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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 does this child...
Always
Usually Sometimes
Never
a. Show interest and
curiosity in learning
new things?
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. Work to finish tasks
he or she starts?
We now have some follow-up questions to ask about:
c. Stay calm and in
control when faced
with a challenge?
d. Care about doing
well in school?
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.
e. Do all required
homework?
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.
The survey should be completed by an adult who is
familiar with this child’s health and health care.
f. Argue too much?
A4
Your participation is important. Thank you.
DURING THE PAST 12 MONTHS, how often was this
child bullied, picked on, or excluded by other children?
If the frequency changed throughout the year, report the
highest frequency.
Never (in the past 12 months)
1-2 times (in the past 12 months)
1-2 times per month
A. This Child’s Health
1-2 times per week
Almost every day
A1 In general, how would you describe this child’s health
(the one named above)?
Excellent
A5
Very good
Good
DURING THE PAST 12 MONTHS, how often did this
child bully others, pick on them, or exclude them?
If the frequency changed throughout the year, report the
highest frequency.
Never (in the past 12 months)
Fair
1-2 times (in the past 12 months)
Poor
1-2 times per month
A2 How would you describe the condition of this child’s
1-2 times per week
teeth?
Almost every day
Excellent
Very good
Good
Fair
Poor
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A6 DURING THE PAST 12 MONTHS, has this child had
Has a doctor or other health care provider EVER told
you that this child has...
FREQUENT or CHRONIC difficulty with any of the
following?
Yes
No
A10 Asthma?
a. Breathing or other respiratory
problems (such as wheezing or
shortness of breath)
Yes
No
If yes, does this child CURRENTLY have the
condition?
b. Eating or swallowing because of
a health condition
Yes
No
If yes, is it:
c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea
Mild
Moderate
Severe
A11 Brain injury, concussion or head injury?
d. Repeated or chronic physical pain,
including headaches or other back
or body pain
Yes
No
If yes, does this child CURRENTLY have the
condition?
e. Toothaches
f. Bleeding gums
Yes
No
If yes, is it:
g. Decayed teeth or cavities
Mild
A7 Does this child have any of the following?
Yes
No
Yes
No
If yes, does this child CURRENTLY have the
condition?
Yes
b. Serious difficulty walking or climbing
stairs
Mild
Moderate
Yes
e. Blindness or problems with seeing,
even when wearing glasses
No
If yes, does this child CURRENTLY have the
condition?
Has a doctor or other health care provider EVER told
you that this child has...
Yes
No
If yes, does this child CURRENTLY have the
condition?
No
If yes, is it:
A8 Allergies (including food, drug, insect, or other)?
Mild
Moderate
Yes
No
If yes, does this child CURRENTLY have the
condition?
If yes, is it:
Moderate
Yes
Severe
No
If yes, is it:
A9 Arthritis?
Mild
No
Moderate
Severe
A15 Heart Condition?
If yes, does this child CURRENTLY have the
condition?
Yes
Severe
A14 Epilepsy or Seizure Disorder?
No
Yes
Severe
A13 Diabetes?
d. Deafness or problems with hearing
Mild
No
If yes, is it:
c. Difficulty dressing or bathing
Yes
Severe
A12 Cerebral Palsy?
a. Serious difficulty concentrating,
remembering, or making decisions
because of a physical, mental, or
emotional condition
Yes
Moderate
Yes
No
If yes, does this child CURRENTLY have the
condition?
No
If yes, is it:
Yes
Mild
Moderate
Severe
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...
A16 Frequent or severe headaches, including migraine?
Has a doctor or other health care provider EVER told
you that this child has...
A21 Blood Disorders (such as Sickle Cell Disease,
Thalassemia, or Hemophilia)?
Yes
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
If yes, is it:
No
Mild
If yes, is it:
Mild
Moderate
Severe
Yes
Yes
Severe
No
If yes, was this child diagnosed with:
No
If yes, does this child CURRENTLY have the
condition?
Sickle Cell Disease?
Yes
No
Thalassemia?
Yes
No
Hemophilia?
Yes
No
Other Blood
Disorders?
Yes
No
No
If yes, is it:
Mild
Moderate
Severe
A22 Cystic Fibrosis?
A18 Anxiety Problems?
Yes
Yes
No
Yes
Mild
No
Moderate
Severe
If yes, was this condition identified through a
blood test done shortly after birth? These tests
are sometimes called newborn screening.
