3 Cognitive Interview Version 2

Generic Clearance for Questionnaire Pretesting Research

nscht2_20_092319

NSCH Questionnaire Cognitive Interviews

OMB: 0607-0725

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0607-0725 can be found here:

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26020206

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

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

NSCH-T2
(09/23/2019) Draft 8

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26020198

Start Here

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

Yes

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. Toothaches
f. Bleeding gums

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.
Your participation is important. Thank you.

g. Decayed teeth or cavities
A4

Does this child have any of the following?
a. Serious difficulty concentrating,
remembering, or making decisions
because of a physical, mental, or
emotional condition

A. This Child’s Health

b. Serious difficulty walking or climbing
stairs
c. Difficulty dressing or bathing

A1 In general, how would you describe this child’s health

(the one named above)?

d. Deafness or problems with hearing

Excellent

e. Blindness or problems with seeing,
even when wearing glasses

Very good

Has a doctor or other health care provider EVER told
you that this child has...

Good
Fair

Poor

Allergies (including food, drug, insect, or other)?
Yes

If yes, does this child CURRENTLY have the
condition?

A2 How would you describe the condition of this child’s

teeth?

Yes

Mild

Very good
Good

If yes, is it:

Excellent

Severe

Arthritis?
Yes

Fair

Moderate

If yes, does this child CURRENTLY have the
condition?

Poor

Yes

If yes, is it:
Mild

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Moderate

Severe

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26020180

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...
A12 Frequent or severe headaches, including migraine?

Yes

If yes, does this child CURRENTLY have the
condition?
Yes

If yes, is it:

If yes, is it:
Mild

Moderate

Severe

Mild

Moderate

Severe

A13 Tourette Syndrome?

A8 Cerebral Palsy?

Yes

If yes, does this child CURRENTLY have the
condition?
Yes

If yes, is it:

If yes, is it:
Mild

Moderate

Mild

Severe

Moderate

Severe

A14 Anxiety Problems?

A9 Diabetes?

Yes

If yes, does this child CURRENTLY have the
condition?
Yes

Mild

Moderate

Mild

Severe

Yes

Severe

If yes, does this child CURRENTLY have the
condition?

Yes

If yes, is it:

If yes, is it:
Mild

Moderate

Mild

Severe

A11 Heart Condition?

Yes

Moderate

A15 Depression?

A10 Epilepsy or Seizure Disorder?

Yes

If yes, is it:

Yes

Moderate

Severe

A16 Down Syndrome?

Yes

If yes, was this child born with the condition?
Yes

If yes, is it:

Mild

Moderate

Severe

If yes, is it:
Mild

Moderate

Severe

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26029173

Has a doctor or other health care provider EVER told
you that this child has...
A17 Blood Disorders (such as Sickle Cell Disease,

A21 Behavioral or Conduct Problems?

Thalassemia, or Hemophilia)?
Yes

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

If yes, does this child CURRENTLY have the
condition?

If yes, is it:
Mild

Moderate

Severe
Yes

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Yes

If yes, is it:
Mild

If yes, was this child diagnosed with:

Moderate

Severe

A22 Developmental Delay?

Sickle Cell Disease?

Yes

Thalassemia?

Yes

If yes, does this child CURRENTLY have the
condition?

Hemophilia?

Yes

Other Blood
Disorders?

Yes

If yes, is it:
Mild

A18 Cystic Fibrosis?

Yes

Moderate

Severe

A23 Intellectual Disability (formerly known as Mental

Retardation)?

If yes, is it:
Mild

Moderate

Yes

Severe

Yes

If yes, does this child CURRENTLY have the
disability?

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.

Yes

If yes, is it:
Mild

A19 Other genetic or inherited condition?

Yes

Moderate

Severe

A24 Speech or other language disorder?

If yes, specify: C

Yes

Is it:

If yes, does this child CURRENTLY have the
condition?
Mild

Moderate

Yes

Severe

Mild

Yes

If yes, does this child CURRENTLY have the
disorder?

Yes

If yes, is it:

If yes, is it:
Mild

Severe

If yes, does this child CURRENTLY have the
disability?

Yes

Moderate

A25 Learning Disability?

A20 Substance Use Disorder?

Yes

If yes, is it:

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Yes

Mild
Moderate

Moderate

Severe

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26020164

A26 Has a doctor or other health care provider EVER told

A31 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).

you that this child has Attention Deficit Disorder or
Attention Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?

