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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. 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
A5
Poor
Allergies (including food, drug, insect, or other)?
Yes
No
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
No
If yes, is it:
Excellent
A6
Severe
Arthritis?
Yes
Fair
Moderate
No
If yes, does this child CURRENTLY have the
condition?
Poor
Yes
No
If yes, is it:
Mild
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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...
A12 Frequent or severe headaches, including migraine?
Yes
Yes
No
If yes, does this child CURRENTLY have the
condition?
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
No
If yes, is it:
If yes, is it:
Mild
Moderate
Severe
Mild
Moderate
Severe
A13 Tourette Syndrome?
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
A14 Anxiety Problems?
A9 Diabetes?
Yes
Yes
No
If yes, does this child CURRENTLY have the
condition?
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
Mild
Moderate
Mild
Severe
Yes
No
Severe
No
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
Yes
No
No
If yes, is it:
If yes, is it:
Mild
Moderate
Mild
Severe
A11 Heart Condition?
Yes
Moderate
A15 Depression?
A10 Epilepsy or Seizure Disorder?
Yes
No
If yes, is it:
If yes, is it:
Yes
No
Moderate
Severe
A16 Down Syndrome?
No
Yes
If yes, was this child born with the condition?
Yes
No
If yes, is it:
No
Mild
Moderate
Severe
If yes, is it:
Mild
Moderate
Severe
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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
No
No
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
No
If yes, is it:
Mild
No
If yes, was this child diagnosed with:
Moderate
Severe
A22 Developmental Delay?
Sickle Cell Disease?
Yes
No
Yes
No
Thalassemia?
Yes
No
If yes, does this child CURRENTLY have the
condition?
Hemophilia?
Yes
No
Yes
Other Blood
Disorders?
Yes
No
If yes, is it:
Mild
A18 Cystic Fibrosis?
Yes
No
Moderate
Severe
A23 Intellectual Disability (formerly known as Mental
Retardation)?
If yes, is it:
Mild
Moderate
Yes
Severe
Yes
No
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
No
No
If yes, is it:
Mild
A19 Other genetic or inherited condition?
Yes
No
No
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
No
Mild
Yes
If yes, does this child CURRENTLY have the
disorder?
No
Yes
No
If yes, is it:
No
If yes, is it:
Mild
Severe
If yes, does this child CURRENTLY have the
disability?
No
Yes
Moderate
A25 Learning Disability?
A20 Substance Use Disorder?
Yes
No
If yes, is it:
Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Yes
No
Mild
Moderate
Moderate
Severe
Severe
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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
If yes, does this child CURRENTLY have the
condition?
Yes
No
Moderate
Mild
Severe
A27 How old was this child when a doctor or other health
Don’t know
Severe
ADHD?
Yes
No
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 have Autism,
ASD, Asperger’s Disorder or PDD?
Age in years
No
If yes, is it:
If yes, is it:
Mild
No ➔ SKIP to question A34
Yes
Yes
No
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
No
child’s health conditions or problems affected their
ability to do things other children their age do?
No
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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B. This Child as an Infant
B1
C4
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?
C5
Birth Month / 4-Digit Birth Year
/
What is this child’s CURRENT height?
Your best estimate is fine.
2 0
feet AND
B3
How much did they weigh when born? Answer in pounds
and ounces OR kilograms and grams. Your best estimate is
fine.
inches
OR
meters AND
pounds AND
ounces
C6
OR
kilograms AND
B4
centimeters
How much does this child CURRENTLY weigh?
Your best estimate is fine.
grams
pounds
OR
What was the age of the mother when this child was
born? Your best estimate is fine.
kilograms
Age in years
C7
C. Health Care Services
C1
Yes, it’s too high
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
Yes, it’s too low
No, I am not concerned
C8
No ➔ SKIP to question C5
C2
If yes, at their LAST medical care visit, did this child
have a chance to speak with a doctor or other health
care provider privately, without you or another
caregiver in the room?
Has a doctor or other health care provider ever told
you that this child is overweight?
Yes
No
C9
Yes
No
C3
Are you concerned about this child’s weight?
Is there a place you or another caregiver USUALLY
take this child when they are sick or you need advice
about their health?