If yes, is it:
Mild
No
If yes, is it:
If yes, does this child CURRENTLY have the
condition?
Moderate
Severe
A19 Depression?
Yes
No
A23 Other genetic or inherited condition?
Yes
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, specify: C
No
If yes, is it:
Is it:
Mild
A20
Moderate
Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
A17 Tourette Syndrome?
Yes
No
Moderate
Severe
Mild
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
A24 Substance Use Disorder?
No
If yes, is it:
Mild
Severe
Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Down Syndrome?
Yes
Moderate
Yes
Moderate
No
If yes, does this child CURRENTLY have the
disorder?
Severe
Yes
No
If yes, is it:
Mild
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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.
A25 Behavioral or Conduct Problems?
Yes
Has a doctor or other health care provider EVER told
you that this child has...
A30
Yes
No
No
If yes, specify: C
If yes, does this child CURRENTLY have the
condition?
Yes
Any other mental health condition?
No
If yes, does this child CURRENTLY have the
condition?
If yes, is it:
Mild
Moderate
Severe
Yes
A26 Developmental Delay?
Yes
If yes, is it:
No
Mild
If yes, does this child CURRENTLY have the
condition?
Yes
No
A31
No
Moderate
Severe
Has a doctor or other health care provider EVER told
you that this child has Autism or Autism Spectrum
Disorder (ASD)? Include diagnoses of Asperger’s Disorder
or Pervasive Developmental Disorder (PDD).
If yes, is it:
Mild
Moderate
No ➔ SKIP to question A36 on page 6
Yes
Severe
If yes, does this child CURRENTLY have the
condition?
A27 Intellectual Disability (formerly known as Mental
Retardation)?
Yes
Yes
No
If yes, is it:
If yes, does this child CURRENTLY have the
disability?
Yes
No
Mild
A32
No
If yes, is it:
Mild
Moderate
Moderate
Severe
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?
Severe
Don’t know
Age in years
A28 Speech or other language disorder?
Yes
A33 What type of doctor or other health care provider was
No
the FIRST to tell you that this child had Autism, ASD,
Asperger’s Disorder or PDD? Mark (X) ONE box.
If yes, does this child CURRENTLY have the
condition?
Yes
Primary Care Provider
No
Specialist
If yes, is it:
Mild
Moderate
School Psychologist/Counselor
Severe
Other Psychologist (Non-School)
A29 Learning Disability?
Yes
Psychiatrist
No
If yes, does this child CURRENTLY have the
disability?
Yes
Other, specify: C
No
If yes, is it:
Mild
Don’t know
Moderate
Severe
A34 Is this child CURRENTLY taking medication for Autism,
ASD, Asperger’s Disorder or PDD?
Yes
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B. This Child as an Infant
A35 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
B1
No
Yes
No
A36 Has a doctor or other health care provider EVER told
you that this child has Attention Deficit Disorder or
Attention Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?
B2
No ➔ SKIP to question A39
Yes
Was this child born more than 3 weeks before his or
her due date?
How much did he or she weigh when born? Answer in
pounds and ounces OR kilograms and grams. Your best
estimate is fine.
If yes, does this child CURRENTLY have the
condition?
Yes
pounds AND
ounces
OR
No
If yes, is it:
kilograms AND
Mild
Moderate
A37 Is this child CURRENTLY taking medication for ADD or
B3
ADHD?
Yes
grams
Severe
What was the age of the mother when this child was
born? Your best estimate is fine.
No
Age in years
A38 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?
C. Health Care Services
C1
Yes
No
A39 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?
Yes
This child does not have any
health conditions ➔ SKIP to question B1
Never
No ➔ SKIP to question C4 on page 7
C2
Sometimes
Usually
Always
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.
0 visits
A40 To what extent do this child’s health conditions or
1 visit
problems affect his or her ability to do things?
2 or more visits
Very little
Somewhat
DURING THE PAST 12 MONTHS, did this child see a
doctor, nurse, or other health care professional for
medical care (for example, preventive care, sick care,
hospitalizations)?
C3
A great deal
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
10-20 minutes
More than 20 minutes
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C4 What is this child’s CURRENT height?
C10 Is there a place that this child USUALLY goes when
Your best estimate is fine.
feet AND
he or she needs routine preventive care, such as a
physical examination or well-child check-up?
inches
Yes
OR
No ➔ SKIP to question C12
meters AND
centimeters
C11 If yes, is this the same place this child goes when he
or she is sick?
