NSCH-T1 NSCH Topical 1 (0-5) - English

National Survey of Children's Health

NSCH_T1_FINAL

National Survey of Children's Health

OMB: 0607-0990

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26016204

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 conducting the National Survey of Children’s Health on behalf of the U.S. 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. The data collected under this agreement are confidential under 13 U.S.C.
Section 9. All access to Title 13 data from this survey is restricted to Census Bureau employees and those holding Census Bureau
Special Sworn Status pursuant to 13 U.S.C. Section 23(c).
Any information you provide will be shared among a limited number of Census Bureau and HHS staff only for work-related purposes
identified above and as permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a).
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-T1
(04/13/2016)

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Start Here

A3

How well do each of the following phrases describe
this child?
Definitely Somewhat
true
true

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.

a. This child is affectionate
and tender with you

We now have some follow-up questions to ask about:

b. This child bounces back
quickly when things do not
go his or her way

Not
true

c. This child shows interest
and curiosity in learning
new things
These questions will collect more detailed information
on various aspects of this child’s health including his
or her health status, visits to health care providers,
health care costs, and health insurance coverage.

d. This child smiles and
laughs a lot
A4

We have selected only one child per household in an
effort to minimize the amount of time necessary to
complete the follow-up questions.

DURING THE PAST 12 MONTHS, has this child had
FREQUENT or CHRONIC difficulty with any of the
following?

The survey should be completed by an adult who is
familiar with this child’s health and health care.

a. Breathing or other respiratory
problems (such as wheezing or
shortness of breath)

Your participation is important. Thank you.

b. Eating or swallowing because of
a health condition

Yes

No

d. Repeated or chronic physical pain,
including headaches or other back
or body pain

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

(the one named above)?
Excellent

e. Using his or her hands

Very good

f. Coordination or moving around

Good

g. Toothaches

Fair

h. Bleeding gums

Poor

teeth?

No

c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea

A. This Child’s Health

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

Yes

i.
A5

This child does not have any teeth

Decayed teeth or cavities

Does this child have any of the following?

a. Deafness or problems with hearing

Excellent

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

Very good
Good
Fair
Poor

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A6 Has a doctor or other health care provider EVER told

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

you that this child has...
Allergies (including food, drug, insect, or other)?
Yes

A11 Cerebral Palsy?

No

Yes

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

No

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:

No

If yes, is it:

Mild

Moderate

Severe

Mild

Moderate

Severe

A12 Cystic Fibrosis?

A7 Arthritis?

Yes

No

Yes

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

No

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:

No

If yes, is it:

Mild

Moderate

Severe

Mild

Moderate

Severe

A13 Diabetes?

A8 Asthma?

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

Thalassemia, or Hemophilia)?

Yes

No

Severe

No

If yes, does this child CURRENTLY have the condition?

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

Moderate

A14 Down Syndrome?

A9 Blood Disorders (such as Sickle Cell Disease,

Yes

No

Yes

No

No

If yes, is it:

If yes, is it:

Mild

Mild

Moderate

Moderate

Severe

Severe
A15 Epilepsy or Seizure Disorder?

A10

Brain Injury, Concussion or Head Injury?
Yes

Yes

No

If yes, does this child CURRENTLY have the condition?

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

Yes

No

No

If yes, is it:

If yes, is it:
Mild

No

Mild
Moderate

Moderate

Severe

Severe

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

A22 Has a doctor, other health care provider, or educator

EVER told you that this child has...
Examples of educators are teachers and school nurses.

A16 Heart Condition?

Yes

Behavioral or Conduct Problems?

No

Yes

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

No

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:
Mild

Moderate

No

If yes, is it:

Severe

Mild

Moderate

Severe

A17 Frequent or Severe Headaches, including Migraine?

Yes

A23 Developmental Delay?

No

Yes

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

No

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:
Mild

Moderate

No

If yes, is it:

Severe

Mild

Moderate

Severe

A18 Tourette Syndrome?

Yes

A24 Intellectual Disability (also known as Mental Retardation)?

No

Yes

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

No

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:
Mild

Moderate

No

If yes, is it:

Severe

Mild

Moderate

Severe

A19 Anxiety Problems?

