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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 often...
Always
Usually Sometimes
Never
a. Is this child
affectionate and
tender with you?
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.
b. Does this child
bounce back
quickly when
things do not go
his or her way?
We now have some follow-up questions to ask about:
c. Does this child
show 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.
d. Does this child
smile and laugh?
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.
A4
The survey should be completed by an adult who is
familiar with this child’s health and health care.
Your participation is important. Thank you.
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)
b. Eating or swallowing because of
a health condition
c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea
A. This Child’s Health
d. Repeated or chronic physical pain,
including headaches or other back
or body pain
A1 In general, how would you describe this child’s health
(the one named above)?
Excellent
e. Using his or her hands
Very good
f. Coordination or moving around
Good
g. Toothaches
Fair
h. Bleeding gums
Poor
i.
A2 How would you describe the condition of this child’s
A5
Decayed teeth or cavities
Does this child have any of the following?
teeth?
This child does not have any teeth
a. Deafness or problems with hearing
Excellent
b. Blindness or problems with seeing,
even when wearing glasses
Very good
Good
Fair
Poor
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Has a doctor or other health care provider EVER told
you that this child has...
A6
Allergies (including food, drug, insect, or other)?
Yes
Has a doctor or other health care provider EVER told
you that this child has...
A12 Epilepsy or Seizure Disorder?
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
If yes, does this child CURRENTLY have the
condition?
No
Yes
No
If yes, is it:
If yes, is it:
Mild
Moderate
Severe
A7 Arthritis?
Mild
Moderate
Severe
A13 Heart Condition?
Yes
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, does this child CURRENTLY have the
condition?
No
Yes
If yes, is it:
No
If yes, is it:
Mild
Moderate
Severe
A8 Asthma?
Mild
Moderate
Severe
A14 Frequent or severe headaches, including migraine?
Yes
No
Yes
Yes
No
Yes
Mild
Moderate
Severe
Mild
Yes
No
Severe
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
Moderate
Mild
Severe
Cerebral Palsy?
Yes
Moderate
A15 Tourette Syndrome?
A9 Brain injury, concussion or head injury?
Yes
No
If yes, is it:
If yes, is it:
Yes
No
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
A10
No
Moderate
Severe
A16 Anxiety Problems?
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, does this child CURRENTLY have the
condition?
Yes
No
No
If yes, is it:
If yes, is it:
Mild
Moderate
Mild
Severe
A11 Diabetes?
Moderate
Severe
A17 Depression?
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
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...
A18 Down Syndrome?
Yes
Has a doctor or other health care provider EVER told
you that this child has...
A21 Other genetic or inherited condition?
Yes
No
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, specify: C
No
Is it:
If yes, is it:
Mild
Moderate
Mild
Severe
Thalassemia, or Hemophilia)?
Yes
No
If yes, is it:
Mild
Moderate
No
Has a doctor, other health care provider, or educator
EVER told you that this child has...
Examples of educators are teachers and school nurses.
Severe
Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Yes
Severe
Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
A19 Blood Disorders (such as Sickle Cell Disease,
Yes
Moderate
A22 Behavioral or Conduct Problems?
Yes
No
No
If yes, does this child CURRENTLY have the
condition?
If yes, was this child diagnosed with:
Sickle Cell Disease?
Yes
No
Thalassemia?
Yes
No
Hemophilia?
Yes
No
Other Blood Disorders?
Yes
No
Yes
No
If yes, is it:
Mild
Yes
Yes
If yes, is it:
No
If yes, is it:
Moderate
Severe
If yes, was this condition identified through a
blood test done shortly after birth? These tests
are sometimes called newborn screening.
Yes
No
If yes, does this child CURRENTLY have the
condition?
No
Mild
Severe
A23 Developmental Delay?
A20 Cystic Fibrosis?
Yes
Moderate
Mild
Moderate
Severe
A24 Intellectual Disability (formerly known as Mental
Retardation)?
No
Yes
No
If yes, does this child CURRENTLY have the
disability?
Yes
No
If yes, is it:
Mild
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Moderate
Severe
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Has a doctor, other health care provider, or educator
EVER told you that this child has...
Examples of educators are teachers and school nurses.
A29 How old was this child when a doctor or other health
care provider FIRST told you that he or she had Autism,
ASD, Asperger’s Disorder or PDD?
A25 Speech or other language disorder?