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 ➔ SKIP to question C11 on page 7
0 visits
1 visit
2 or more visits
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C10 If yes, where does this child USUALLY go first?
C15 DURING THE PAST 12 MONTHS, did this child see a
Mark (X) ONE box.
dentist or other health care provider for any kind of
dental or oral health care?
Doctor’s Office
Yes, saw a dentist or other oral health care provider
Hospital Emergency Room
Yes, saw another kind of health care provider
Hospital Outpatient Department
No ➔ SKIP to question C18
Clinic or Health Center
C16 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?
Retail Store Clinic or “Minute Clinic”
School (Nurse’s Office, Athletic Trainer’s Office)
No preventive visits in
the past 12 months ➔ SKIP to question C18
Some other place
Yes, 1 visit
C11 Is there a place that this child USUALLY goes when
they need routine preventive care, such as a physical
examination or well-child check-up?
Yes, 2 or more visits
C17 If yes, DURING THE PAST 12 MONTHS, what
Yes
preventive dental service(s) did this child receive?
Mark (X) ALL that apply.
No ➔ SKIP to question C13
Check-up
C12 If yes, is this the same place this child goes when they
Cleaning
are sick?
Yes
Instruction on tooth brushing and oral health care
No
X-Rays
Fluoride treatment
C13 DURING THE PAST 12 MONTHS, has this child had
Sealant (plastic coatings on back teeth)
their vision tested, such as with pictures, shapes, or
letters?
Don’t know
Yes
No ➔ SKIP to question C15
C18 DURING THE PAST 12 MONTHS, has this child
received any treatment or counseling from a mental
health professional? Mental health professionals include
psychiatrists, psychologists, psychiatric nurses, and clinical
social workers.
C14 If yes, where was this child’s vision tested?
Mark (X) ALL that apply.
Yes
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 C20 on page 8
Clinic or health center
School
Other, specify:
C19 How difficult was it to get the mental health treatment
or counseling that this child needed?
C
Not difficult
Somewhat difficult
Very difficult
It was not possible to obtain care
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C20 DURING THE PAST 12 MONTHS, has this child taken
C26 Did any of the following reasons contribute to this child
any medication because of difficulties with their
emotions, concentration, or behavior?
not receiving needed health services? Mark (X) Yes or No
for each item.
Yes
Yes
a. This child was not eligible for the
services
No
b. The services this child needed were
not available in your area
C21 DURING THE PAST 12 MONTHS, did this child see a
c. There were problems getting an
appointment when this child needed
one
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.
Yes
d. There were problems with getting
transportation or child care
No, but this child needed to see a specialist
e. The clinic or doctor’s office wasn’t
open when this child needed care
f. There were issues related to cost
No, this child did not need to
see a specialist ➔ SKIP to question C23
C22 How difficult was it to get the specialist care that this
C27 DURING THE PAST 12 MONTHS, how often were you
frustrated in your efforts to get services for this child?
child needed?
Not difficult
Never
Somewhat difficult
Sometimes
Very difficult
Usually
It was not possible to obtain care
Always
C23 DURING THE PAST 12 MONTHS, did this child use any
No
C28 DURING THE PAST 12 MONTHS, how many times did
this child visit a hospital emergency room?
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.
None
1 time
Yes
2 or more times
No
C29 DURING THE PAST 12 MONTHS, was this child admitted
to the hospital to stay for at least one night?
C24 DURING THE PAST 12 MONTHS, was there any time
when this child needed health care but it was not
received? By health care, we mean medical care as well
as other kinds of care like dental care, vision care, and
mental health services.
Yes
Yes
No
C30 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).
No ➔ SKIP to question C27
C25 If yes, which types of care were not received?
Mark (X) ALL that apply.
Yes
Medical Care
No ➔ SKIP to question C33 on page 9
Dental Care
C31 If yes, how old was this child at the time of the FIRST
plan?
Vision Care
Hearing Care
Years AND
Months
Mental Health Services
Other, specify:
C
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C32 Is this child CURRENTLY receiving services under one
D4
of these plans?
Yes
Answer the following questions only if this child had a
health care visit IN THE PAST 12 MONTHS. Otherwise
skip to question D13 on page 10.
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers...
No
Always
C33 Has this child EVER received special services to
meet their developmental needs such as speech,
occupational, or behavioral therapy?