No ➔ SKIP to question A31

Yes

If yes, does this child CURRENTLY have the
condition?
Yes

Moderate

Mild

Severe

A27 How old was this child when a doctor or other health

Don’t know

Severe

ADHD?
Yes

A33 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?

A28 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.
Primary Care Provider

Moderate

A32 Is this child CURRENTLY taking medication for ADD or

care provider FIRST told you that they had Autism,
ASD, Asperger’s Disorder or PDD?
Age in years

If yes, is it:

If yes, is it:
Mild

No ➔ SKIP to question A34

Yes

A34 Do you think this child has EVER had a concussion or

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.

Specialist
School Psychologist/Counselor

No ➔ SKIP to question A35

Other Psychologist (Non-School)

Yes

Psychiatrist

If yes, did you seek medical care from a doctor or
other health care provider?

Other, specify: C

No ➔ SKIP to question A35

Yes

If yes, did a doctor or other health care
provider tell you that your child had a
concussion or brain injury?

Don’t know

Yes
A29 Is this child CURRENTLY taking medication for Autism,

A35 DURING THE PAST 12 MONTHS, how often have this

ASD, Asperger’s Disorder or PDD?
Yes

child’s health conditions or problems affected their
ability to do things other children their age do?

This child does not have any
health conditions ➔ SKIP to question B1 on page 6

A30 At any time DURING THE PAST 12 MONTHS, did this

Never

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?

Sometimes
Usually

Yes

No
Always
A36 To what extent do this child’s health conditions or

problems affect their ability to do things?
Very little
Somewhat
A great deal

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26020156

B. This Child as an Infant
B1

Was this child born more than 3 weeks before their
due date?

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

Yes

10-20 minutes

No
B2

More than 20 minutes

What month and year was this child born?

Birth Month / 4-Digit Birth Year

What is this child’s CURRENT height?
Your best estimate is fine.

2 0

feet AND

inches

OR
B3

How much did they weigh when born? Answer in pounds
and ounces OR kilograms and grams. Your best estimate is
fine.
pounds AND

ounces

meters AND
C5

centimeters

How much does this child CURRENTLY weigh?
Your best estimate is fine.

OR
pounds
kilograms AND
B4

grams

What was the age of the mother when this child was
born? Your best estimate is fine.
Age in years

kilograms
C6

Are you concerned about this child’s weight?
Yes, it’s too high

C. Health Care Services

Yes, it’s too low
No, I am not concerned

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?

Has a doctor or other health care provider ever told
you that this child is overweight?

Yes

No ➔ SKIP to question C4

C2 If yes, DURING THE PAST 12 MONTHS, how many times C8

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.

Is there a place you or another caregiver USUALLY
take this child when they are sick or you need advice
about their health?
Yes
No ➔ SKIP to question C10 on page 7

0 visits
1 visit
2 or more visits

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26020149

If yes, where does this child USUALLY go first?
Mark (X) ONE box.

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?

Doctor’s Office
Hospital Emergency Room

No preventive visits in the past
12 months ➔ SKIP to question C17

Hospital Outpatient Department

Yes, 1 visit

Clinic or Health Center

Yes, 2 or more visits

Retail Store Clinic or “Minute Clinic”

C16 If yes, DURING THE PAST 12 MONTHS, what

PREVENTIVE dental service(s) did this child receive?
Mark (X) ALL that apply.

School (Nurse’s Office, Athletic Trainer’s Office)
Some other place

Check-up

C10 Is there a place that this child USUALLY goes when

Cleaning

they need routine preventive care, such as a physical
examination or well-child check-up?

Instruction on tooth brushing and oral health care

Yes

X-Rays

No ➔ SKIP to question C12

Fluoride treatment

C11 If yes, is this the same place this child goes when they

Sealant (plastic coatings on back teeth)

are sick?

Don’t know

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.

C12 DURING THE PAST 12 MONTHS, has this child had

their vision tested, such as with pictures, shapes, or
letters?

Yes

No, but this child needed to see a mental health
professional

No ➔ SKIP to question C14

No, this child did not need to see a
mental health professional ➔ SKIP to question C19

C13 If yes, where was this child’s vision tested?

Mark (X) ALL that apply.
Eye doctor or eye specialist (ophthalmologist,
optometrist) office

C18 How difficult was it to get the mental health treatment

or counseling that this child needed?

Pediatrician or other general doctor’s office

Not difficult

Clinic or health center

Somewhat difficult

School

Very difficult

Other, specify:

It was not possible to obtain care
C19 DURING THE PAST 12 MONTHS, has this child taken

any medication because of difficulties with their
emotions, concentration, or behavior?