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
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.
No
Primary Care Provider
If yes, is it:
Mild
Moderate
Specialist
Severe
School Psychologist/Counselor
A26 Learning Disability?
Yes
Don’t know
Age in years
No
Other Psychologist (Non-School)
No
If yes, does this child CURRENTLY have the
disability?
Yes
Psychiatrist
Other, specify:
No
C
If yes, is it:
Mild
Moderate
Severe
Has a doctor or other health care provider EVER told
you that this child has...
Don’t know
A31 Is this child CURRENTLY taking medication for Autism,
ASD, Asperger’s Disorder or PDD?
A27 Any other mental health condition?
Yes
Yes
No
No
A32 At any time DURING THE PAST 12 MONTHS, did this
If yes, specify: C
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?
If yes, does this child CURRENTLY have the
condition?
Yes
Yes
A33 Has a doctor or other health care provider EVER told
If yes, is it:
Mild
Moderate
you that this child has Attention Deficit Disorder or
Attention Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?
Severe
A28 Has a doctor or other health care provider EVER told
If yes, does this child CURRENTLY have the
condition?
No ➔ SKIP to question A33
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, is it:
Mild
No
If yes, is it:
Mild
No ➔ SKIP to question A36 on
page 6
Yes
you that this child has Autism or Autism Spectrum
Disorder (ASD)? Include diagnoses of Asperger’s Disorder
or Pervasive Developmental Disorder (PDD).
Yes
No
No
Moderate
Severe
A34 Is this child CURRENTLY taking medication for ADD or
Moderate
ADHD?
Severe
Yes
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A35 At any time DURING THE PAST 12 MONTHS, did this
B5
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
If yes, how old was this child when he or she
COMPLETELY stopped breastfeeding or being fed
breast milk?
No
days
OR
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?
weeks
This child does not have any
health conditions ➔ SKIP to question B1
OR
Never
months
Sometimes
OR
Usually
Check this box if child is still breastfeeding
Always
B6
How old was this child when he or she was FIRST fed
formula?
A37 To what extent do this child’s health conditions or
problems affect his or her ability to do things?
Check this box if child has never been fed formula
OR
Very little
At birth
Somewhat
OR
A great deal
days
OR
B. This Child as an Infant
B1
weeks
Was this child born more than 3 weeks before his or
her due date?
OR
Yes
months
No
B2
How much did he or she weigh when born? Answer in
pounds and ounces OR kilograms and grams. Your best
estimate is fine.
pounds AND
B7
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.
Check this box if child has never been fed anything
other than breast milk or formula
OR
ounces
OR
At birth
kilograms AND
B3
grams
OR
What was the age of the mother when this child was
born? Your best estimate is fine.
days
OR
Age in years
B4
weeks
Was this child EVER breastfed or fed breast milk?
OR
Yes
No ➔ SKIP to question B6
months
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C. Health Care Services
C7
C1 DURING THE PAST 12 MONTHS, did this child see a
Yes
doctor, nurse, or other health care professional for
medical care (for example, preventive care, sick care,
hospitalizations)?
No
C8
Yes
No ➔ SKIP to question C4
C2
C3
Has a doctor or other health care provider ever told you
that this child is overweight?
DURING THE PAST 12 MONTHS, did this child’s doctors
or other health care providers ask if you have concerns
about this child’s learning, development, or behavior?
Yes
If yes, DURING THE PAST 12 MONTHS, how many times
did this child visit a doctor, nurse, or other health care
No
professional to receive a PREVENTIVE check-up?
A preventive check-up is when this child was not sick or
C9 Answer the following question only if this child is at
injured, such as an annual or sports physical, or well-child
least 9 months old. Otherwise skip to question C10 .
visit.
DURING THE PAST 12 MONTHS, did a doctor or other
health care provider have you or another caregiver fill
0 visits
out a questionnaire about observations or concerns you
may have about this child’s development, communication,
1 visit
or social behaviors? Sometimes a child’s doctor or other
health care provider will ask a parent to do this at home or
2 or more visits
during a child’s visit.
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.
Yes
If yes, and this child is 9-23 Months:
Did the questionnaire ask about your concerns
or observations about: Mark (X) ALL that apply.
Less than 10 minutes
How this child talks or makes speech sounds?
10-20 minutes
How this child interacts with you and others?