Yes

A25 Speech or Other Language Disorder?

No

Yes

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

No

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:
Mild

Moderate

No

If yes, is it:

Severe

Mild

Moderate

Severe

A20 Depression?

Yes

A26 Learning Disability?

No

Yes

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

No

If yes, does this child CURRENTLY have the condition?

No

Yes

If yes, is it:
Mild

Moderate

No

If yes, is it:

Severe

Mild

Moderate

Severe

A21 Other Genetic or Inherited Condition?

Yes

No

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

No

If yes, is it:
Mild

Moderate

Severe

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A27 Has a doctor or other health care provider EVER told

A31 Is this child CURRENTLY taking medication for Autism,

you that this child has...

ASD, Asperger’s Disorder or PDD?

Any Other Mental Health Condition?
Yes

Yes

No

If yes, specify:

No

A32 At any time DURING THE PAST 12 MONTHS, did this

child receive behavioral treatment for Autism, ASD,
Asperger’s Disorder or PDD, such as training or an
intervention that you or this child received to help
with his or her behavior?

C

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

Yes

A33 Has a doctor or other health care provider EVER told

No

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

If yes, is it:
Mild

No

Moderate

Severe
No ➔ SKIP to question A36

Yes
A28 Has a doctor or other health care provider EVER told

If yes, does this child CURRENTLY have the condition?

you that this child has Autism or Autism Spectrum
Disorder (ASD)? Include diagnoses of Asperger’s Disorder
or Pervasive Developmental Disorder (PDD).

Yes
If yes, is it:

No ➔ SKIP to question A33

Yes

Mild

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

No

Moderate

Severe

A34 Is this child CURRENTLY taking medication for ADD or

No

ADHD?

If yes, is it:
Mild

Moderate

Yes

Severe

A29 How old was this child when a doctor or other health

A35 At any time DURING THE PAST 12 MONTHS, did this

child receive behavioral treatment for ADD or ADHD,
such as training or an intervention that you or this
child received to help with his or her behavior?

care provider FIRST told you that he or she had Autism,
ASD, Asperger’s Disorder or PDD?

Yes
Age in years

No

No

Don’t know
A36 DURING THE PAST 12 MONTHS, how often have this

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

A30 What type of doctor or other health care provider was

the FIRST to tell you that this child had Autism, ASD,
Asperger’s Disorder or PDD? Mark ONE only.

This child does not have
any conditions ➔ SKIP to question B1

Primary Care Provider
Never
Specialist
Sometimes
School Psychologist/Counselor
Usually
Other Psychologist (Non-School)
Always
Psychiatrist
A37 To what extent do this child’s health conditions or

Other, specify:

problems affect his or her ability to do things?

C

Very little
Somewhat

Don’t know

A great deal

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B. This Child as an Infant
B1

B6

Was this child born more than 3 weeks before his or
her due date?

How old was this child when he or she was FIRST fed
formula?
At birth
OR

Yes
days

No
OR
B2

How much did he or she weigh when born?
Answer in pounds and ounces OR kilograms and grams.
Provide your best estimate.

weeks
OR

pounds

AND

ounces

OR

months
OR
kilograms

B3

AND

grams

What was the age of the mother when this child was
born?

Check this box if child has never been fed formula
B7

Age in years
B4

How old was this child when he or she was FIRST fed
anything other than breast milk or formula? Include
juice, cow’s milk, sugar water, baby food, or anything else
that your child might have been given, even water.
At birth
OR

Was this child EVER breastfed or fed breast milk?
Yes

days

No ➔ SKIP to question B6
B5

OR

If yes, how old was this child when he or she
COMPLETELY stopped breastfeeding or being fed
breast milk?

weeks
OR

days

months

OR

OR
Check this box if child has never been fed anything
other than breast milk or formula

weeks
OR

months
OR
Check this box if child is still breastfeeding

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C. Health Care Services
C1

C7

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
No
C8

No ➔ SKIP to question C4
C2

C3

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?

If this child is YOUNGER THAN 9 MONTHS, please
SKIP to question C9 .
DURING THE PAST 12 MONTHS, did a doctor or other
health care provider have you or another caregiver fill
out a questionnaire about specific concerns or
observations 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.

