died
c. Parent or guardian served time in jail
J6
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home
What is the highest grade or level of school you have
completed? Mark (X) ONE box.
8th grade or less
9th-12th grade; No diploma
e. Was a victim of violence or
witnessed violence in his or her
neighborhood
High School Graduate or GED Completed
f. Lived with anyone who was mentally
ill, suicidal, or severely depressed
Completed a vocational, trade, or business school
program
g. Lived with anyone who had a problem
with alcohol or drugs
Some College Credit, but no Degree
h. Treated or judged unfairly because
of his or her race or ethnic group
Associate Degree (AA, AS)
Bachelor’s Degree (BA, BS, AB)
J. About You
Master’s Degree (MA, MS, MSW, MBA)
➜ Complete the questions for up to two adults in the
household who are this child’s primary caregivers.
If there is just one adult primary caregiver, provide
answers for that adult.
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
J7
Married
ADULT 1 (Respondent)
J1
Not married, but living with a partner
How are you related to this child?
Never Married
Biological or Adoptive Parent
Divorced
Step-parent
Separated
Grandparent
Widowed
Foster Parent
Other: Relative
J8
Very Good
What is your sex?
Good
Male
Fair
Female
J3
In general, how is your physical health?
Excellent
Other: Non-Relative
J2
What is your marital status?
Poor
What is your age?
Age in years
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26018036
J9
In general, how is your mental or emotional health?
J16 Where was Adult 2 born?
Excellent
In the United States ➔ SKIP to question J18
Very Good
Outside of the United States
Good
J17 When did Adult 2 come to live in the United States?
Year
Fair
Poor
J10 Were you employed at least 50 out of the past 52 weeks?
J18 What is the highest grade or level of school Adult 2 has
Yes
completed? Mark (X) ONE box.
No
8th grade or less
9th-12th grade; No diploma
J11 Have you ever served on active duty in the
U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
High School Graduate or GED Completed
Never served in the military ➔ SKIP to question J13
Completed a vocational, trade, or business school
program
Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question J13
Some College Credit, but no Degree
Now on active duty
Associate Degree (AA, AS)
On active duty in the past, but not now
Bachelor’s Degree (BA, BS, AB)
J12 Were you deployed at any time during this child’s life?
Master’s Degree (MA, MS, MSW, MBA)
Yes
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
No
J19 What is Adult 2’s marital status?
ADULT 2
Married
J13 How is Adult 2 related to this child?
Not married, but living with a partner
There is only one primary adult
caregiver for this child ➔ SKIP to question K1
Never Married
Biological or Adoptive Parent
Divorced
Step-parent
Separated
Grandparent
Widowed
Foster Parent
J20 In general, how is Adult 2’s physical health?
Other: Relative
Excellent
Other: Non-Relative
Very Good
J14 What is Adult 2’s sex?
Good
Male
Fair
Female
Poor
J15 What is Adult 2’s age?
Age in years
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26018028
K3
Very Good
Income in 2016
Mark (X) the "Yes" box for each type of income this child’s
family received, and give your best estimate of the TOTAL
AMOUNT IN THE LAST CALENDAR YEAR. Mark (X) the
“No” box to show types of income NOT received.
Good
a. Wages, salary, commissions, bonuses, or tips for
all jobs.
J21 In general, how is Adult 2’s mental or emotional health?
Excellent
Fair
Yes ➔
Poor
$
,
.00
TOTAL AMOUNT
in the last calendar year
No
J22 Was Adult 2 employed at least 50 out of the past
,
b. Self-employment income from own nonfarm
businesses or farm business, including
proprietorships and partnerships.
52 weeks?
Yes
Yes ➔
No
$
U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
.00
Loss
TOTAL AMOUNT
in the last calendar year
No
J23 Has Adult 2 ever served on active duty in the
,
,
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Never served in the military ➔ SKIP to question K1
Yes ➔
Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question K1
$
Yes ➔
J24 Was Adult 2 deployed at any time during this child’s life?
Yes
$
,
.00
e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office.
K. Household Information
Yes ➔
How many people are living or staying at this address?
Include everyone who usually lives or stays at this address.
Do NOT include anyone who is living somewhere else for
more than two months, such as a college student living away
or someone in the Armed Forces on deployment.
$
,
,
.00
TOTAL AMOUNT
in the last calendar year
No
f. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support, or alimony.
Number of people
How many of these people in your household are family
members? Family is defined as anyone related to this child
by blood, marriage, adoption, or through foster care.
,
TOTAL AMOUNT
in the last calendar year
No
No
K2
Loss
d. Social security or railroad retirement; retirement,
survivor, or disability pensions.
On active duty in the past, but not now
K1
.00
TOTAL AMOUNT
in the last calendar year
No
Now on active duty
,
,
Yes ➔
$
Number of people
,
.00
TOTAL AMOUNT
in the last calendar year
No
K4
,
The following question is about your 2016 income.
Think about your total combined family income IN THE
LAST CALENDAR YEAR for all members of the family.
What is that amount before taxes? Include money from
jobs, child support, social security, retirement income,
unemployment payments, public assistance, and so forth.
Also, include income from interest, dividends, net income
from businesses, farm, or rent, and any other money income
received.
$
,
.00
,
TOTAL AMOUNT
in the last calendar year
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26018010
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 this child and your family.
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.
Place the completed questionnaire in the postage-paid return envelope. If the envelope has been
misplaced, 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.
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to: Paperwork Project 0607-0990,
U.S. Census Bureau, 4600 Silver Hill Road, Room 8H590, Washington, DC 20233. You may e-mail comments to
[email protected]; use "Paperwork Project 0607-0990" as the subject.
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| File Type | application/pdf |
| File Modified | 2017-06-12 |
| File Created | 2017-06-12 |