More than 20 minutes
C4
If yes, and this child is 2-5 Years:
Did the questionnaire ask about your concerns
or observations about: Mark (X) ALL that apply.
Words and phrases this child uses and
understands?
What is this child’s CURRENT height?
Your best estimate is fine.
feet AND
No
inches
How this child behaves and gets along with
you and others?
OR
C10 Is there a place you or another caregiver USUALLY
meters AND
C5
take this child when he or she is sick or you need
advice about his or her health?
centimeters
Yes
How much does this child CURRENTLY weigh?
Your best estimate is fine.
pounds AND
ounces
No ➔ SKIP to question C12 on page 8
C11 If yes, where does this child USUALLY go first?
Mark (X) ONE box.
OR
Doctor’s Office
kilograms AND
C6
grams
Hospital Emergency Room
Hospital Outpatient Department
Are you concerned about this child’s weight?
Yes, it’s too high
Clinic or Health Center
Yes, it’s too low
Retail Store Clinic or “Minute Clinic”
No, I am not concerned
School (Nurse’s Office, Athletic Trainer’s Office)
Some other place
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C12 Is there a place that this child USUALLY goes when
C18 If yes, DURING THE PAST 12 MONTHS, what
preventive dental service(s) did this child receive?
Mark (X) ALL that apply.
he or she needs routine preventive care, such as a
physical examination or well-child check-up?
Yes
Check-up
No ➔ SKIP to question C14
Cleaning
Instruction on tooth brushing and oral health care
C13 If yes, is this the same place this child goes when he
or she is sick?
X-Rays
Yes
Fluoride treatment
No
Sealant (plastic coatings on back teeth)
C14 DURING THE PAST 12 MONTHS, has this child had his
or her vision tested, such as with pictures, shapes, or
letters?
Don’t know
C19 DURING THE PAST 12 MONTHS, has this child
Yes
received any treatment or counseling from a mental
health professional? Mental health professionals include
psychiatrists, psychologists, psychiatric nurses, and clinical
social workers.
No ➔ SKIP to question C16
C15 If yes, where was this child’s vision tested?
Yes
Mark (X) ALL that apply.
Eye doctor or eye specialist (ophthalmologist,
optometrist) office
No, but this child needed to see a mental health
professional
Pediatrician or other general doctor’s office
No, this child did not need to see a
mental health professional ➔ SKIP to question C21
Clinic or health center
C20 How difficult was it to get the mental health treatment
or counseling that this child needed?
School
Very difficult
Other, specify:
C
Somewhat difficult
Not difficult
C16 DURING THE PAST 12 MONTHS, did this child see a
It was not possible to obtain care
dentist or other oral health care provider for any kind
of dental or oral health care?
C21 DURING THE PAST 12 MONTHS, has this child taken
any medication because of difficulties with his or her
emotions, concentration, or behavior?
Yes, saw a dentist
Yes, saw other oral health care provider
Yes
No ➔ SKIP to question C19
C17 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?
No
C22 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.
No preventive visits in
the past 12 months ➔ SKIP to question C19
Yes
Yes, 1 visit
No, but this child needed to see a specialist
Yes, 2 or more visits
No, this child did not need to see
a specialist ➔ SKIP to question C24 on page 9
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C23 How difficult was it to get the specialist care that this
C28 DURING THE PAST 12 MONTHS, how often were you
child needed?
frustrated in your efforts to get services for this child?
Very difficult
Never
Somewhat difficult
Sometimes
Not difficult
Usually
It was not possible to obtain care
Always
C24 DURING THE PAST 12 MONTHS, did this child use any
C29 DURING THE PAST 12 MONTHS, how many times did
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.
this child visit a hospital emergency room?
None
1 time
Yes
2 or more times
No
C30 DURING THE PAST 12 MONTHS, was this child
admitted to the hospital to stay for at least one night?
C25 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.
Yes
No
C31 Has this child EVER had a special education or early
Yes
intervention plan? Children receiving these services often
have an Individualized Family Service Plan (IFSP) or
Individualized Education Plan (IEP).
No ➔ SKIP to question C28
C26 If yes, which types of care were not received?
Yes
Mark (X) ALL that apply.
No ➔ SKIP to question C34
Medical Care
Dental Care
C32 If yes, how old was this child at the time of the FIRST
plan?