If yes, DURING THE PAST 12 MONTHS, how many times
did this child visit a doctor, nurse, or other health care
professional to receive a PREVENTIVE check-up?
A preventive check-up is when this child was not sick or
injured, such as an annual or sports physical, or well-child
visit.
0 visits ➔ SKIP to question C4

Yes

1 visit

If yes, and this child is 9-23 Months:

2 or more visits

Did the questionnaire ask about your concerns
or observations about: Mark ALL that apply.

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 talks or makes speech sounds?
How this child interacts with you and others?
If yes, and this child is 2-5 Years:

Less than 10 minutes

Did the questionnaire ask about your concerns
or observations about: Mark ALL that apply.

10-20 minutes

Words and phrases this child uses and
understands?

More than 20 minutes
C4

How this child behaves and gets along with
you and others?

What is this child’s CURRENT height?
C9

feet

No

AND

inches

OR

Is there a place that this child USUALLY goes when
he or she is sick or you or another caregiver needs
advice about his or her health?
Yes

meters
C5

AND

centimeters

How much does this child CURRENTLY weigh?

No ➔ SKIP to question C11
C10 If yes, where does this child USUALLY go?

Mark ONE only.
pounds

AND

Doctor’s Office

ounces

OR

Hospital Emergency Room
Hospital Outpatient Department
kilograms

AND

grams
Clinic or Health Center

C6

Are you concerned about this child’s weight?

Retail Store Clinic or “Minute Clinic”

Yes, it’s too high

School (Nurse’s Office, Athletic Trainer’s Office)

Yes, it’s too low

Some other place

No, I am not concerned

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C11 Is there a place that this child USUALLY goes when

C17 If yes, DURING THE PAST 12 MONTHS, what

he or she needs routine preventive care, such as a
physical examination or well-child check-up?

preventive dental services did this child receive?
Mark ALL that apply.

Yes

Check-up

No ➔ SKIP to question C13

Cleaning
Instruction on tooth brushing and oral health care

C12 If yes, is this the same place this child goes when he

or she is sick?
X-Rays
Yes
Fluoride treatment
No
Sealant (plastic coatings on back teeth)
C13 Has this child EVER had his or her vision tested with

pictures, shapes, or letters?
Yes

Don’t know
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.

No ➔ SKIP to question C15
C14 If yes, what kind of place or places did this child have

his or her vision tested? Mark 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

Clinic or health center

C19 How much of a problem was it to get the mental health

School
Other, specify:

treatment or counseling that this child needed?
C

Not a problem
Small problem
Big problem

C15 DURING THE PAST 12 MONTHS, did this child see a

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

C20 DURING THE PAST 12 MONTHS, has this child taken

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

Yes, saw a dentist
Yes, saw other oral health care provider

Yes

No ➔ SKIP to question C18

No

C16 If yes, DURING THE PAST 12 MONTHS, did this child

see a dentist or other oral health care provider for
preventive dental care, such as check-ups, dental
cleanings, dental sealants, or fluoride treatments?

C21 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 C18

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 C23

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C27 DURING THE PAST 12 MONTHS, how often were you

C22 How much of a problem was it to get the specialist

frustrated in your efforts to get services for this child?

care that this child needed?
Not a problem

Never

Small problem

Sometimes

Big problem

Usually
Always

C23 DURING THE PAST 12 MONTHS, did this child use any

type of alternative health care or treatment? Alternative
health care can include acupuncture, chiropractic care,
relaxation therapies, herbal supplements, and others.
Some therapies involve seeing a health care provider,
while others can be done on your own.

C28 DURING THE PAST 12 MONTHS, how many times did

this child visit a hospital emergency room?
No visits

Yes

1 visit

No

2 or more visits

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.

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).
Yes

Yes

No ➔ SKIP to question C32

No ➔ SKIP to question C27

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

C25 If yes, which types of care were not received?

plan?

Mark ALL that apply.
Medical Care

Years

AND

Months

Dental Care
C31 Is this child CURRENTLY receiving services under one

Vision Care

of these plans?

