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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
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.
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)
We now have some follow-up questions to ask about:
b. Eating or swallowing because of
a health condition
c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea
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. Repeated or chronic physical pain,
including headaches or other back
or body pain
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.
e. Using their hands
f. Coordination or moving around
The survey should be completed by a parent or adult
caregiver who lives in this household and who is
familiar with this child’s health and health care.
g. Toothaches
h. Bleeding gums
Your participation is important. Thank you.
i.
A4
Decayed teeth or cavities
Does this child have any of the following?
a. Deafness or problems with hearing
A. This Child’s Health
b. Blindness or problems with seeing,
even when wearing glasses
A1 In general, how would you describe this child’s health
(the one named above)?
Has a doctor or other health care provider EVER told
you that this child has...
Excellent
Very good
A5
Allergies (including food, drug, insect, or other)?
Good
Yes
No
Fair
If yes, does this child CURRENTLY have the
condition?
Yes
Poor
No
If yes, is it:
A2 How would you describe the condition of this child’s
Mild
teeth?
This child does not have any teeth
Moderate
Severe
A6 Arthritis?
Excellent
Yes
No
Very good
If yes, does this child CURRENTLY have the
condition?
Yes
Good
No
If yes, is it:
Fair
Mild
Moderate
Severe
Poor
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Has a doctor or other health care provider EVER told
you that this child has...
A7 Asthma?
Has a doctor or other health care provider EVER told
you that this child has...
A13 Tourette Syndrome?
Yes
Yes
No
If yes, does this child CURRENTLY have the
condition?
Yes
If yes, does this child CURRENTLY have the
condition?
No
Yes
If yes, is it:
No
If yes, is it:
Mild
Moderate
Severe
Mild
Moderate
Severe
A14 Anxiety Problems?
A8 Cerebral Palsy?
Yes
No
Yes
No
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
Moderate
Severe
A15 Depression?
A9 Diabetes?
Yes
Yes
No
If yes, does this child CURRENTLY have the
condition?
Yes
Yes
No
Mild
Moderate
Mild
Severe
Moderate
Severe
A16 Down Syndrome?
A10 Epilepsy or Seizure Disorder?
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, is it:
If yes, is it:
Yes
No
If yes, does this child CURRENTLY have the
condition?
No
If yes, is it:
Mild
No
Moderate
Severe
If yes, is it:
A17 Blood Disorders (such as Sickle Cell Disease,
Mild
Moderate
Thalassemia, or Hemophilia)?
Severe
A11 Heart Condition?
Yes
Yes
No
If yes, is it:
If yes, was this child born with the condition?
Yes
Mild
No
Mild
Moderate
Severe
Yes
A12 Frequent or severe headaches, including migraine?
If yes, does this child CURRENTLY have the
condition?
No
If yes, is it:
Mild
Severe
No
If yes, was this child diagnosed with:
No
Yes
Moderate
Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
If yes, is it:
Yes
No
Moderate
Severe
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Sickle Cell Disease?
Yes
No
Thalassemia?
Yes
No
Hemophilia?
Yes
No
Other Blood Disorders?
Yes
No
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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.
A18 Cystic Fibrosis?
A22 Intellectual Disability (formerly known as Mental
Yes
Retardation)?
No
If yes, is it:
Yes
Mild
Moderate
No
If yes, does this child CURRENTLY have the
disability?
Severe
Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Yes
No
If yes, is it:
Yes
No
Mild
A19 Other genetic or inherited condition?
Yes
Moderate
Severe
A23 Speech or other language disorder?
No
Yes
If yes, specify: C
No
If yes, does this child CURRENTLY have the
condition?
Yes
Is it:
No
If yes, is it:
Mild
Moderate
Severe
Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Yes
Mild
No
Yes
No
If yes, does this child CURRENTLY have the
disability?
Yes
No
If yes, is it:
A20 Behavioral or Conduct Problems?
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).
If yes, is it:
No ➔ SKIP to question A30 on page 5
Yes
Moderate
Moderate
A25 Has a doctor or other health care provider EVER told
No
Mild
Severe
A24 Learning Disability?
Has a doctor, other health care provider, or educator
EVER told you that this child has...
Examples of educators are teachers and school nurses.
Yes
Moderate
Severe
If yes, does this child CURRENTLY have the
condition?
A21 Developmental Delay?
Yes
Yes
No
If yes, is it:
If yes, does this child CURRENTLY have the
condition?
