1 2018 MCH Survey Core_English_Formatted FINAL

Questionnaire and Data Collection Testing, Evaluation, and Research for the Health Resources and Services Administration (HRSA)

2018 MCH Survey Core_English_Formatted FINAL

Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument

OMB: 0915-0379

Document [docx]
Download: docx | pdf


Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument- Control #: 0915-0379

Screener and Core Questionnaire Expiration Date: 06/30/2020


  1. Screener

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0379. Public reporting burden for this collection of information is estimated to average 1 hours per response, including the time for reviewing instructions, searching existing data sources, 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 HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857.

    1. Are there any children 0-17 years old who usually live or stay at this household?

      1. ☐ No [If no, STOP HERE. This is the end of the survey]

      2. ☐ Yes

    2. How many children 0-17 years old usually live or stay at this household?

Shape1 Shape2 Number of children living or staying at this address

    1. What is the primary language spoken in the household?

      1. ☐ English

      2. ☐ Spanish

      3. ☐ Another language, please specify Shape3

Answer the remaining questions for each of the children 0-17 years old who usually live or stay at this address.

Start with the YOUNGEST CHILD, who we will call "Child 1" and continue with the next youngest until you have answered the questions for all children who usually live or stay at this address.

    1. CHILD 1

What is this child’s first name, initials, or nickname?

Shape4

    1. Is this child of Hispanic, Latino, or Spanish origin?

      1. ☐ No, not of Hispanic, Latino, or Spanish origin

      2. ☐ Yes, Mexican, Mexican American, Chicano

      3. ☐ Yes, Puerto Rican

      4. ☐ Yes, Cuban

      1. ☐ Yes, another Hispanic, Latino, or Spanish origin, please specify

Shape5

    1. What is this child’s race? Select one or more.

      1. ☐ White

      2. ☐ Black or African American

      3. ☐ American Indian or Alaska Native please specify,

Shape6

      1. ☐ Asian Indian

      2. ☐ Chinese

      3. ☐ Filipino

      4. ☐ Japanese

      5. ☐ Korean

      6. ☐ Vietnamese

      7. ☐ Other Asian, please specify

Shape7

      1. ☐ Native Hawaiian

      2. ☐ Guamanian or Chamorro

      3. ☐ Samoan

      4. ☐ Other Pacific Islander, please specify

Shape8

☐



    1. What is this child’s sex?

      1. ☐ Male

      2. ☐ Female

    2. How old is this child? If the child is less than one month old, round age in months to 1.

Shape9 Shape10 Years (or) Shape11 Shape12 Months

If this child is YOUNGER THAN 4 YEARS OLD, Go to A10.

    1. Puerto Rico: How well does this child speak Spanish?

All Other Jurisdictions: How well does this child speak English?

      1. ☐ Very well

      2. ☐ Well

      3. ☐ Not well

      4. ☐ Not at all

    1. Does this child CURRENTLY need or use medicine prescribed by a doctor, other than vitamins?

      Shape13

      1. ☐ Yes

      2. ☐ No [Go to A11]

[If yes] is this child’s need for prescription medicine because of ANY medical, behavioral, or other health condition?

Shape14

      1. ☐ Yes

      1. ☐ No [Go to A11]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Does this child need or use more medical care, mental health, or educational services than is usual for most children of the same age?

      Shape15

      1. ☐ Yes

      2. ☐ No [Go to A12]

[If yes] is this child’s need for medical care, mental health, or educational services because of ANY medical, behavioral, or other health condition?

Shape16

      1. ☐ Yes

      1. ☐ No [Go to A12]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Is this child limited or prevented in any way in his or her ability to do the things most children of the same age can do?

      Shape17

      1. ☐ Yes

      2. ☐ No [Go to A13]

[If yes] is this child’s limitation in abilities because of ANY medical, behavioral, or other health condition?

Shape18

      1. ☐ Yes

      1. ☐ No [Go to A13]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Does this child need or get special therapy, such as physical, occupational, or speech therapy?

      Shape19

      1. ☐ Yes

      2. ☐ No [Go to A14]

[If yes] is this because of ANY medical, behavioral, or other health condition?