Hearing Care

Yes

Mental Health Services

No

Other, specify:

C

C32 Has this child EVER received special services to meet

his or her developmental needs such as speech,
occupational, or behavioral therapy?
Yes

C26 Which of the following contributed to this child not

receiving needed health services:
Yes

a. This child was not eligible for the
services?

No ➔ SKIP to question D1

No

C33 If yes, how old was this child when he or she began

receiving these special services?

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

D5

Yes

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, were any decisions
needed about this child’s health care services or
treatment, such as whether to start or stop a
prescription or therapy services, get a referral to a
specialist, or have a medical procedure?

No ➔ SKIP to question D7
D6

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

Yes, one person

Usually Sometimes Never

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

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 If yes, how much of a problem was it to get referrals?

Not a problem
Small problem
D7

Big problem
D4 Answer the following questions only if this child had a

Does anyone help you arrange or coordinate this
child’s care among the different doctors or services
that this child uses?
Yes

health care visit IN THE PAST 12 MONTHS. Otherwise,
SKIP to question E1 .

No
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers:
Always

a. Spend enough time
with this child?

Usually Sometimes

Did not see more than one
health care provider in
PAST 12 MONTHS ➔ SKIP to question D11

Never

D8

b. Listen carefully to
you?
c. Show sensitivity to
your family’s values
and customs?
d. Provide the specific
information you
needed concerning
this child?

DURING THE PAST 12 MONTHS, have you felt that you
could have used extra help arranging or coordinating
this child’s care among the different health care
providers or services?
Yes
No ➔ SKIP to question D10

D9

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

If yes, DURING THE PAST 12 MONTHS, how often
did you get as much help as you wanted with
arranging or coordinating this child’s health care?
Usually
Sometimes
Never

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D10 Overall, how satisfied are you with the communication

E2

among this child’s doctors and other health care
providers?

Indicate whether any of the following is a reason this
child was not covered by health insurance DURING
THE PAST 12 MONTHS:
Yes

Very satisfied

No

a. Change in employer or employment
status

Somewhat satisfied
Somewhat dissatisfied

b. Cancellation due to overdue
premiums

Very dissatisfied

c. Dropped coverage because it was
unaffordable
d. Dropped coverage because benefits
were inadequate

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

e. Dropped coverage because choice
of health care providers was
inadequate

No ➔ SKIP to question E1

f. Problems with application or
renewal process
g. Other, specify: C

Did not need health care
provider to communicate
with these providers ➔ SKIP to question E1
D12 If yes, overall, how satisfied are you with the health

care provider’s communication with the school, child
care provider, or special education program?

E3

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

Very satisfied

Yes

Somewhat satisfied

No ➔ SKIP to question F1

Somewhat dissatisfied

E4

Is this child covered by any of the following types of
health insurance or health coverage plans?

Very dissatisfied

Yes

a. Insurance through a current or
former employer or union

E. This Child’s Health
Insurance Coverage
E1

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

DURING THE PAST 12 MONTHS, was this child EVER
covered by ANY kind of health insurance or health
coverage plan?

d. TRICARE or other military
health care

Yes, this child was covered
all 12 months ➔ SKIP to question E4

e. Indian Health Service

Yes, but this child had a gap in coverage

f. Other, specify: C

No

E5

How often does this child’s health insurance offer
benefits or cover services that meet this child’s needs?
Always
Usually
Sometimes
Never

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E6

How often does this child’s health insurance allow him
F3
or her to see the health care providers he or she needs?
Always

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

Usually

No

Sometimes
F4

Never
E7

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
F5

Sometimes

No at home care was provided by me or other family
members

F. Providing for This
Child’s Health

Less than 1 hour per week

Including co-pays and amounts 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.
$0 (No medical or health-related
expenses) ➔ SKIP to question F4

1-4 hours per week
5-10 hours per week
11 or more hours per week
F6

$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

No health or medical care was arranged or coordinated
by me or other family members

$500-$999
$1,000-$5,000

Less than 1 hour per week

More than $5,000
F2

IN AN AVERAGE WEEK, how many hours do you or
other family members spend providing health care at
home for this child? Care might include changing
bandages, or giving medication and therapies when needed.
This child does not need health care provided
on a weekly basis

Never

F1

No

a. Stopped working 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?