Vision Care
Years AND
Hearing Care
C33 Is this child CURRENTLY receiving services under one
Mental Health Services
Other, specify:
Months
of these plans?
Yes
C
No
C27 Did any of the following reasons contribute to this child C34 Has this child EVER received special services to meet
his or her developmental needs such as speech,
occupational, or behavioral therapy?
not receiving needed health services? Mark (X) Yes or No
for each item.
Yes
No
Yes
a. This child was not eligible for the
services
b. The services this child needed were
not available in your area
No ➔ SKIP to question D1 on page 10
C35 If yes, how old was this child when he or she began
receiving these special services?
c. There were problems getting an
appointment when this child needed
one
d. There were problems with getting
transportation or child care
Years AND
Months
C36 Is this child CURRENTLY receiving these special
services?
e. The clinic or doctor’s office wasn’t
open when this child needed care
Yes
f. There were issues related to cost
No
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D. Experience with This
Child’s Health Care
Providers
D6
If yes, DURING THE PAST 12 MONTHS, how often did
this child’s doctors or other health care providers...
Always
Usually Sometimes Never
a. Discuss with you
the range of options
to consider for his
or her health care or
treatment?
D1 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.
b. Make it easy for you
to raise concerns or
disagree with
recommendations
for this child’s health
care?
Yes, one person
Yes, more than one person
c. Work with you to
decide together
which health care
and treatment
choices would be
best for this child?
No
D2 DURING THE PAST 12 MONTHS, did this child need a
referral to see any doctors or receive any services?
Yes
D7
No ➔ SKIP to question D4
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?
D3 How difficult was it to get referrals?
No
Very difficult
Yes
Somewhat difficult
Did not see more than one health care provider
in PAST 12 MONTHS
Not difficult
D8
It was not possible to get a referral
D4 Answer the following questions only if this child has had
a health care visit IN THE PAST 12 MONTHS. Otherwise
skip to Section E on page 11.
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
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers...
Always
Usually Sometimes
No ➔ SKIP to question D10
Never
a. Spend enough time
with this child?
D9
b. Listen carefully to
you?
Usually
c. Show sensitivity to
your family’s values
and customs?
d. Provide the specific
information you
needed concerning
this child?
If yes, DURING THE PAST 12 MONTHS, how often
did you get as much help as you wanted with
arranging or coordinating this child’s health care?
Sometimes
Never
D10 DURING THE PAST 12 MONTHS, how satisfied were
you with the communication among this child’s doctors
and other health care providers?
e. Help you feel like a
partner in this
child’s care?
Very satisfied
D5 DURING THE PAST 12 MONTHS, did this child need
Somewhat satisfied
any decisions to be made regarding his or her health
care, such as whether to get prescriptions, referrals,
or procedures?
Somewhat dissatisfied
Yes
Very dissatisfied
No ➔ SKIP to question D7
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D11 DURING THE PAST 12 MONTHS, did this child’s health
E3
care provider communicate with the child’s school, child
care provider, or special education program?
Is this child CURRENTLY covered by ANY kind of
health insurance or health coverage plan?
Yes
Yes
No ➔ SKIP to question F1 on page 12
No ➔ SKIP to question E1
E4
Did not need health care
provider to communicate
with these providers ➔ SKIP to question E1
Is this child CURRENTLY 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
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?
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
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
d. TRICARE or other military
health care
Very dissatisfied
e. Indian Health Service
E. This Child’s Health
Insurance Coverage
E1
E2
f. Other, specify: C
DURING THE PAST 12 MONTHS, was this child EVER
covered by ANY kind of health insurance or health
coverage plan?
E5
How often does this child’s health insurance offer
benefits or cover services that meet this child’s needs?
Yes, this child was covered
all 12 months ➔ SKIP to question E4
Always
Yes, but this child had a gap in coverage
Usually
No
Sometimes
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
Never
E6
No
How often does this child’s health insurance allow him
or her to see the health care providers he or she needs?
a. Change in employer or employment
status
Always
b. Cancellation due to overdue
premiums
Usually
c. Dropped coverage because it was
unaffordable
Sometimes
d. Dropped coverage because benefits
were inadequate
Never
e. Dropped coverage because choice
of health care providers was
inadequate
E7
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?
f. Problems with application or
renewal process
This child does not use mental or behavioral
health services
g. Other, specify: C
Always
Usually
Sometimes
Never
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F. Providing for This
Child’s Health
F1
F5
IN AN AVERAGE WEEK, how many hours do you or
other family members spend providing health care at
home for this child? Care might include changing bandages,
or giving medication and therapies when needed.