Shape20

      1. ☐ Yes

      1. ☐ No [Go to A14]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Does this child have any kind of emotional, developmental, or behavioral problem for which he or she needs treatment or counseling?

      Shape21

      1. ☐ Yes

      2. ☐ No [Go to A15]

[If yes] has his or her emotional, developmental, or behavioral problem lasted or is it expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

If respondent has another child, continue with A15. Else continue with Section B.

    1. CHILD 2

What is this child’s first name, initials, or nickname?

Shape22

    1. Is this child of Hispanic, Latino, or Spanish origin?

      1. ☐ No, not of Hispanic, Latino, or Spanish origin

      2. ☐ Yes, Mexican, Mexican American, Chicano

      3. ☐ Yes, Puerto Rican

      4. ☐ Yes, Cuban

      5. ☐ Yes, another Hispanic, Latino, or Spanish origin, please specify Shape23

    2. What is this child’s race? Select one or more.

      1. ☐ White

      2. ☐ Black or African American

      3. ☐ American Indian or Alaska Native please specify,

Shape24

      1. ☐ Asian Indian

      2. ☐ Chinese

      3. ☐ Filipino

      4. ☐ Japanese

      5. ☐ Korean

      6. ☐ Vietnamese

      7. ☐ Other Asian, please specify

Shape25

      1. ☐ Native Hawaiian

      2. ☐ Guamanian or Chamorro

      3. ☐ Samoan

      4. ☐ Other Pacific Islander, please specify

Shape26

    1. ☐

    1. What is this child’s sex?

      1. ☐ Male

      2. ☐ Female

    2. How old is this child? If the child is less than one month old, round age in months to 1.

Shape27 Shape28 Years (or) Shape29 Shape30 Months

If this child is YOUNGER THAN 4 YEARS OLD, Go to A21.

    1. Puerto Rico: How well does this child speak Spanish?

All Other Jurisdictions: How well does this child speak English?

      1. ☐ Very well

      2. ☐ Well

      3. ☐ Not well

      4. ☐ Not at all

    1. Does this child CURRENTLY need or use medicine prescribed by a doctor, other than vitamins?

      Shape31

      1. ☐ Yes

      2. ☐ No [Go to A22]

[If yes] is this child’s need for prescription medicine because of ANY medical, behavioral, or other health condition?

Shape32

      1. ☐ Yes

      1. ☐ No [Go to A22]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Does this child need or use more medical care, mental health, or educational services than is usual for most children of the same age?

      Shape33

      1. ☐ Yes

      2. ☐ No [Go to A23]

[If yes] is this child’s need for medical care, mental health, or educational services because of ANY medical, behavioral, or other health condition?

Shape34

      1. ☐ Yes

      1. ☐ No [Go to A23]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Is this child limited or prevented in any way in his or her ability to do the things most children of the same age can do?

      Shape35

      1. ☐ Yes

      2. ☐ No [Go to A24]

[If yes] is this child’s limitation in abilities because of ANY medical, behavioral, or other health condition?

Shape36

      1. ☐ Yes

      1. ☐ No [Go to A24]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Does this child need or get special therapy, such as physical, occupational, or speech therapy?

      Shape37

      1. ☐ Yes

      2. ☐ No [Go to A25]

[If yes] is this because of ANY medical, behavioral, or other health condition?

Shape38

      1. ☐ Yes

      1. ☐ No [Go to A25]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Does this child have any kind of emotional, developmental, or behavioral problem for which he or she needs treatment or counseling?

      Shape39

      1. ☐ Yes

      2. ☐ No [Go to A26]

[If yes] has his or her emotional, developmental, or behavioral problem lasted or is it expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

If respondent has another child, continue with A26. Else continue with Section B.

    1. CHILD 3

What is this child’s first name, initials, or nickname?