C14 DURING THE PAST 12 MONTHS, did this child see a

dentist or other health care provider for any kind of
dental or oral health care?

Yes

Yes, saw a dentist or other oral health care provider

Yes, saw another kind of health care provider
No ➔ SKIP to question C17
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26020131

C20 DURING THE PAST 12 MONTHS, did this child see a

C25 Did any of the following reasons contribute to this child

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.

not receiving needed health services? Mark (X) Yes or No
for each item.
Yes

Yes

b. The services this child needed were
not available in your area

No, but this child needed to see a specialist

c. There were problems getting an
appointment when this child needed
one

No, this child did not need to
see a specialist ➔ SKIP to question C22

d. There were problems with getting
transportation or child care

C21 How difficult was it to get the specialist care that this

child needed?
Not difficult

e. The clinic or doctor’s office wasn’t
open when this child needed care

Somewhat difficult

f. There were issues related to cost

Very difficult

a. This child was not eligible for the
services

C26 DURING THE PAST 12 MONTHS, how often were you

frustrated in your efforts to get services for this child?
It was not possible to obtain care

Never

C22 DURING THE PAST 12 MONTHS, did this child use any

Sometimes

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

Usually
Always
C27 DURING THE PAST 12 MONTHS, how many times did

this child visit a hospital emergency room?

None
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

1 time
2 or more times
C28 DURING THE PAST 12 MONTHS, was this child

admitted to the hospital to stay for at least one night?

No ➔ SKIP to question C26

Yes

C24 If yes, which types of care were not received?

Mark (X) ALL that apply.
Medical Care

C29 Has this child EVER had a special education or early

intervention plan? Children receiving these services often
have an Individualized Family Service Plan (IFSP) or
Individualized Education Plan (IEP).

Dental Care
Vision Care

Yes

Hearing Care

No ➔ SKIP to question C32 on page 9

Mental Health Services

C30 If yes, how old was this child at the time of the FIRST

plan?
Other, specify: C
Years AND

Months

C31 Is this child CURRENTLY receiving services under one

of these plans?
Yes
No

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26020123

C32 Has this child EVER received special services to meet

their developmental needs such as speech, occupational,
or behavioral therapy?

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 10.
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers...

Yes
No ➔ SKIP to question D1

Always

C33 If yes, how old was this child when they began receiving

these special services?
Years AND

Usually Sometimes

Never

a. Spend enough time
with this child?
b. Listen carefully to
you?

Months

c. Show sensitivity to
your family’s values
and customs?

C34 Is this child CURRENTLY receiving these special

services?

d. Provide the specific
information you
needed concerning
this child?

Yes
No

D. Experience with This
Child’s Health Care
Providers

e. Help you feel like a
partner in this
child’s care?
D5

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.

DURING THE PAST 12 MONTHS, did this child need
any decisions to be made regarding their health care,
such as whether to get prescriptions, referrals, or
procedures?
Yes
No ➔ SKIP to question D7

If yes, DURING THE PAST 12 MONTHS, how often did
this child’s doctors or other health care providers...

Yes, one person

Always

Yes, more than one person
No

b. Make it easy for you
to raise concerns or
disagree with
recommendations
for this child’s health
care?

D2 DURING THE PAST 12 MONTHS, did this child need a

referral to see any doctors or receive any services?
Yes
No ➔ SKIP to question D4

c. Work with you to
decide together which
health care and
treatment choices would
be best for this child?

D3 How difficult was it to get referrals?

Not difficult
Somewhat difficult

Usually Sometimes Never

a. Discuss with you the
range of options to
consider for their health
care or treatment?

Very difficult

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?

Yes

It was not possible to get a referral

No
Did not see more than one health care provider in the
PAST 12 MONTHS ➔ SKIP to question D11 on
page 10

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26020115

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?

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

Yes

a. Change in employer or employment
status

No ➔ SKIP to question D10

b. Cancellation due to overdue
premiums

D9 If yes, DURING THE PAST 12 MONTHS, how often

c. Dropped coverage because it was
unaffordable

did you get as much help as you wanted with
arranging or coordinating this child’s health care?