Never
b. Listen carefully to
you?
Yes
c. Show sensitivity to
your family’s values
and customs?
No ➔ SKIP to question D1
d. Provide the specific
information you
needed concerning
this child?
C34 If yes, how old was this child when they began
receiving these special services?
Years AND
Usually Sometimes
a. Spend enough time
with this child?
Months
e. Help you feel like a
partner in this
child’s care?
C35 Is this child CURRENTLY receiving these special
services?
D5
Yes
No
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
D. Experience with This
Child’s Health Care
Providers
D1
No ➔ SKIP to question D7
D6
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.
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?
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
No
D2
c. Work with you to
decide together which
health care and
treatment choices would
be best for this child?
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
D3
D7
How difficult was it to get referrals?
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
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 10
Very difficult
It was not possible to get a referral
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D8 DURING THE PAST 12 MONTHS, have you felt that you
D14 If yes, have they talked with you about when this child
will need to see doctors or other health care providers
who treat adults?
could have used extra help arranging or coordinating
this child’s care among the different health care
providers or services?
Yes
Yes
No
No ➔ SKIP to question D10
D15 Has this child’s doctor or other health care provider
actively worked with this child to:
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?
Yes
Sometimes
Never
b. Gain skills to manage their
health and health care. For
example, by understanding current
health needs, knowing what to do
in a medical emergency, or taking
medications they may need?
D10 DURING THE PAST 12 MONTHS, how satisfied were
you with the communication between this child’s
doctors and other health care providers?
c. Understand the changes in
health care that happen at
age 18. For example, by
understanding changes in privacy,
consent, access to information, or
decision-making?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
D16 Did you and this child receive a summary of your
child’s medical history (for example, medical conditions,
allergies, medications, immunizations)?
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
Yes
No ➔ SKIP to question D13
Don’t
know
a. Make positive choices about
their health. For example, by
eating healthy, getting regular
exercise, not using tobacco,
alcohol or other drugs, or
delaying sexual activity?
Usually
Very dissatisfied
No
No
D17 Have this child’s doctors or other health care providers
worked with you and this child to create a plan of care
to meet their health goals and needs?
Did not need health care
provider to communicate
with these providers ➔ SKIP to question D13
Yes
D12 If yes, during this time, how satisfied were you with the
No ➔ SKIP to question D20 on page 11
health care provider’s communication with the school,
child care provider, or special education program?
D18 If yes, do you and this child have access to this plan of
Very satisfied
care?
Somewhat satisfied
Yes
Somewhat dissatisfied
No
Very dissatisfied
D19 Does this plan of care address transition to doctors and
other health care providers who treat adults?
D13 Do any of this child’s doctors or other health care
Yes
providers treat only children?
Yes
No
No ➔ SKIP to question D15
No, child already sees providers who treat adults
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D20 Eligibility for health insurance often changes in young
E4
adulthood. Do you know how this child will be insured
as they become an adult?
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
Yes ➔ SKIP to question E1
a. Insurance through a current or
former employer or union
No
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
D21 If no, has anyone discussed with you how to obtain or
keep some type of health insurance coverage as this
child becomes an adult?
Yes
No
d. TRICARE or other military
health care
No
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
No
Never
E6
a. Change in employer or employment
status
How often does this child’s health insurance allow
them to see the health care providers they need?
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
f. Problems with application or
renewal process
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
g. Other, specify: C
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
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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
$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 Schooling
and Activities
Never
F3
DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?
G1
Yes
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.
No missed school days
No
F4
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?
1-3 days
DURING THE PAST 12 MONTHS, have you or other
family members...
Yes
4-6 days
No
a. Left a job or taken a leave of
absence because of this child’s
health or health conditions?
7-10 days
b. Cut down on the hours you work
because of this child’s health or
health conditions?
This child was not enrolled in school
11 or more days
G2
c. Avoided changing jobs because of
concerns about maintaining health
insurance for this child?
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?
None
1 time
2 or more times
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G3 SINCE STARTING KINDERGARTEN, has this child
G8 DURING THE PAST 12 MONTHS, how often was this
repeated any grades?
child bullied, picked on, or excluded by other children?
If the frequency changed throughout the year, report the
highest frequency.