C5 How much does this child CURRENTLY weigh?
Yes
Your best estimate is fine.
No
pounds
C12 DURING THE PAST 12 MONTHS, has this child had his
OR
or her vision tested, such as with pictures, shapes, or
letters?
kilograms
C6
Yes
Are you concerned about this child’s weight?
Yes, it’s too high
No ➔ SKIP to question C14
C13 If yes, where was this child’s vision tested?
Mark (X) ALL that apply.
Yes, it’s too low
Eye doctor or eye specialist (ophthalmologist,
optometrist) office
No, I am not concerned
Pediatrician or other general doctor’s office
C7
C8
Has a doctor or other health care provider ever told
you that this child is overweight?
Clinic or health center
Yes
School
No
Other, specify:
Is there a place you or another caregiver USUALLY
take this child when he or she is sick or you need
advice about his or her health?
C14 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
No ➔ SKIP to question C10
C9
C
Yes, saw a dentist
Yes, saw other oral health care provider
If yes, where does this child USUALLY go first?
Mark (X) ONE box.
No ➔ SKIP to question C17 on page 8
Doctor’s Office
C15 If yes, DURING THE PAST 12 MONTHS, did this child
Hospital Emergency Room
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 Outpatient Department
Clinic or Health Center
No preventive visits in the past
12 months ➔ SKIP to question C17 on page 8
Retail Store Clinic or “Minute Clinic”
Yes, 1 visit
School (Nurse’s Office, Athletic Trainer’s Office)
Yes, 2 or more visits
Some other place
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C16 If yes, DURING THE PAST 12 MONTHS, what
C21 How difficult was it to get the specialist care that this
child needed?
preventive dental service(s) did this child receive?
Mark (X) ALL that apply.
Very difficult
Check-up
Somewhat difficult
Cleaning
Not difficult
Instruction on tooth brushing and oral health care
It was not possible to obtain care
X-Rays
C22
Fluoride treatment
Sealant (plastic coatings on back teeth)
Don’t know
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.
Yes
C17 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.
No
C23 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, but this child needed to see a mental health
professional
Yes
No, this child did not need to see a
mental health professional ➔ SKIP to question C19
No ➔ SKIP to question C26 on page 9
C24 If yes, which types of care were not received?
C18 How difficult was it to get the mental health treatment
Mark (X) ALL that apply.
or counseling that this child needed?
Medical Care
Very difficult
Dental Care
Somewhat difficult
Vision Care
Not difficult
Hearing Care
It was not possible to obtain care
Mental Health Services
C19 DURING THE PAST 12 MONTHS, has this child taken
Other, specify: C
any medication because of difficulties with his or her
emotions, concentration, or behavior?
Yes
No
C25 Did any of the following reasons contribute to this child
not receiving needed health services? Mark (X) Yes or No
for each item.
Yes
C20 DURING THE PAST 12 MONTHS, did this child see a
a. This child was not eligible for the
services
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.
b. The services this child needed were
not available in your area
c. There were problems getting an
appointment when this child needed
one
Yes
No, but this child needed to see a specialist
d. There were problems with getting
transportation or child care
No, this child did not need to
see a specialist ➔ SKIP to question C22
e. The clinic or doctor’s office wasn’t
open when this child needed care
f. There were issues related to cost
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D. Experience with This
Child’s Health Care
Providers
C26 DURING THE PAST 12 MONTHS, how often were you
frustrated in your efforts to get services for this child?
Never
Sometimes
D1
Usually
Always
C27 DURING THE PAST 12 MONTHS, how many times did
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.
this child visit a hospital emergency room?
Yes, one person
None
Yes, more than one person
1 time
No
2 or more times
C28 DURING THE PAST 12 MONTHS, was this child
D2
admitted to the hospital to stay for at least one night?
DURING THE PAST 12 MONTHS, did this child need a
referral to see any doctors or receive any services?
Yes
Yes
No
No ➔ SKIP to question D4
C29 Has this child EVER had a special education or early
D3
intervention plan? Children receiving these services often
have an Individualized Family Service Plan (IFSP) or
Individualized Education Plan (IEP).
How difficult was it to get referrals?
Very difficult
Yes
Somewhat difficult
No ➔ SKIP to question C32
Not difficult
It was not possible to get a referral
C30 If yes, how old was this child at the time of the FIRST
plan?
D4
Years AND
Months
C31 Is this child CURRENTLY receiving services under one
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, how often did this
child’s doctors or other health care providers...
of these plans?