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

D10 DURING THE PAST 12 MONTHS, how satisfied were

you with the communication between this child’s
doctors and other health care providers?

g. Other, specify: C

Very satisfied
Somewhat satisfied

Somewhat dissatisfied

Is this child CURRENTLY covered by ANY kind of
health insurance or health coverage plan?
Yes

Very dissatisfied
No ➔ SKIP to question F1 on page 11
D11 DURING THE PAST 12 MONTHS, did this child’s health

care provider communicate with the child’s school, child E4
care provider, or special education program?
Yes

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

a. Insurance through a current or
former employer or union

No ➔ SKIP to question E1
Did not need health care provider to communicate
with these providers ➔ SKIP to question E1

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

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

d. TRICARE or other military
health care

Somewhat satisfied

e. Indian Health Service
Somewhat dissatisfied
f. Other, specify: C
Very dissatisfied

E. This Child’s Health
Insurance Coverage
E1

How often does this child’s health insurance offer
benefits or cover services that meet this child’s needs?
Always

DURING THE PAST 12 MONTHS, was this child EVER
covered by ANY kind of health insurance or health
coverage plan?
Yes, this child was covered
all 12 months ➔ SKIP to question E4

Usually
Sometimes

Yes, but this child had a gap in coverage

Never

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26020107

How often does this child’s health insurance allow
them to see the health care providers they need?

DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?

Always
Yes
Usually
No
Sometimes
Never

DURING THE PAST 12 MONTHS, have you or other
family members...
Yes

b. Cut down on the hours you work
because of this child’s health or
health conditions?

This child does not use mental or behavioral
health services

c. Avoided changing jobs because of
concerns about maintaining health
insurance for this child?

Always
Usually
Sometimes

a. Left a job or taken a leave of
absence because of this child’s
health or health conditions?

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?

Never

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

F. Providing for This
Child’s Health

Less than 1 hour per week
1-4 hours per week

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.

5-10 hours per week
11 or more hours per week
F6

$0 (No medical or health-related
expenses) ➔ SKIP to question F4
$1-$249

IN AN AVERAGE WEEK, how many hours do you or
other family members spend arranging or coordinating
health or medical care for this child, such as making
appointments or locating services?
This child does not need health care coordinated
on a weekly basis

$250-$499

Less than 1 hour per week
$500-$999
1-4 hours per week
$1,000-$5,000
5-10 hours per week
More than $5,000
11 or more hours per week
F2

How often are these costs reasonable?
Always
Usually
Sometimes
Never

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26020099

G. This Child’s Schooling
and Activities

DURING THE PAST 12 MONTHS, did this child
participate in...
Yes

a. A sports team or did they 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
G6
G2

DURING THE PAST 12 MONTHS, how many times has
this child’s school contacted you or another adult in
your household about any problems they are 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?

Compared to other children their age, how much
difficulty does this child have making or keeping
friends?

Yes

No difficulty

A little difficulty
A lot of difficulty

G4 DURING THE PAST 12 MONTHS, how often did you

attend events or activities that this child participated in?
G8 DURING THE PAST 12 MONTHS, how often was this

Always

child bullied, picked on, or excluded by other children?
If the frequency changed throughout the year, report the
highest frequency.

Usually
Sometimes

1-2 times (in the past 12 months)

Rarely

Never (in the past 12 months)

Never

1-2 times per week
1-2 times per month
Almost every day

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26020081

G9 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.

How often does this child go to bed at about the same
time on weeknights?
Always

1-2 times (in the past 12 months)

Usually

Never (in the past 12 months)

Sometimes

1-2 times per week

Rarely

1-2 times per month

Never

Almost every day
H5
G10 How often does this child...
Always

Usually Sometimes

Never

Less than 6 hours

a. Show interest and
curiosity in learning
new things?

6 hours

b. Work to finish tasks
they start?

7 hours

c. Stay calm and in
control when faced
with a challenge?

8 hours
9 hours

d. Care about doing
well in school?

10 hours

e. Do all required
homework?

11 or more hours
H6

f. Argue too much?

H. About You and This
Child
H1

DURING THE PAST WEEK, how many hours of sleep
did this child get on most weeknights?

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

Was this child born in the United States?

1 hour

Yes ➔ SKIP to question H3

2 hours

3 hours
4 or more hours

If no, how long has this child been living in the United
States?
H7

Years AND

Months

How well can you and this child share ideas or talk
about things that really matter?
Very well

How many times has this child moved to a new address
since they were born?

Somewhat well
Not very well

Number of times

Not well at all

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I. About Your Family and
Household

How well do you think you are handling the day-to-day
demands of raising children?
Very well
I1

Somewhat well

DURING THE PAST WEEK, on how many days did all the
family members who live in the household eat a meal
together?

Not very well
0 days
Not well at all
1-3 days
H9

DURING THE PAST MONTH, how often have you felt...
Never

4-6 days

Rarely Sometimes Usually Always

a. That this child
is much harder
to care for than
most children
their age?