Yes
1-2 times (in the past 12 months)
No
Never (in the past 12 months)
G4 DURING THE PAST 12 MONTHS, how often did you
attend events or activities that this child participated in?
1-2 times per week
Always
1-2 times per month
Usually
Almost every day
Sometimes
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.
Rarely
Never
1-2 times (in the past 12 months)
G5 DURING THE PAST 12 MONTHS, did this child
participate in...
Yes
Never (in the past 12 months)
No
a. A sports team or did they take
sports lessons after school or
on weekends?
1-2 times per week
1-2 times per month
b. Any clubs or organizations after
school or on weekends?
c. Any other organized activities or
lessons, such as music, dance,
language, or other arts?
Almost every day
G10 How often does this child...
Always
d. Any type of community service or
volunteer work at school, place of
worship, or in the community?
a. Show interest and
curiosity in learning
new things?
e. Any paid work, including regular
jobs as well as babysitting, cutting
grass, or other occasional work?
b. Work to finish tasks
they start?
c. Stay calm and in
control when faced
with a challenge?
G6 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
d. Care about doing
well in school?
e. Do all required
homework?
1-3 days
f. Argue too much?
4-6 days
H. About You and This
Child
Every day
G7 Compared to other children their age, how much
difficulty does this child have making or keeping
friends?
Usually Sometimes
H1 Was this child born in the United States?
Yes ➔ SKIP to question H3 on page 14
No difficulty
No
A little difficulty
H2 If no, how long has this child been living in the
United States?
A lot of difficulty
Years AND
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H3
How many times has this child moved to a new address H8 How well do you think you are handling the day-to-day
since they were born?
demands of raising children?
Very well
Number of times
Somewhat well
H4
How often does this child go to bed at about the same
time on weeknights?
Not very well
Always
Usually
Not well at all
H9
DURING THE PAST MONTH, how often have you felt...
Never
Sometimes
Rarely
Never
H5
Less than 6 hours
b. That this child
does things
that really
bother you
a lot?
6 hours
c. Angry with
this child?
DURING THE PAST WEEK, how many hours of sleep
did this child get on most weeknights?
7 hours
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?
8 hours
9 hours
Yes
10 hours
No ➔ SKIP to question I1 on page 15
11 or more hours
H6
H11 If yes, did you receive emotional support from...
Yes
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.
a. Spouse or domestic partner?
b. Other family member or close friend?
c. Health care provider?
Less than 1 hour
d. Place of worship or religious leader?
1 hour
e. Support or advocacy group related
to specific health condition?
2 hours
f. Peer support group?
3 hours
g. Counselor or other mental health
professional?
4 or more hours
h. Other person, specify:
H7
Rarely Sometimes Usually Always
a. That this child
is much harder
to care for than
most children
their age?
C
How well can you and this child share ideas or talk
about things that really matter?
Very well
Somewhat well
Not very well
Not well at all
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I. About Your Family and
Household
I1
I5
DURING THE PAST WEEK, on how many days did all the
family members who live in the household eat a meal
together?
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
0 days
1-3 days
I6
4-6 days
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?
Never
Every day
Rarely
I2
Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?
Somewhat often
Very often
Yes
No ➔ SKIP to question I4
I7
I3
I4
If yes, does anyone smoke inside your home?
Which of these statements best describes your
household’s ability to afford the food you need
DURING THE PAST 12 MONTHS?
Yes
We could always afford to eat good nutritious meals.
No
We could always afford enough to eat but not always
the kinds of food we should eat.
Sometimes we could not afford enough to eat.
DURING THE PAST 12 MONTHS, how often were
pesticides used inside your residence to control for
insects? If the frequency changed throughout the year,
report the highest frequency.
More than once a week
Often we could not afford enough to eat.
I8
At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive...
Once a week
Yes
Once a month
a. Cash assistance from a government
welfare program?
Once every 2-5 months
b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?
Once every 6 months
c. Free or reduced-cost breakfasts or
lunches at school?
Once during the past 12 months
d. Benefits from the Woman, Infants,
and Children (WIC) Program?
Never
Don’t know
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I9
In your neighborhood, is/are there...
Yes
No
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.
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 their
neighborhood
I10 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 their race or ethnic group
b. We watch out for
each other’s
children in this
neighborhood
c. This child is
safe in our
neighborhood
i.