Yes
Always
Usually Sometimes
a. Spend enough time
with this child?
No
b. Listen carefully to
you?
C32 Has this child EVER received special services to meet
his or her developmental needs such as speech,
occupational, or behavioral therapy?
c. Show sensitivity to
your family’s values
and customs?
Yes
d. Provide the specific
information you
needed concerning
this child?
No ➔ SKIP to question D1
C33 If yes, how old was this child when he or she began
receiving these special services?
Years AND
e. Help you feel like a
partner in this
child’s care?
Months
C34 Is this child CURRENTLY receiving these special
services?
Yes
No
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D5 DURING THE PAST 12 MONTHS, did this child need
D10 DURING THE PAST 12 MONTHS, how satisfied were
any decisions to be made regarding his or her health
care, such as whether to get prescriptions, referrals,
or procedures?
you with the communication among this child’s doctors
and other health care providers?
Very satisfied
Yes
Somewhat satisfied
No ➔ SKIP to question D7
Somewhat dissatisfied
D6 If yes, DURING THE PAST 12 MONTHS, how often did
this child’s doctors or other health care providers...
Always
Very dissatisfied
Usually Sometimes Never
a. Discuss with you
the range of options
to consider for his
or her health care or
treatment?
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?
Yes
b. Make it easy for you
to raise concerns or
disagree with
recommendations
for this child’s health
care?
c. Work with you to
decide together
which health care
and treatment
choices would be
best for this child?
No ➔ SKIP to question E1 on page 11
Did not need health care provider to communicate
with these providers ➔ SKIP to question E1 on
page 11
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
Somewhat satisfied
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?
Somewhat dissatisfied
Very dissatisfied
Yes
No
Did not see more than one health care provider
in PAST 12 MONTHS
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
No ➔ SKIP to question D10
D9 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?
Usually
Sometimes
Never
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E. This Child’s Health
Insurance Coverage
E4
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
E1
DURING THE PAST 12 MONTHS, was this child EVER
covered by ANY kind of health insurance or health
coverage plan?
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
Yes, this child was covered
all 12 months ➔ SKIP to question E4
Yes, but this child had a gap in coverage
No
E2
No
a. Insurance through a current or
former employer or union
d. TRICARE or other military
health care
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
e. Indian Health Service
f. Other, specify: C
No
a. Change in employer or employment
status
b. Cancellation due to overdue
premiums
E5
c. Dropped coverage because it was
unaffordable
Always
d. Dropped coverage because benefits
were inadequate
Usually
e. Dropped coverage because choice
of health care providers was
inadequate
Sometimes
Never
f. Problems with application or
renewal process
g. Other, specify: C
How often does this child’s health insurance offer
benefits or cover services that meet this child’s needs?
E6
How often does this child’s health insurance allow him
or her to see the health care providers he or she needs?
Always
E3
Usually
Is this child CURRENTLY covered by ANY kind of
health insurance or health coverage plan?
Sometimes
Yes
Never
No ➔ SKIP to question F1 on page 12
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?
This child does not use mental or behavioral
health services
Always
Usually
Sometimes
Never
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F. Providing for This
Child’s Health
F1
F5
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.
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 at home
on a weekly basis
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
Never
F3
DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?
Yes
No
F4
DURING THE PAST 12 MONTHS, have you or other
family members...
Yes
a.
No
Left a job or taken a leave of
absence because of this child’s
health or health conditions?
b. Cut down on the hours you work
because of this child’s health or
health conditions?
c. Avoided changing jobs because of
concerns about maintaining health
insurance for this child?
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G. This Child’s Schooling
and Activities
G5
DURING THE PAST 12 MONTHS, did this child
participate in...
Yes
No
a. A sports team or did he or she
take sports lessons after school
or on weekends?
G1 DURING THE PAST 12 MONTHS, about how many days
did this child miss school because of illness or injury?
Include days missed from any formal home schooling.
b. Any clubs or organizations after
school or on weekends?
No missed school days
c. Any other organized activities or
lessons, such as music, dance,
language, or other arts?
1-3 days
4-6 days
d. Any type of community service or
volunteer work at school, place of
worship, or in the community?
7-10 days
e. Any paid work, including regular
jobs as well as babysitting, cutting
grass, or other occasional work?
11 or more days
This child was not enrolled in school
G2
G6
DURING THE PAST 12 MONTHS, how many times has
this child’s school contacted you or another adult in
your household about any problems he or she is
having with school?