This child does not need health care provided
on a weekly basis
Including co-pays and amounts reimbursed 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.
Less than 1 hour per week
1-4 hours per week
5-10 hours per week
$0 (No medical or health-related
expenses) ➔ SKIP to question F4
11 or more hours per week
$1-$249
F6
$250-$499
$500-$999
F2
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?
$1,000-$5,000
This child does not need health care coordinated
on a weekly basis
More than $5,000
Less than 1 hour per week
1-4 hours per week
How often are these costs reasonable?
Always
5-10 hours per week
Usually
11 or more hours per week
Sometimes
G. This Child’s Learning
Never
F3
DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?
Answer the following question only if this child is at
least 1 year old. Otherwise skip to H1 on page 15.
G1
Yes
Yes
No
a. Say at least one word, such as "hi"
or "dog"?
No
F4
Is this child able to do the following...
Mark (X) Yes or No for each item.
b. Use 2 words together, such as
"car go"?
DURING THE PAST 12 MONTHS, have you or other
family members...
Yes
c. Use 3 words together in a sentence,
such as, "Mommy come now."?
No
a. Left a job or taken a leave of
absence because of this child’s
health or health conditions?
d. Ask questions like "who," "what,"
"when," "where"?
b. Cut down on the hours you work
because of this child’s health or
health conditions?
e. Ask questions like "why" and "how"?
f. Tell a story with a beginning,
middle, and end?
c. Avoided changing jobs because of
concerns about maintaining health
insurance for this child?
g. Understand the meaning of the
word "no"?
h. Follow a verbal direction without
hand gestures, such as "Wash your
hands."?
i.
Point to things in a book when
asked?
j. Follow 2-step directions, such as
"Get your shoes and put them in the
basket."?
k. Understand words such as "in,"
"on," and "under"?
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G2 Is this child 3 years old or older?
G8 Can this child rhyme words?
Yes
Yes
No ➔ SKIP to question H1 on page 15
No
G3 Has this child started school? Include any formal
G9 How often can this child explain things he or she has seen
home schooling.
or done so that you get a very good idea what happened?
Yes, preschool
Always
Yes, kindergarten
Most of the time
Yes, first grade
About half the time
No
Sometimes
Never
G4 Are you concerned about how this child is learning to
do things for him or herself?
G10 How often can this child write his or her first name, even
Yes, somewhat concerned
if some of the letters aren’t quite right or are backwards?
Yes, very concerned
Always
No
Most of the time
About half the time
G5 How confident are you that this child is ready to be in
school?
Sometimes
Completely confident
Never
Mostly confident
G11 How high can this child count?
Somewhat confident
This child cannot count
Not at all confident
Up to five
G6 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?
Up to ten
Up to 20
Always
Up to 50
Most of the time
Up to 100 or more
About half the time
Sometimes
G12 How often can this child identify basic shapes such as
a triangle, circle, or square?
Never
Always
G7 About how many letters of the alphabet can this child
Most of the time
recognize?
About half the time
All of them
Sometimes
Most of them
Never
About half of them
Some of them
None of them
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G13 Can this child identify the colors red, yellow, blue,
G19 How often does this child become angry or anxious
and green by name?
when going from one activity to another?
Yes, all of them
Always
Yes, some of them
Most of the time
No, none of them
About half the time
G14 How often is this child easily distracted?
Sometimes
Always
Most of the time
Never
G20 How often does this child show concern when others
are hurt or unhappy?
About half the time
Always
Sometimes
Most of the time
Never
About half the time
G15 How often does this child keep working at something
until he or she is finished?
Sometimes
Always
Most of the time
Never
G21 When excited or all wound up, how often can this child
calm down quickly?
About half the time
Always
Sometimes
Most of the time
Never
About half the time
G16 When this child is paying attention, how often can he
Sometimes
or she follow instructions to complete a simple task?
Always
Most of the time
Never
G22 How often does this child lose control of his or her
temper when things do not go his or her way?
About half the time
Always
Sometimes
Most of the time
Never
About half the time
G17 How does this child usually hold a pencil?