Yes
No
Mild
Moderate
Severe
A26 How old was this child when a doctor or other health
care provider FIRST told you that they had Autism, ASD,
Asperger’s Disorder or PDD?
If yes, is it:
Mild
No
Moderate
Severe
Age in years
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A27 What type of doctor or other health care provider was
A33 Do you think this child has EVER had a concussion or
the FIRST to tell you that this child had Autism, ASD,
Asperger’s Disorder or PDD? Mark (X) ONE box.
brain injury? A concussion or brain injury is when a blow
or jolt to the head causes problems such as headaches,
dizziness, being dazed or confused, difficulty remembering
or concentrating, vomiting, blurred vision, changes in mood
or behavior, or being knocked out.
Primary Care Provider
Specialist
No ➔ SKIP to question A34
Yes
School Psychologist/Counselor
If yes, did you seek medical care from a doctor or
other health care provider?
Other Psychologist (Non-School)
No ➔ SKIP to question A34
Yes
Psychiatrist
Other, specify:
If yes, did a doctor or other health care
provider tell you that your child had a
concussion or brain injury?
C
Yes
Don’t know
A34 DURING THE PAST 12 MONTHS, how often have this
child’s health conditions or problems affected their
ability to do things other children their age do?
A28 Is this child CURRENTLY taking medication for Autism,
ASD, Asperger’s Disorder or PDD?
Yes
No
This child does not have any
health conditions ➔ SKIP to question B1 on page 6
No
Never
A29 At any time DURING THE PAST 12 MONTHS, did this
Sometimes
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 their behavior?
Usually
Always
Yes
No
A30 Has a doctor or other health care provider EVER told
A35 To what extent do this child’s health conditions or
problems affect their ability to do things?
you that this child has Attention Deficit Disorder or
Attention Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?
Very little
Somewhat
No ➔ SKIP to question A33
Yes
A great deal
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, is it:
Mild
Moderate
Severe
A31 Is this child CURRENTLY taking medication for ADD or
ADHD?
Yes
No
A32 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 their behavior?
Yes
No
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B. This Child as an Infant
B1
B7
Was this child born more than 3 weeks before their
due date?
How old was this child when they were FIRST fed formula?
Check this box if child has never been fed formula
OR
Yes
At birth
No
B2
OR
What month and year was this child born?
days
Birth Month / 4-Digit Birth Year
OR
/
2 0
weeks
B3
How much did they weigh when born? Answer in pounds
and ounces OR kilograms and grams. Your best estimate
is fine.
OR
months
pounds AND
ounces
B8
OR
kilograms AND
B4
grams
How old was this child when they were 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
What was the age of the mother when this child was
born? Your best estimate is fine.
At birth
Age in years
B5
OR
Was this child EVER breastfed or fed breast milk?
days
Yes
OR
No ➔ SKIP to question B7
B6
weeks
If yes, how old was this child when they COMPLETELY
stopped breastfeeding or being fed breast milk?
OR
months
days
OR
weeks
OR
months
OR
Check this box if child is still breastfeeding
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C. Health Care Services
C7
DURING THE PAST 12 MONTHS, did a doctor or other
health care provider have you or another caregiver fill
out a questionnaire about observations or concerns 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.
C1 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?
Yes
No ➔ SKIP to question C4
C2
Answer the following question only if this child is at
least 9 months old. Otherwise skip to question C8 .
Yes
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.
No
If yes, and this child is 9-23 Months:
Did the questionnaire ask about your concerns
or observations about: Mark (X) ALL that apply.
How this child talks or makes speech sounds?
How this child interacts with you and others?
0 visits
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?
1 visit
2 or more visits
C3
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.
How this child behaves and gets along with
you and others?
C8
Less than 10 minutes
Is there a place you or another caregiver USUALLY
take this child when they are sick or you need advice
about their health?
Yes
10-20 minutes
No ➔ SKIP to question C10 on page 8
More than 20 minutes
C9
C4 Are you concerned about this child’s weight?
If yes, where does this child USUALLY go first?
Mark (X) ONE box.
Yes, it’s too high
Doctor’s Office
Yes, it’s too low
Hospital Emergency Room
No, I am not concerned
Hospital Outpatient Department
Clinic or Health Center
C5
C6
Has a doctor or other health care provider ever told you
that this child is overweight?
Retail Store Clinic or “Minute Clinic”
Yes
School (Nurse’s Office, Athletic Trainer’s Office)
No
Some other place
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
No
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C10 Is there a place that this child USUALLY goes when
C16 If yes, DURING THE PAST 12 MONTHS, what
PREVENTIVE dental service(s) did this child receive?