Shape40

    1. Is this child of Hispanic, Latino, or Spanish origin?

      1. ☐ No, not of Hispanic, Latino, or Spanish origin

      2. ☐ Yes, Mexican, Mexican American, Chicano

      3. ☐ Yes, Puerto Rican

      4. ☐ Yes, Cuban

      5. ☐ Yes, another Hispanic, Latino, or Spanish origin, please specify Shape41

    2. What is this child’s race? Select one or more.

      1. ☐ White

      2. ☐ Black or African American

      3. ☐ American Indian or Alaska Native please specify,

Shape42

      1. ☐ Asian Indian

      2. ☐ Chinese

      3. ☐ Filipino

      4. ☐ Japanese

      5. ☐ Korean

      6. ☐ Vietnamese

      7. ☐ Other Asian, please specify

Shape43

      1. ☐ Native Hawaiian

      2. ☐ Guamanian or Chamorro

      3. ☐ Samoan

      4. ☐ Other Pacific Islander, please specify

Shape44

☐

    1. What is this child’s sex?

      1. ☐ Male

      2. ☐ Female

    2. How old is this child? If the child is less than one month old, round age in months to 1.

Shape45 Shape46 Years (or) Shape47 Shape48 Months

If this child is YOUNGER THAN 4 YEARS OLD, Go to A32.

    1. Puerto Rico: How well does this child speak Spanish?

All Other Jurisdictions: How well does this child speak English?

      1. ☐ Very well

      2. ☐ Well

      3. ☐ Not well

      4. ☐ Not at all

    1. Does this child CURRENTLY need or use medicine prescribed by a doctor, other than vitamins?

      Shape49

      1. ☐ Yes

      2. ☐ No [Go to A33]

[If yes] is this child’s need for prescription medicine because of ANY medical, behavioral, or other health condition?

Shape50

      1. ☐ Yes

      1. ☐ No [Go to A33]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Does this child need or use more medical care, mental health, or educational services than is usual for most children of the same age?

      Shape51

      1. ☐ Yes

      2. ☐ No [Go to A34]

[If yes] is this child’s need for medical care, mental health, or educational services because of ANY medical, behavioral, or other health condition?

Shape52

      1. ☐ Yes

      1. ☐ No [Go to A34]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Is this child limited or prevented in any way in his or her ability to do the things most children of the same age can do?

      Shape53

      1. ☐ Yes

      2. ☐ No [Go to A35]

[If yes] is this child’s limitation in abilities because of ANY medical, behavioral, or other health condition?

Shape54

      1. ☐ Yes

      1. ☐ No [Go to A35]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Does this child need or get special therapy, such as physical, occupational, or speech therapy?

      Shape55

      1. ☐ Yes

      2. ☐ No [Go to A36]

[If yes] is this because of ANY medical, behavioral, or other health condition?

Shape56

      1. ☐ Yes

      1. ☐ No [Go to A36]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Does this child have any kind of emotional, developmental, or behavioral problem for which he or she needs treatment or counseling?

      Shape57

      1. ☐ Yes

      2. ☐ No [Go to A37]

[If yes] has his or her emotional, developmental, or behavioral problem lasted or is it expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

If respondent has another child, continue with A37. Else continue with Section B.

    1. CHILD 4

What is this child’s first name, initials, or nickname?

Shape58

    1. Is this child of Hispanic, Latino, or Spanish origin?

      1. ☐ No, not of Hispanic, Latino, or Spanish origin

      2. ☐ Yes, Mexican, Mexican American, Chicano

      3. ☐ Yes, Puerto Rican

      4. ☐ Yes, Cuban

      5. ☐ Yes, another Hispanic, Latino, or Spanish origin, please specify Shape59

    2. What is this child’s race? Select one or more.

      1. ☐ White

      2. ☐ Black or African American

      3. ☐ American Indian or Alaska Native please specify,

Shape60

      1. ☐ Asian Indian

      2. ☐ Chinese

      3. ☐ Filipino

      4. ☐ Japanese

      5. ☐ Korean

      6. ☐ Vietnamese

      7. ☐ Other Asian, please specify

Shape61

      1. ☐ Native Hawaiian

      2. ☐ Guamanian or Chamorro

      3. ☐ Samoan

      4. ☐ Other Pacific Islander, please specify

Shape62

    1. ☐

    1. What is this child’s sex?

      1. ☐ Male

      2. ☐ Female

    2. How old is this child? If the child is less than one month old, round age in months to 1.

Shape63 Shape64 Years (or) Shape65 Shape66 Months

If this child is YOUNGER THAN 4 YEARS OLD, Go to A43

    1. Puerto Rico: How well does this child speak Spanish?

All Other Jurisdictions: How well does this child speak English?