Sometimes
Uses fingers to hold the pencil
Never
Grips the pencil in his or her fist
This child cannot hold a pencil
G23 Compared to other children his or her age, how much
difficulty does this child have making or keeping
friends?
G18 How often does this child play well with others?
A lot of difficulty
Always
A little difficulty
Most of the time
No difficulty
About half the time
Sometimes
Never
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G24 Compared to other children his or her age, how often
H6
is this child able to sit still?
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 MOST WEEKDAYS, about how much time did this
child spend in front of a TV, computer, cellphone or
other electronic device watching programs, playing
games, accessing the internet or using social media?
Do not include time spent doing schoolwork.
Less than 1 hour
H1 Was this child born in the United States?
1 hour
Yes ➔ SKIP to question H3
2 hours
No
3 hours
H2 If no, how long has this child been living in the
United States?
Years AND
4 or more hours
Months
H8
H3 How many times has this child moved to a new address
DURING THE PAST WEEK, how many days did you or
other family members read to this child?
0 days
since he or she was born?
1-3 days
Number of times
4-6 days
H4 How often does this child go to bed at about the same
Every day
time on weeknights?
Always
H9
Usually
DURING THE PAST WEEK, how many days did you or
other family members tell stories or sing songs to this
child?
Sometimes
0 days
Rarely
1-3 days
Never
4-6 days
Every day
H5 DURING THE PAST WEEK, how many hours of sleep
did this child get during an average day (count both
nighttime sleep and naps)?
H10 How well do you think you are handling the day-to-day
demands of raising children?
Less than 7 hours
Very well
7 hours
Somewhat well
8 hours
Not very well
9 hours
Not at all
10 hours
11 hours
12 or more hours
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26018051
I. About Your Family and
Household
H11 DURING THE PAST MONTH, how often have you
felt...
Never
Rarely Sometimes Usually Always
a. That this
child is much
harder to care
for than most
children his
or her age?
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
c. Angry with
this child?
Every day
H12 DURING THE PAST 12 MONTHS, was there someone
I2
that you could turn to for day-to-day emotional support
with parenting or raising children?
Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?
Yes
Yes
No ➔ SKIP to question I4
No ➔ SKIP to question H14
H13 If yes, did you receive emotional support from...
Yes
I3
If yes, does anyone smoke inside your home?
Yes
No
No
a. Spouse or domestic partner?
b. Other family member or close friend?
I4
c. Health care provider?
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.
d. Place of worship or religious leader?
More than once a week
e. Support or advocacy group related
to specific health condition?
Once a week
f. Peer support group?
Once a month
g. Counselor or other mental health
professional?
Once every 2-5 months
h. Other person, specify:
Once every 6 months
C
Once during the past 12 months
Never
H14 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.
Don’t know
I5
Yes
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?
Yes
No
No
H15 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?
Yes
No
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26018044
I6
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
I10 In your neighborhood, is/are there...
Yes
None of
the time
No
a. Sidewalks or walking paths?
a. Talk together
about what to do
b. A park or playground?
b. Work together to
solve our problems
c. A recreation center, community
center, or boys’ and girls’ club?
c. Know we have
strengths to draw on
d. A library or bookmobile?
d. Stay hopeful
even in difficult
times
e. Litter or garbage on the street
or sidewalk?
f. Poorly kept or rundown housing?
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?
Never
g. Vandalism such as broken
windows or graffiti?
I11 To what extent do you agree with these statements
about your neighborhood or community?
Rarely
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree
Somewhat often
a. People in this
neighborhood
help each other
out
b. We watch out for
each other’s
children in this
neighborhood
Very often
I8
Which of these statements best describes your
household’s ability to afford the food you need
DURING THE PAST 12 MONTHS?
We could always afford to eat good nutritious meals.
c. This child is
safe in our
neighborhood
We could always afford enough to eat but not always
the kinds of food we should eat.
d. When we
encounter
difficulties, we
know where to
go for help in
our community
Sometimes we could not afford enough to eat.
Often we could not afford enough to eat.
I9
At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive...
Yes
I12 The next questions are about events that may have
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.
No
a. Cash assistance from a government
welfare program?