Usually

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

1-4 hours per week

How often are these costs reasonable?

5-10 hours per week

Always

11 or more hours per week

Usually
Sometimes
Never

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G. This Child’s Learning

G7

How often can this child explain things he or she has
seen or done so that you get a very good idea what
happened?

G1 Has this child started school? Include homeschooling.

All of the time

This child is younger than 3
years old ➔ SKIP to question H1

Most of the time

Yes

Some of the time

No
G2 How well is this child learning to do things for him or

herself?

None of the time
G8

How often can this child write his or her first name, even
if some of the letters aren’t quite right or are backwards?

Very well

All of the time

Somewhat

Most of the time

Poorly

Some of the time

Not at all

None of the time

G3 How confident are you that this child will be successful

G9

in elementary or primary school?

How high can this child count?
Not at all

Very confident
Up to five
Mostly confident
Up to ten
Somewhat confident
Up to 20
Not confident at all
Up to 50
G4 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 100 or more
G10 How often can this child identify basic shapes such as

a triangle, circle, or square?

All of the time
Most of the time

All of the time

Some of the time

Most of the time

None of the time

Some of the time
None of the time

G5 About how many letters of the alphabet can this child

recognize?

G11 How often is this child easily distracted?

All of them

All of the time

Most of them

Most of the time

Some of them

Some of the time

None of them

None of the time

G6 Can this child rhyme words?

G12 How often does this child keep working at something

until he or she is finished?

Yes

All of the time
No
Most of the time
Some of the time
None of the time
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26016071

G13 When he or she is paying attention, how often can this

G19 How often does this child lose control of his or her

child follow instructions to complete a simple task?

temper when things do not go his or her way?

All of the time

All of the time

Most of the time

Most of the time

Some of the time

Some of the time

None of the time

None of the time

G14 When this child holds a pencil, does he or she use

G20 Compared to other children his or her age, how much

difficulty does this child have making or keeping
friends?

fingers to hold, or does he or she grip it in his or her
fist?
Uses fingers

No difficulty

Grips in fist

A little difficulty

Cannot hold a pencil

A lot of difficulty

G15 How often does this child play well with others?

G21 Compared to other children his or her age, how often

is this child able to sit still?

All of the time

All of the time

Most of the time

Most of the time

Some of the time

Some of the time

None of the time

None of the time

G16 How often does this child become angry or anxious

when going from one activity to another?

G22 IN THE PAST 12 MONTHS, were you ever asked to keep

your child home from any child care or preschool
because of their behavior (things like hitting, kicking,
biting, tantrums or disobeying)? Mark ONE only.

All of the time
Most of the time

This child did not attend child care or preschool

Some of the time

No

None of the time

Yes, I was told to pick up my child early on 1 or
more days

G17 How often does this child show concern when others

Yes, I had to keep my child home for 1 full day or more

are hurt or unhappy?

Yes permanently, I was told my child could no longer
attend this child care center or preschool

All of the time
Most of the time

H. About You and This
Child

Some of the time
None of the time
H1

Was this child born in the United States?

G18 How often can this child calm down when excited or

all wound up?

Yes ➔ SKIP to question H3

All of the time
Most of the time

No
H2

Some of the time
None of the time

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

Years

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AND

Months

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26016063

H3 How many times has this child moved to a new address

H8

since he or she was born?

Number of times
H4

None

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

Less than 1 hour
1 hour

Always

2 hours

Usually

3 hours

Sometimes

4 or more hours

Rarely
Never
H5

H9

DURING THE PAST WEEK, how many hours of sleep
did this child get during an average day (count both
nighttime sleep and naps)?

DURING THE PAST WEEK, how many days did you or
other family members read to this child?
0 days
1-3 days

Less than 7 hours

4-6 days

7 hours

Every day

8 hours

H10 DURING THE PAST WEEK, how many days did you or

other family members tell stories or sing songs to this
child?