      1. ☐ Very well

      2. ☐ Well

      3. ☐ Not well

      4. ☐ Not at all

    1. Does this child CURRENTLY need or use medicine prescribed by a doctor, other than vitamins?

      Shape67

      1. ☐ Yes

      2. ☐ No [Go to A44]

[If yes] is this child’s need for prescription medicine because of ANY medical, behavioral, or other health condition?

Shape68

      1. ☐ Yes

      1. ☐ No [Go to A44]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Does this child need or use more medical care, mental health, or educational services than is usual for most children of the same age?

      Shape69

      1. ☐ Yes

      2. ☐ No [Go to A45]

[If yes] is this child’s need for medical care, mental health, or educational services because of ANY medical, behavioral, or other health condition?

Shape70

      1. ☐ Yes

      1. ☐ No [Go to A45]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Is this child limited or prevented in any way in his or her ability to do the things most children of the same age can do?

      Shape71

      1. ☐ Yes

      2. ☐ No [Go to A46]

[If yes] is this child’s limitation in abilities because of ANY medical, behavioral, or other health condition?

Shape72

      1. ☐ Yes

      1. ☐ No [Go to A46]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Does this child need or get special therapy, such as physical, occupational, or speech therapy?

      Shape73

      1. ☐ Yes

      2. ☐ No [Go to A47]

[If yes] is this because of ANY medical, behavioral, or other health condition?

Shape74

      1. ☐ Yes

      1. ☐ No [Go to A47]

[If yes] is this a condition that has lasted or is expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

    1. Does this child have any kind of emotional, developmental, or behavioral problem for which he or she needs treatment or counseling?

      Shape75

      1. ☐ Yes

      2. ☐ No [Go to A48]

[If yes] has his or her emotional, developmental, or behavioral problem lasted or is it expected to last 12 months or longer?

      1. ☐ Yes

      1. ☐ No

If there are no other children, continue to Section B.

If there are more than four children 0-17 years old who usually live or stay at this address, list the age and sex for each. Do not repeat information for children already included for Child 1 through Child 4.

    1. CHILD 5

What is this child’s first name, initials, or nickname?

Shape76

    1. How old is this child?

Shape77 Shape78 Years (or) Shape79 Shape80 Months

    1. What is this child’s sex?

      1. ☐ Male

      2. ☐ Female

    2. CHILD 6

What is this child’s first name, initials, or nickname?

Shape81

    1. How old is this child?

Shape82 Shape83 Years (or) Shape84 Shape85 Months

    1. What is this child’s sex?

      1. ☐ Male

      2. ☐ Female

    2. CHILD 7

What is this child’s first name, initials, or nickname?

Shape86

    1. How old is this child?

Shape87 Shape88 Years (or) Shape89 Shape90 Months

    1. What is this child’s sex?

      1. ☐ Male

      2. ☐ Female

    2. CHILD 8

What is this child’s first name, initials, or nickname?

Shape91

    1. How old is this child?

Shape92 Shape93 Years (or) Shape94 Shape95 Months

    1. What is this child’s sex?

      1. ☐ Male

      2. ☐ Female

    2. CHILD 9

What is this child’s first name, initials, or nickname?

Shape96

    1. How old is this child?

Shape97 Shape98 Years (or) Shape99 Shape100 Months

    1. What is this child’s sex?

      1. ☐ Male

      2. ☐ Female

    2. CHILD 10

What is this child’s first name, initials, or nickname?

Shape101

    1. How old is this child?

Shape102 Shape103 Years (or) Shape104 Shape105 Months

    1. What is this child’s sex?

      1. ☐ Male

      2. ☐ Female

  1. This Child’s Health

We now have some follow up questions to ask about [SPECIFY CHILD]. 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. We have selected only one child per household in an effort to minimize the amount of time necessary to complete the follow-up questions.