DURING THE PAST WEEK, on how many days did
this child exercise, play a sport, or participate in
physical activity for at least 60 minutes?
0 days
None
1-3 days
1 time
4-6 days
2 or more times
Every day
G3 SINCE STARTING KINDERGARTEN, has this child
repeated any grades?
G7
Yes
Compared to other children his or her age, how much
difficulty does this child have making or keeping
friends?
No difficulty
No
A little difficulty
G4 DURING THE PAST 12 MONTHS, how often did you
attend events or activities that this child participated in?
A lot of difficulty
Always
Usually
Sometimes
Rarely
Never
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H. About You and This
Child
H1
H7
How well can you and this child share ideas or talk
about things that really matter?
Very well
Was this child born in the United States?
Somewhat well
Yes ➔ SKIP to question H3
Not very well
No
Not well at all
H2
If no, how long has this child been living in the United
States?
Years AND
H3
H8
Months
How well do you think you are handling the day-to-day
demands of raising children?
Very well
How many times has this child moved to a new address
since he or she was born?
Somewhat well
Not very well
Number of times
Not at all
H4
How often does this child go to bed at about the same
time on weeknights?
H9
Never
Always
Sometimes
b. That this child
does things
that really
bother you
a lot?
Rarely
Never
DURING THE PAST WEEK, how many hours of sleep
did this child get on most weeknights?
Less than 6 hours
Rarely Sometimes Usually Always
a. That this child
is much harder
to care for than
most children
his or her age?
Usually
H5
DURING THE PAST MONTH, how often have you felt...
c. Angry with
this child?
H10 DURING THE PAST 12 MONTHS, was there someone
that you could turn to for day-to-day emotional support
with parenting or raising children?
6 hours
7 hours
Yes
8 hours
No ➔ SKIP to question I1 on page 15
9 hours
10 hours
H11 If yes, did you receive emotional support from...
Yes
a. Spouse or domestic partner?
11 or more hours
b. Other family member or close friend?
H6
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.
c. Health care provider?
d. Place of worship or religious leader?
Less than 1 hour
e. Support or advocacy group related
to specific health condition?
1 hour
f. Peer support group?
2 hours
g. Counselor or other mental health
professional?
3 hours
h. Other person, specify:
C
4 or more hours
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No
26028068
I. About Your Family and
Household
I1
I6
All of
the time
DURING THE PAST WEEK, on how many days did all the
family members who live in the household eat a meal
together?
Some of
the time
None of
the time
b. Work together to
solve our problems
1-3 days
c. Know we have
strengths to draw on
4-6 days
d. Stay hopeful even
in difficult times
Every day
Most of
the time
a. Talk together
about what to do
0 days
I2
When your family faces problems, how often are you
likely to do each of the following?
I7
Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?
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
Yes
Rarely
No ➔ SKIP to question I4
I3
Somewhat often
If yes, does anyone smoke inside your home?
Yes
Very often
I8
No
I4
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.
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.
We could always afford enough to eat but not always
the kinds of food we should eat.
More than once a week
Sometimes we could not afford enough to eat.
Once a week
Often we could not afford enough to eat.
Once a month
I9
At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive:
Once every 2-5 months
I5
Yes
Once every 6 months
a. Cash assistance from a government
welfare program?
Once during the past 12 months
b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?
Never
c. Benefits from the Woman, Infants,
and Children (WIC) Program?
Don’t know
d. Free or reduced-cost breakfasts or
lunches at school?
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
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26028050
I10 In your neighborhood, is/are there...
Yes
No
I13 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.
a. Sidewalks or walking paths?
b. A park or playground?
To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated
c. A recreation center, community
center, or boys’ and girls’ club?
d. A library or bookmobile?
b. Parent or guardian died
e. Litter or garbage on the street
or sidewalk?
c. Parent or guardian served time in jail
f. Poorly kept or rundown housing?
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home
g. Vandalism such as broken
windows or graffiti?
e. Was a victim of violence or
witnessed violence in his or her
neighborhood
I11 To what extent do you agree with these statements
about your neighborhood or community?
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree
f. Lived with anyone who was mentally
ill, suicidal, or severely depressed
a. People in this
neighborhood
help each other
out
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
b. We watch out for
each other’s
children in this
neighborhood
c. This child is
safe in our
neighborhood
d. When we
encounter
difficulties, we
know where to
go for help in
our community
e. This child is safe
at school
I12 Other than you or other adults in your home, is there at
least one other adult in this child’s school, neighborhood,
or community who knows this child well and who he or
she can rely on for advice or guidance?