To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated
b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?
c. Free or reduced-cost breakfasts or
lunches at school?
b. Parent or guardian died
d. Benefits from the Woman, Infants,
and Children (WIC) Program?
c. Parent or guardian served time in jail
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home
e. Was a victim of violence or
witnessed violence in his or her
neighborhood
f. Lived with anyone who was mentally
ill, suicidal, or severely depressed
g. Lived with anyone who had a problem
with alcohol or drugs
h. Treated or judged unfairly because
of his or her race or ethnic group
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26018036
J. Child’s Caregivers
J7
Married
➜ 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.
J1
Not married, but living with a partner
Never Married
How are you related to this child?
Divorced
Biological or Adoptive Parent
Separated
Step-parent
Grandparent
Widowed
J8
Foster Parent
In general, how is your physical health?
Excellent
Other: Relative
Very Good
Other: Non-Relative
J2
What is your marital status?
Good
What is your sex?
Fair
Male
Poor
Female
J9
J3
What is your age?
Excellent
Age in years
J4
J5
In general, how is your mental or emotional health?
Very Good
Where were you born?
Good
In the United States ➔ SKIP to question J6
Fair
Outside of the United States
Poor
When did you come to live in the United States?
J10
Year
Were you employed at least 50 out of the past 52 weeks?
Yes
No
J6
What is the highest grade or level of school you have
completed? Mark (X) ONE box.
J11
8th grade or less
Have you ever served on active duty in the
U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
9th-12th grade; No diploma
Never served in the
military ➔ SKIP to question J13 on page 19
High School Graduate or GED Completed
Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question J13 on page 19
Completed a vocational, trade, or business school
program
Now on active duty
On active duty in the past, but not now
Some College Credit, but no Degree
Associate Degree (AA, AS)
J12
Were you deployed at any time during this child’s life?
Yes
Bachelor’s Degree (BA, BS, AB)
No
Master’s Degree (MA, MS, MSW, MBA)
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
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26018028
Questions J13 - J24 ask about another adult primary
caregiver who may be in the household in addition to
yourself.
J19 What is this primary caregiver’s marital status?
Married
J13 How is this adult primary caregiver in the household
Not married, but living with a partner
related to this child?
There is only one primary adult caregiver for
this child ➔ SKIP to question K1 on page 20
Never Married
Biological or Adoptive Parent
Divorced
Step-parent
Separated
Grandparent
Widowed
Foster Parent
J20 In general, how is this primary caregiver’s physical
health?
Other: Relative
Excellent
Other: Non-Relative
Very Good
J14 What is this primary caregiver’s sex?
Good
Male
Fair
Female
Poor
J15 What is this primary caregiver’s age?
J21 In general, how is this primary caregiver’s mental or
emotional health?
Age in years
Excellent
J16 Where was this primary caregiver born?
Very Good
In the United States ➔ SKIP to question J18
Good
Outside of the United States
Fair
J17 When did this primary caregiver come to live in the
United States?
Year
Poor
J22 Was this primary caregiver employed at least 50 out of
the past 52 weeks?
Yes
J18 What is the highest grade or level of school this primary
caregiver has completed? Mark (X) ONE box.
8th grade or less
No
J23 Has this primary caregiver ever served on active duty in
the U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
9th-12th grade; No diploma
High School Graduate or GED Completed
Never served in the
military ➔ SKIP to question K1 on page 20
Completed a vocational, trade, or business school
program
Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question K1 on page 20
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)
J24 Was this primary caregiver 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
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26018010
K. Household Information
K1
d. Social security or railroad retirement; retirement,
survivor, or disability pensions.
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.
Yes ➔
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.
Yes ➔
Number of people
$
,
$
b. Self-employment income from own nonfarm
businesses or farm business, including
proprietorships and partnerships.
Yes ➔
$
,
.00
,
No
$
,
$
.00
,
.00
,
,
.00
TOTAL AMOUNT
in the last calendar year
The following question is about your 2017 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
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Yes ➔
,
Loss
TOTAL AMOUNT
in the last calendar year
No
$
No
K4
.00
,
,
TOTAL AMOUNT
in the last calendar year
Yes ➔
TOTAL AMOUNT
in the last calendar year
No
.00
f. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support, or alimony.
Income in 2017
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.
a. Wages, salary, commissions, bonuses, or tips for
all jobs.
Yes ➔
,
e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office.
No
K3
,
TOTAL AMOUNT
in the last calendar year
No
Number of people
K2
$
Loss
TOTAL AMOUNT
in the last calendar year
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 | 2018-02-08 |
| File Created | 2018-02-07 |