Every day
I2

b. That this child
does things
that really
bother you
a lot?

Yes
No ➔ SKIP to question I4

c. Angry with
this child?

that you could turn to for day-to-day emotional support
with parenting or raising children?
Yes

No
I4

No ➔ SKIP to question I1
H11 If yes, did you receive emotional support from...
Yes

If yes, does anyone smoke inside your home?
Yes

H10 DURING THE PAST 12 MONTHS, was there someone

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

Once a week

a. Spouse or domestic partner?

Once a month

b. Other family member or close friend?

Once every 2-5 months

c. Health care provider?

Once every 6 months

d. Place of worship or religious leader?

Once during the past 12 months

e. Support or advocacy group related
to specific health condition?

Never

f. Peer support group?

Don’t know

g. Counselor or other mental health
professional?
h. Other person, specify:

Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?

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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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?

In your neighborhood, is/are there...

Yes

a. Sidewalks or walking paths?

Never

b. A park or playground?

Rarely

c. A recreation center, community
center, or boys’ and girls’ club?

Somewhat often

d. A library or bookmobile?

Very often

e. Litter or garbage on the street
or sidewalk?
I7

Which of these statements best describes your
household’s ability to afford the food you need
DURING THE PAST 12 MONTHS?

f. Poorly kept or rundown housing?
g. Vandalism such as broken
windows or graffiti?

We could always afford to eat good nutritious meals.
We could always afford enough to eat but not always
the kinds of food we should eat.

I10

To what extent do you agree with these statements
about your neighborhood or community?
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

Sometimes we could not afford enough to eat.
a. People in this
neighborhood help
each other out

Often we could not afford enough to eat.

b. We watch out for
each other’s
children in this
neighborhood

At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive...
Yes

a. Cash assistance from a government
welfare program?

c. This child is
safe in our
neighborhood

b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?

d. When we
encounter
difficulties, we
know where to
go for help in
our community

c. Free or reduced-cost breakfasts or
lunches at school?
d. Benefits from the Woman, Infants,
and Children (WIC) Program?

e. This child is safe
at school
I11

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 they
can rely on for advice or guidance?
Yes
No

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J. Child’s Caregivers

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.
To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated

➜ Complete the questions for UP TO TWO ADULTS
in the household who are this child’s primary
caregivers.

CAREGIVER 1 (You)
J1

b. Parent or guardian died

How are you related to this child?
Biological or Adoptive Parent

c. Parent or guardian served time in jail

Step-parent

d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home

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: Non-Relative

Other: Relative

g. Lived with anyone who had a problem
with alcohol or drugs

What is your sex?

h. Treated or judged unfairly because
of their race or ethnic group

Male

Female

Treated or judged unfairly because
of their sexual orientation or gender
identity?
J3

What is your age?

I13 When your family faces problems, how often are you

likely to do each of the following?
All of
the time

a. Talk together
about what to do

Most of
the time

Age in years
Some of
the time

None of
the time
J4

In the United States ➔ SKIP to question J6 on
page 17

b. Work together to
solve our problems

Outside of the United States

c. Know we have
strengths to draw on
d. Stay hopeful even
in difficult times

Where were you born?

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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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?

8th grade or less

Yes

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
Associate Degree (AA, AS)

Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question J13

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)
J7

J12 Were you deployed at any time during this child’s life?

Yes

What is your marital status?

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 18

Separated

CAREGIVER 2

Widowed
J8

In general, how is your physical health?

J14 How is Caregiver 2 related to this child?

Excellent

Biological or Adoptive Parent

Very good

Step-parent

Good

Grandparent

Fair

Foster Parent

Poor

Other: Relative
Other: Non-Relative

In general, how is your mental or emotional health?
Excellent

J15 What is Caregiver 2’s sex?

Very good

Male

Good

Female

Fair
J16 What is Caregiver 2’s age?

Poor
Age in years

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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.

Yes

8th grade or less

9th-12th grade; No diploma
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.

Completed a vocational, trade, or business school
program

Never served in the military ➔ SKIP to question K1
Some College Credit, but no Degree
Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question K1

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)

J25 Was Caregiver 2 deployed at any time during this child’s

life?

J20 What is Caregiver 2’s marital status?

Yes

Married

Not married, but living with a partner
Never Married

K. Household Information

Divorced
K1

Separated
Widowed

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.

J21 In general, how is Caregiver 2’s physical health?

Number of people
Excellent
Very good

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.
Number of people

Fair
Poor

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Income in 2019
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