Mark (X) ALL that apply.
they need routine preventive care, such as a physical
examination or well-child check-up?
Yes
Check-up
No ➔ SKIP to question C12
Cleaning
Instruction on tooth brushing and oral health care
C11 If yes, is this the same place this child goes when they
are sick?
X-Rays
Yes
Fluoride treatment
No
Sealant (plastic coatings on back teeth)
C12 DURING THE PAST 12 MONTHS, has this child had
their vision tested, such as with pictures, shapes, or
letters?
Don’t know
C17 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 C14
C13 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 C19
Clinic or health center
C18 How difficult was it to get the mental health treatment
or counseling that this child needed?
School
Not difficult
Other, specify:
C
Somewhat difficult
Very difficult
C14 DURING THE PAST 12 MONTHS, did this child see a
It was not possible to obtain care
dentist or other health care provider for any kind of
dental or oral health care?
C19 DURING THE PAST 12 MONTHS, has this child taken
any medication because of difficulties with their
emotions, concentration, or behavior?
Yes, saw a dentist or other oral health care provider
Yes, saw another kind of health care provider
Yes
No ➔ SKIP to question C17
C15 If yes, DURING THE PAST 12 MONTHS, did this
child see a dentist or other health care provider for
PREVENTIVE dental care, such as check-ups, dental
cleanings, dental sealants, or fluoride treatments?
No
C20 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 C17
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 C22 on page 9
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C21 How difficult was it to get the specialist care that this
C26 DURING THE PAST 12 MONTHS, how often were you
child needed?
frustrated in your efforts to get services for this child?
Not difficult
Never
Somewhat difficult
Sometimes
Very difficult
Usually
It was not possible to obtain care
Always
C22 DURING THE PAST 12 MONTHS, did this child use any
C27 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
C28 DURING THE PAST 12 MONTHS, was this child
admitted to the hospital to stay for at least one night?
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
C29 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 C26
C24 If yes, which types of care were not received?
Yes
Mark (X) ALL that apply.
No ➔ SKIP to question C32
Medical Care
Dental Care
C30 If yes, how old was this child at the time of the FIRST
plan?
Vision Care
Years AND
Hearing Care
C31 Is this child CURRENTLY receiving services under one
Mental Health Services
Other, specify:
Months
of these plans?
Yes
C
No
C25 Did any of the following reasons contribute to this child C32 Has this child EVER received special services to
meet their 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
C33 If yes, how old was this child when they 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
C34 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 their
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?
Yes
Not difficult
No
Somewhat difficult
Did not see more than one health
care provider in the PAST 12
MONTHS ➔ SKIP to question D11 on page 11
Very difficult
D8
It was not possible to get a referral
D4 Answer the following questions only if this child had a
health care visit IN THE PAST 12 MONTHS. Otherwise
skip to question E1 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 between 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 their 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 them
to see the health care providers they need?
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 at home
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
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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26010124
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 they have 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 themselves?
G10 How often can this child write their first name, even if
No
some of the letters aren’t quite right or are backwards?
Yes, somewhat concerned
Always
Yes, very concerned
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 they are 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 they
Sometimes
follow instructions to complete a simple task?
Always
Most of the time
Never
G22 How often does this child lose control of their temper
when things do not go their 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 their fist
This child cannot hold a pencil
G23 Compared to other children their age, how much
difficulty does this child have making or keeping
friends?
G18 How often does this child play well with others?
No difficulty
Always
A little difficulty
Most of the time
A lot of difficulty
About half the time
Sometimes
Never
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G24 Compared to other children their age, how often is
H5
this child able to sit still?
DURING THE PAST WEEK, how many hours of sleep
did this child get during an average day (count both
nighttime sleep and naps)?
Always
Less than 7 hours
Most of the time
7 hours
About half the time
8 hours
Sometimes
9 hours
Never
10 hours
G25 How often...
Always
Usually Sometimes
Never
11 hours
a. Is this child
affectionate and
tender with you?
12 or more hours
b. Does this child
bounce back
quickly when things
do not go their way?
H6
c. Does this child
show interest and
curiosity in learning
new things?
On their side
On their back
d. Does this child
smile and laugh?
On their stomach
H. About You and This
Child
H7 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.
H1 Was this child born in the United States?
Yes ➔ SKIP to question
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.
Less than 1 hour
H3
1 hour
No
2 hours
H2 If no, how long has this child been living in the
3 hours
United States?