    1. In general, how would you describe this child’s health?

      1. ☐ Excellent

      2. ☐ Very Good

      3. ☐ Good

      4. ☐ Fair

      5. ☐ Poor

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. How would you describe the condition of this child’s teeth?

      1. ☐ Excellent

      2. ☐ Very Good

      3. ☐ Good

      4. ☐ Fair

      5. ☐ Poor

      6. ☐ Child does not have teeth

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

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

      YES

      NO

      Don’t Know

      Prefer Not to Answer

      B3a. Breathing or other respiratory problems (such as wheezing or shortness of breath)

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      B3b. Eating or swallowing because of a health condition

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      B3c. Digesting food, including stomach/intestinal problems, constipation, or diarrhea

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      B3d. Repeated or chronic physical pain, including headaches or other back or body pain

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      B3e. Using his or her hands

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      B3f. Coordination or moving around

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      B3g. Toothaches

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      B3h. Bleeding gums

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      B3i. Decayed teeth or cavities

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      B3j. Ear infections

      1 ☐

      2 ☐

      77 ☐

      99 ☐

    2. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Does this child have any of the following?

YES

NO

Don’t Know

Prefer Not to Answer

B4a. Deafness or problems with hearing

1 ☐

2 ☐

77 ☐

99 ☐

B4b. Blindness or problems with seeing, even when wearing glasses

1 ☐

2 ☐

77 ☐

99 ☐

    1. Has a doctor or other health care provider EVER told you that this child has any of the following? If yes, does this child CURRENTLY have the condition?

      Ever?

      Currently?

      Don’t Know

      Prefer Not to Answer

      B5a. Asthma

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

      B5b. Diabetes

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

      B5c. Down Syndrome

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

      B5d. Frequent or Severe Headaches, including Migraine

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

      B5e. Brain Injury, Concussion or Head Injury

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

      B5f. Anxiety

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

      B5g. Depression

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

      B5h. Autism, ASD, Autism Spectrum Disorder (ASD), Asperger’s Disorder, or Pervasive Developmental Disorder (PDD)

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

      B5i. Attention Deficit Disorder (ADD ) or Attention Deficit/Hyperactivity Disorder(ADHD)

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

      B5j. Developmental Delay

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

      B5k. Behavior or Conduct Problems

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

      B5l. Intellectual Disability (also known as mental retardation)

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

      B5m. Speech or Other Language Disorder

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

      B5n. Learning Disability

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

      B5o. Another Mental Health Condition

      1 ☐ Yes

      2 ☐ No

      1 ☐ Yes

      2 ☐ No

      77 ☐

      99 ☐

    2. DURING THE PAST 12 MONTHS, how often has this child’s health conditions or problems affected his or her ability to do things other children his or her age do?

      1. ☐ This child does not have any health conditions [Go to B8]

      2. ☐ Never [Go to B8]

      3. ☐ Sometimes

      4. ☐ Usually

      5. ☐ Always

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. To what extent do this child’s health conditions or problems affect his or her ability to do things?

      1. ☐ Very little

      2. ☐ Somewhat

      3. ☐ A great deal

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

Has a doctor or other health care provider EVER told you that this child has Substance Abuse Disorder? Substance Abuse Disorder occurs when the frequent or continued use of alcohol and/or drugs have caused health problems, disability, and failure to meet major responsibilities at work, school, or home.

Shape106

      1. ☐ Yes

      2. ☐ No [Go to B9]

      1. ☐ Don’t Know [Go to B9]

      1. ☐ Prefer Not to Answer [Go to B9]

[If yes] does this child CURRENTLY have the condition?

Shape107

      1. ☐ Yes

      1. ☐ No [Go to B9]

      1. ☐ Don’t Know [Go to B9]

      1. ☐ Prefer Not to Answer [Go to B9]

[If yes] is it:

      1. ☐ Mild

      1. ☐ Moderate

      2. ☐ Severe

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

Does this child have any of the following?