Treated or judged unfairly because
of their sexual orientation or gender
identity?
I13 When your family faces problems, how often are you
likely to do each of the following?
d. When we
encounter
difficulties, we
know where to
go for help in
our community
All of
the time
Most of
the time
Some of
the time
None of
the time
a. Talk together
about what to do
b. Work together to
solve our problems
e. This child is safe
at school
c. Know we have
strengths to draw on
d. Stay hopeful even
in difficult times
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
J6
➜ Complete the questions for UP TO TWO ADULTS
8th grade or less
in the household who are this child’s primary
caregivers.
9th-12th grade; No diploma
CAREGIVER 1 (You)
J1
High School Graduate or GED Completed
Completed a vocational, trade, or business school
program
How are you related to this child?
Biological or Adoptive Parent
Some College Credit, but no Degree
Step-parent
Associate Degree (AA, AS)
Grandparent
Bachelor’s Degree (BA, BS, AB)
Foster Parent
Master’s Degree (MA, MS, MSW, MBA)
Other: Relative
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
Other: Non-Relative
J7
J2
What is the highest grade or level of school you have
completed? Mark (X) ONE box.
What is your marital status?
What is your sex?
Married
Male
Not married, but living with a partner
Female
Never Married
J3
What is your age?
Divorced
Age in years
J4
Separated
Widowed
Where were you born?
In the United States ➔ SKIP to question J6
J8
Excellent
Outside of the United States
J5
In general, how is your physical health?
Very good
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.
Good
Fair
4-Digit Year
Poor
J9
In general, how is your mental or emotional health?
Excellent
Very good
Good
Fair
Poor
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J10 Were you employed at least 50 out of the past
J17 Where was Caregiver 2 born?
52 weeks?
In the United States ➔ SKIP to question J19
Yes
Outside of the United States
No
J18 When did Caregiver 2 come to live in the United States?
Indicate the 4-digit year in which Caregiver 2 came to live in
the United States.
J11 Have you ever served on active duty in the
U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
4-Digit Year
Never served in the military ➔ SKIP to question J13
Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question J13
J19 What is the highest grade or level of school Caregiver 2
has completed? Mark (X) ONE box.
Now on active duty
8th grade or less
On active duty in the past, but not now
9th-12th grade; No diploma
J12 Were you deployed at any time during this child’s life?
High School Graduate or GED Completed
Yes
Completed a vocational, trade, or business school
program
No
Some College Credit, but no Degree
J13 Does this child have another primary adult caregiver
Associate Degree (AA, AS)
who lives in this household?
Yes - Complete Questions J14 - J25
Bachelor’s Degree (BA, BS, AB)
No - SKIP to Question K1 on page 19
Master’s Degree (MA, MS, MSW, MBA)
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
CAREGIVER 2
J20 What is Caregiver 2’s marital status?
J14 How is Caregiver 2 related to this child?
Married
Biological or Adoptive Parent
Not married, but living with a partner
Step-parent
Never Married
Grandparent
Divorced
Foster Parent
Separated
Other: Relative
Widowed
Other: Non-Relative
J21 In general, how is Caregiver 2’s physical health?
J15 What is Caregiver 2’s sex?
Excellent
Male
Very good
Female
Good
J16 What is Caregiver 2’s age?
Fair
Poor
Age in years
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J22 In general, how is Caregiver 2’s mental or emotional
K3
health?
Excellent
Very good
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.
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.
J23 Was Caregiver 2 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.
J24 Has Caregiver 2 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
$
,
.00
f. Any other sources of income received such as
Veterans’ (VA) payments, unemployment
compensation, child support, alimony, gifts, prize
winnings, etc.
How many people are living or staying at this address?
Include everyone who usually lives or stays at this address.
Do NOT include anyone who is living somewhere else for
more than two months, such as a college student living away
or someone in the Armed Forces on deployment.
Yes ➔
$
K4
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
Number of people
,
TOTAL AMOUNT
in the last calendar year
No
K. Household Information
K2
.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
J25 Was Caregiver 2 deployed at any time during this child’s
life?
,
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.
$
,
.00
,
TOTAL AMOUNT
in the last calendar year
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26030015
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 |