Years AND
4 or more hours
Months
H3 How many times has this child moved to a new address
H8 DURING THE PAST WEEK, how many days did you or
other family members read to this child?
since they were born?
0 days
Number of times
1-3 days
H4 How often does this child go to bed at about the same
4-6 days
time on weeknights?
Every day
Always
Usually
Sometimes
Rarely
Never
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H9 DURING THE PAST WEEK, how many days did you or
H14 Does this child receive care for at least 10 hours per
week from someone other than their parent or guardian?
This could be a day care center, preschool, Head Start
program, family child care home, nanny, au pair, babysitter
or relative.
other family members tell stories or sing songs to this
child?
0 days
1-3 days
Yes
4-6 days
No
H15 DURING THE PAST 12 MONTHS, did you or anyone in
Every day
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?
H10 How well do you think you are handling the day-to-day
demands of raising children?
Yes
Very well
No
Somewhat well
I. About Your Family and
Household
Not very well
Not well at all
H11 DURING THE PAST MONTH, how often have you felt...
Never
I1
Rarely Sometimes Usually Always
a. That this child
is much harder
to care for than
most children
their age?
b. That this child
does things
that really
bother you a
lot?
c. Angry with
this child?
DURING THE PAST WEEK, on how many days did all
the family members who live in the household eat a
meal together?
0 days
1-3 days
4-6 days
Every day
I2
Yes
H12 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
No ➔ SKIP to question I4
I3
If yes, does anyone smoke inside your home?
Yes
No ➔ SKIP to question H14
H13 If yes, did you receive emotional support from...
Yes
Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?
No
No
I4
a. Spouse or domestic partner?
b. Other family member or close friend?
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.
More than once a week
c. Health care provider?
Once a week
d. Place of worship or religious leader?
Once a month
e. Support or advocacy group related
to specific health condition?
Once every 2-5 months
f. Peer support group?
Once every 6 months
g. Counselor or other mental health
professional?
Once during the past 12 months
h. Other person, specify:
Never
C
Don’t know
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I5
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?
I9
In your neighborhood, is/are there...
Yes
No
a. Sidewalks or walking paths?
Yes
b. A park or playground?
No
c. A recreation center, community
center, or boys’ and girls’ club?
d. A library or bookmobile?
I6
SINCE THIS CHILD WAS BORN, how often has it been
very hard to cover the basics, like food or housing,
on your family’s income?
e. Litter or garbage on the street
or sidewalk?
f. Poorly kept or rundown housing?
Never
g. Vandalism such as broken
windows or graffiti?
Rarely
Somewhat often
I10
Very often
To what extent do you agree with these statements
about your neighborhood or community?
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree
I7
Which of these statements best describes your
household’s ability to afford the food you need
DURING THE PAST 12 MONTHS?
a. People in this
neighborhood
help each other
out
We could always afford to eat good nutritious meals.
b. We watch out for
each other’s
children in this
neighborhood
We could always afford enough to eat but not always
the kinds of food we should eat.
c. This child is
safe in our
neighborhood
Sometimes we could not afford enough to eat.
Often we could not afford enough to eat.
I8
d. When we
encounter
difficulties, we
know where to
go for help in
our community
At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive...
Yes
No
a. Cash assistance from a government
welfare program?
b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?
c. Free or reduced-cost breakfasts or
lunches at school?
d. Benefits from the Woman, Infants,
and Children (WIC) Program?
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I11 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.
J. Child’s Caregivers
➜ Complete the questions for UP TO TWO ADULTS
in the household who are this child’s primary
caregivers.
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. Parent or guardian died
CAREGIVER 1 (You)
J1
How are you related to this child?
c. Parent or guardian served time in jail
Biological or Adoptive Parent
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home
Step-parent
Grandparent
e. Was a victim of violence or
witnessed violence in their
neighborhood
Foster Parent
f. Lived with anyone who was mentally
ill, suicidal, or severely depressed
Other: Relative
g. Lived with anyone who had a problem
with alcohol or drugs
Other: Non-Relative
h. Treated or judged unfairly because
of their race or ethnic group
J2
What is your sex?
Male
I12 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
Female
None of
the time
a. Talk together
about what to do
b. Work together to
solve our problems
J3
c. Know we have
strengths to draw on
d. Stay hopeful
even in difficult
times
What is your age?
Age in years
J4
Where were you born?
In the United States ➔ SKIP to question J6 on page 19
Outside of the United States
J5
When did you come to live in the United States?