Yes
No
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26028043
J. Child’s Caregivers
J6
➜ Complete the questions for up to two adults in the
What is the highest grade or level of school you have
completed? Mark (X) ONE box.
8th grade or less
household who are this child’s primary caregivers.
If there is just one adult primary caregiver, provide
answers for that adult.
9th-12th grade; No diploma
High School Graduate or GED Completed
J1
J2
J3
How are you related to this child?
Biological or Adoptive Parent
Completed a vocational, trade, or business school
program
Step-parent
Some College Credit, but no Degree
Grandparent
Associate Degree (AA, AS)
Foster Parent
Bachelor’s Degree (BA, BS, AB)
Other: Relative
Master’s Degree (MA, MS, MSW, MBA)
Other: Non-Relative
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
What is your sex?
J7
What is your marital status?
Male
Married
Female
Not married, but living with a partner
Never Married
What is your age?
Divorced
Age in years
Separated
J4
Where were you born?
Widowed
In the United States ➔ SKIP to question J6
J8
In general, how is your physical health?
Outside of the United States
Excellent
J5
When did you come to live in the United States?
Very Good
Year
Good
Fair
Poor
J9
In general, how is your mental or emotional health?
Excellent
Very Good
Good
Fair
Poor
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26028035
J10 Were you employed at least 50 out of the past
J17 When did this primary caregiver come to live in the
52 weeks?
United States?
Year
Yes
No
J11 Have you ever served on active duty in the
J18 What is the highest grade or level of school this primary
caregiver has completed? Mark (X) ONE box.
U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
8th grade or less
Never served in the military ➔ SKIP to question J13
9th-12th grade; No diploma
Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question J13
High School Graduate or GED Completed
Now on active duty
Completed a vocational, trade, or business school
program
On active duty in the past, but not now
Some College Credit, but no Degree
J12 Were you deployed at any time during this child’s life?
Associate Degree (AA, AS)
Yes
Bachelor’s Degree (BA, BS, AB)
No
Master’s Degree (MA, MS, MSW, MBA)
Questions J13 - J24 ask about another adult primary
caregiver who may be in the household in addition to
yourself.
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
J13 How is this adult primary caregiver in the household
related to this child?
J19 What is this primary caregiver’s marital status?
There is only one primary adult caregiver in the
household for this child ➔ SKIP to question K1 on
page 19
Married
Not married, but living with a partner
Biological or Adoptive Parent
Never Married
Step-parent
Divorced
Grandparent
Separated
Foster Parent
Widowed
Other: Relative
Other: Non-Relative
J20 In general, how is this primary caregiver’s physical
health?
Excellent
J14 What is this primary caregiver’s sex?
Male
Very Good
Female
Good
Fair
J15 What is this primary caregiver’s age?
Poor
Age in years
J16 Where was this primary caregiver born?
In the United States ➔ SKIP to question J18
Outside of the United States
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26028027
J21 In general, how is this primary caregiver’s mental or
K3
emotional health?
Excellent
Very Good
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.
Good
Yes ➔
Fair
$
,
.00
TOTAL AMOUNT
in the last calendar year
No
Poor
,
b. Self-employment income from own nonfarm
businesses or farm business, including
proprietorships and partnerships.
J22 Was this primary caregiver employed at least 50 out of
the past 52 weeks?
Yes
Yes ➔
No
No
$
,
,
.00
Loss
TOTAL AMOUNT
in the last calendar year
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
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.
Yes ➔
Never served in the military ➔ SKIP to question K1
$
,
.00
Loss
TOTAL AMOUNT
in the last calendar year
No
Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question K1
,
d. Social security or railroad retirement; retirement,
survivor, or disability pensions.
Now on active duty
Yes ➔
On active duty in the past, but not now
$
Yes ➔
No
K2
$
,
,
.00
TOTAL AMOUNT
in the last calendar year
No
K. Household Information
f. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support, or alimony.
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.
Number of people
.00
e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office.
Yes
K1
,
TOTAL AMOUNT
in the last calendar year
No
J24 Was this primary caregiver deployed at any time during
this child’s life?
,
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.
Number of people
,
.00
TOTAL AMOUNT
in the last calendar year
No
K4
,
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
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26028019
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 | 2018-02-08 |