9 hours

H6

ON AN AVERAGE WEEKDAY, about how much time
does this child usually spend with computers, cell
phones, handheld video games, and other electronic
devices, doing things other than schoolwork?

10 hours

0 days

11 hours

1-3 days

12 or more hours

4-6 days

Answer the next question only if this child is LESS THAN
12 MONTHS OLD. Otherwise, SKIP to question H7 .

Every day

In which position do you most often lay this baby down H11 How well do you think you are handling the day-to-day
to sleep now? Mark ONE only.
demands of raising children?

H7

On his or her side

Very well

On his or her back

Somewhat well

On his or her stomach

Not very well

ON AN AVERAGE WEEKDAY, about how much time
does this child usually spend in front of a TV watching
TV programs, videos, or playing video games?

Not at all
H12 DURING THE PAST MONTH, how often have you felt:
Never

Rarely Sometimes Usually Always

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

None
Less than 1 hour
1 hour

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

2 hours
3 hours
4 or more hours

c. Angry with
this child?

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26016055

H13 DURING THE PAST 12 MONTHS, was there someone

I2

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

Yes

Yes

No ➔ SKIP to question I4

No ➔ SKIP to question H15
H14 If yes, did you receive emotional support from:
Yes

I3
No

No

b. Other family member or close friend?

I4

c. Health care provider?

When your family faces problems, how often are you
likely to do each of the following?
All of
the time

d. Place of worship or religious leader?

Some of None of
the time the time

b. Work together to
solve our problems

f. Peer support group?

c. Know we have
strengths to draw on

g. Counselor or other mental health
professional?

d. Stay hopeful
even in difficult
times

C

I5
H15 Does this child receive care for at least 10 hours per

week from someone other than his or her parent or
guardian? This could be a day care center, preschool,
Head Start program, family child care home, nanny,
au pair, babysitter or relative.

SINCE THIS CHILD WAS BORN, how often has it been
very hard to get by on your family’s income – hard to
cover the basics like food or housing?
Never
Rarely

Yes

Somewhat often

No

Very often

H16 DURING THE PAST 12 MONTHS, did you or anyone in

Most of
the time

a. Talk together
about what to do

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

I6

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?

The next question is about whether you were able to
afford the food you need. Which of these statements
best describes the food situation in your household
IN THE PAST 12 MONTHS?
We could always afford to eat good nutritious meals.

Yes

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

No

Sometimes we could not afford enough to eat.

I. About Your Family and
Household

Often we could not afford enough to eat.
I7

I1

If yes, does anyone smoke inside your home?
Yes

a. Spouse?

h. Other person, specify:

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

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

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

0 days

a. Cash assistance from a government
welfare program?

1-3 days

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

4-6 days

c. Free or reduced-cost breakfasts or
lunches at school?

Every day

d. Benefits from the Woman, Infants,
and Children (WIC) Program?

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§;"]X¤

No

26016048

I8

In your neighborhood, is/are there:

Yes

J. About You

No

a. Sidewalks or walking paths?

➜ Complete the questions for each of the two adults
in the household who are this child’s primary
caregivers. If there is just one adult, provide
answers for that adult.

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

ADULT 1 (Respondent)

d. A library or bookmobile?
e. Litter or garbage on the street
or sidewalk?

J1

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

f. Poorly kept or rundown housing?

Step-parent

g. Vandalism such as broken
windows or graffiti?
I9

Grandparent

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

Foster Parent

Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

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

Aunt or Uncle
Other: Relative
Other: Non-Relative
J2

What is your sex?
Male

c. This child is
safe in our
neighborhood
d. When we
encounter
difficulties, we
know where to
go for help in
our community
I10 The next questions are about events that may have

Female
J3

What is your age?

Age in years
J4

Where were you born?

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

In the United States ➔ SKIP to question J6
Outside of the United States
J5

When did you come to live in the United States?
Year

b. Parent or guardian died
c. Parent or guardian served time in jail
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home
e. Was a victim of violence or
witnessed violence in neighborhood
f. Lived with anyone who was mentally
ill, suicidal, or severely depressed
g. Lived with anyone who had a problem
with alcohol or drugs
h. Treated or judged unfairly because
of his or her race or ethnic group
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26016030

J6

What is the highest grade or year of school you have
completed? Mark ONE only.