Indicate the 4-digit year in which you came to live in the
United States.
4-Digit Year
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J6
What is the highest grade or level of school you have
completed? Mark (X) ONE box.
J10 Were you employed at least 50 out of the past 52 weeks?
Yes
8th grade or less
No
9th-12th grade; No diploma
High School Graduate or GED Completed
J11 Have you ever served on active duty in the
U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
Completed a vocational, trade, or business school
program
Never served in the
military ➔ SKIP to question J13
Some College Credit, but no Degree
Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question J13
Associate Degree (AA, AS)
Now on active duty
Bachelor’s Degree (BA, BS, AB)
On active duty in the past, but not now
Master’s Degree (MA, MS, MSW, MBA)
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
J12 Were you deployed at any time during this child’s life?
Yes
J7
What is your marital status?
No
Married
Not married, but living with a partner
J13 Does this child have another primary adult caregiver
who lives in this household?
Never Married
Yes - Complete Questions J14 - J25
Divorced
No - SKIP to Question K1 on page 20
Separated
Widowed
J8
J9
CAREGIVER 2
J14 How is Caregiver 2 related to this child?
In general, how is your physical health?
Biological or Adoptive Parent
Excellent
Step-parent
Very good
Grandparent
Good
Foster Parent
Fair
Other: Relative
Poor
Other: Non-Relative
In general, how is your mental or emotional health?
J15 What is Caregiver 2’s sex?
Excellent
Male
Very good
Female
Good
J16 What is Caregiver 2’s age?
Fair
Age in years
Poor
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J17 Where was Caregiver 2 born?
J22 In general, how is Caregiver 2’s mental or emotional
health?
In the United States ➔ SKIP to question J19
Excellent
Outside of the United States
Very good
J18 When did Caregiver 2 come to live in the United States?
Good
Indicate the 4-digit year in which Caregiver 2 came to live
in the United States.
Fair
Poor
4-Digit Year
J19 What is the highest grade or level of school Caregiver 2 J23 Was Caregiver 2 employed at least 50 out of the past 52
weeks?
has completed? Mark (X) ONE box.
8th grade or less
Yes
9th-12th grade; No diploma
No
High School Graduate or GED Completed
J24 Has Caregiver 2 ever served on active duty in the U.S.
Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
Never served in the
military ➔ SKIP to question K1
Completed a vocational, trade, or business school
program
Some College Credit, but no Degree
Associate Degree (AA, AS)
Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question K1
Bachelor’s Degree (BA, BS, AB)
Now on active duty
Master’s Degree (MA, MS, MSW, MBA)
On active duty in the past, but not now
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
J25 Was Caregiver 2 deployed at any time during this child’s
life?
Yes
J20 What is Caregiver 2’s marital status?
Married
No
Not married, but living with a partner
Never Married
Divorced
K. Household Information
K1
K4
Separated
Widowed
J21 In general, how is Caregiver 2’s physical health?
Excellent
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
K2
Very good
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.
Good
Number of people
Fair
Poor
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26010041
K3 Income in 2019
K4
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 ➔
$
,
,
.00
$
TOTAL AMOUNT
in the last calendar year
No
$
,
,
.00
,
.00
,
TOTAL AMOUNT
in the last calendar year
b. Self-employment income from own nonfarm
businesses or farm business, including
proprietorships and partnerships.
Yes ➔
The following question is about your 2019 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.
Loss
TOTAL AMOUNT
in the last calendar year
No
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Yes ➔
$
,
,
.00
Loss
TOTAL AMOUNT
in the last calendar year
No
d. Social security or railroad retirement; retirement,
survivor, or disability pensions.
Yes ➔
$
,
,
.00
TOTAL AMOUNT
in the last calendar year
No
e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office.
Yes ➔
$
,
,
.00
TOTAL AMOUNT
in the last calendar year
No
f. Any other sources of income received such as
Veterans’ (VA) payments, unemployment
compensation, child support, alimony, gifts, prize
winnings, etc.
Yes ➔
No
$
,
,
.00
TOTAL AMOUNT
in the last calendar year
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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.
We estimate that completing the National Survey of Children’s Health will take 33 minutes on average. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to U.S. Department of Commerce, 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. This collection has been approved by the Office of Management and Budget (OMB).
The eight-digit OMB approval number that appears at the upper left of the form confirms this approval. If this number
were not displayed, we could not conduct this survey.
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| File Type | application/pdf |
| File Modified | 2019-09-23 |
| File Created | 2019-09-23 |