ADULT 2
J11 How is Adult 2 related to this child?

8th grade or less

Biological or Adoptive Parent

9th-12th grade; No diploma

Step-parent

High School Graduate or GED Completed

Foster Parent

Some College Credit, but no Degree

Aunt or Uncle

Associate Degree (AA, AS)

Other: Relative

Bachelor’s Degree (BA, BS, AB)

Other: Non-Relative

Master’s Degree (MA, MS, MSW, MBA)

There is only one primary adult
caregiver for this child ➔ SKIP to question K1

Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
J7

Grandparent

Completed a vocational, trade, or business school
program

J12 What is Adult 2’s sex?

Male

What is your marital status?
Married
Not married, but living with a partner

Female
J13 What is Adult 2’s age?

Never Married
Age in years

Divorced
Separated

J14 Where was Adult 2 born?

In the United States ➔ SKIP to question J16

Widowed
J8

Outside of the United States

In general, how is your physical health?
Excellent

J15 When did Adult 2 come to live in the United States?

Year

Very Good
Good
Fair

J16

Poor
J9

What is the highest grade or year of school Adult 2 has
completed? Mark ONE only.
8th grade or less

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

9th-12th grade; No diploma

Very Good

High School Graduate or GED Completed

Good

Completed a vocational, trade, or business school
program

Fair

Some College Credit, but no Degree

Poor

Associate Degree (AA, AS)

J10 Were you employed at least 50 out of the past 52 weeks?

Bachelor’s Degree (BA, BS, AB)

Yes

Master’s Degree (MA, MS, MSW, MBA)

No

Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)

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§;"]?¤

26016022

J17 What is Adult 2’s marital status?

K3

Married
Not married, but living with a partner
Never Married

Income IN THE LAST CALENDAR YEAR
(January 1 - December 31, 2015)
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 from all jobs?
Yes

Divorced
Separated

C

No

$

Widowed

Total Amount

b. Self-employment income from own nonfarm businesses
or farm business, including proprietorships and
partnerships?

J18 In general, how is Adult 2’s physical health?

Excellent

Yes

C

No

Very Good

$

Total Amount

Good

c. Interest, dividends, net rental income, royalty income,
or income from estates and trusts?

Fair
Poor

Yes

J19 In general, how is Adult 2’s mental or emotional health?

C

No

$

Total Amount

Excellent

d. Social security or railroad retirement; retirement,
survivor, or disability pensions?

Very Good

Yes

Good
Fair

C

No

$

Total Amount

Poor

e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office?

J20 Was Adult 2 employed at least 50 out of the past 52

weeks?

Yes

Yes
No

Total Amount

f. Any other sources of income received regularly such as
Veterans’ (VA) payments, unemployment compensation,
child support, or alimony?

How many people are living or staying at this address?
Include everyone who usually lives or stays at this address.
Do NOT include anyone who is living somewhere else for
more than two months, such as a college student living away
or someone in the Armed Forces on deployment.

Yes

$
K4

Number of people
K2

No

$

K. Household Information
K1

C

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.

C

No

Total Amount

The following question is about your income and is very
important. 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 business, farm, or rent, and any other money
income received.

Number of people

$
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19

Total Amount

§;"]7¤

26016014

Mailing Instructions
Thank you for your participation.
On behalf of the U.S. Department of Health and Human Services, we would like to thank you for the time
and effort you have spent sharing information about this child and your family.
Your answers are important to us and will help researchers, policymakers, and family advocates to better
understand the health and health care needs of children in our diverse population.
Place the completed questionnaire in the postage-paid return envelope. If the envelope has been
misplaced, mail the questionnaire to:
U.S. Census Bureau
ATTN: DCB 60-A
1201 E. 10th Street
Jeffersonville, IN 47132-0001
You may also call 1-800-845-8241 to request a replacement envelope.

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to: Paperwork Project
,
U.S. Census Bureau, 4600 Silver Hill Road, Room 8H590, Washington, DC 20233. You may e-mail comments to
[email protected]; use "Paperwork Project
" as the subject.

NSCH-T1

20

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