YES

NO

Don’t Know

Prefer Not to Answer

B9a. Serious difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition

1 ☐

2 ☐

77 ☐

99 ☐

B9b. Serious difficulty walking or climbing stairs

1 ☐

2 ☐

77 ☐

99 ☐

B9c. Difficulty dressing or bathing

1 ☐

2 ☐

77 ☐

99 ☐

B9d. Difficulty doing errands alone, such as visiting a doctor’s office or shopping, because of a physical, mental, or emotional condition

1 ☐

2 ☐

77 ☐

99 ☐

B9e. Deafness or problems with hearing

1 ☐

2 ☐

77 ☐

99 ☐

B9f. Blindness or problems with seeing, even when wearing glasses

1 ☐

2 ☐

77 ☐

99 ☐
Shape108

    1. Has a doctor or other health care provider ever told you that this child had…

YES

NO

Don’t Know

Prefer Not to Answer

B10a. Rheumatic heart disease

1 ☐

2 ☐

77 ☐

99 ☐

B10b. Rheumatic fever

1 ☐

2 ☐

77 ☐

99 ☐

B10c. Impetigo (or other skin infections)

1 ☐

2 ☐

77 ☐

99 ☐

[If yes to rheumatic heart disease or fever] Do they take any medication for this condition?

Shape109

      1. ☐ Yes

        Shape110

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

[If yes] Do they take Oral medication (pills) or get a shot?

      1. ☐ Oral Medication (Pills) [Go to B11]

      1. ☐ Shot [Go to B11]

[If no] Why not? Check all that apply.

      1. ☐ Cannot afford the cost.

      2. ☐ No transportation.

      3. ☐ No-one to take my child to hospital.

      4. ☐ Not important

      5. ☐ Other Reason, please specify Shape111

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. Has a doctor or other health care provider ever told you that this child had blood problems such as leukemia, anemia or sickle cell disease? Please do not include Sickle Cell Trait.

[Read if necessary]: Children with anemia have problems with their blood that can cause them to be very tired.

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don't Know

      1. ☐ Prefer not to answer

Now I’m going to ask you a few questions about injury prevention for your child.

    1. Have you or any other adult in your child's life discussed avoidance of violence or prevention of injury with your child?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. Do you ever discuss with your child the dangers of playing on the road, climbing trees and swimming in the ocean?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. Do you accompany your child during outdoor activities like swimming or playing?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

When your child rides a bicycle, how often does he or she wear a helmet?

      1. ☐ My child does not ride a bicycle

      2. ☐ Never wears a helmet

      3. ☐ Rarely wears a helmet

      4. ☐ Sometimes wears a helmet

      5. ☐ Most of the time wears a helmet

      6. ☐ Always wears a helmet

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 0-11 YEARS OLD]

How often does your child ride in a child safety seat or booster seat?

      1. ☐ Always

      2. ☐ Nearly always

      3. ☐ Sometimes

      4. ☐ Seldom

      5. ☐ Never [If child 0-11 years old, go to B18]

      6. ☐ My child does not ride in cars [If child 0-11 years old, go to B18]

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 0-11 YEARS OLD]

Where is your child's safety seat located in your car?

      1. ☐ Front passenger

      2. ☐ Behind passenger

      3. ☐ Behind driver

      4. ☐ Middle of the back seat

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Are your child's immunizations up to date?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

  1. This Child as an Infant

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

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

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

Shape112 Shape113 pounds AND Shape114 Shape115 ounces

Shape116 Shape117 kilograms AND Shape118 Shape119 grams

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. How old were you when this child was born?

Shape120 Shape121 Years

    1. [ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD, ELSE GO TO I3]

In which position do you most often lay this baby down to sleep now?

      1. ☐ On his or her side

      2. ☐ On his or her back

      3. ☐ On his or her stomach

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD. ELSE GO TO SECTION D]

Was this child EVER breastfed or fed breast milk?

Shape122

      1. ☐ Yes

      2. ☐ No [Go to C6]

      1. ☐ Don’t Know [Go to C6]

      1. ☐ Prefer Not to Answer [Go to C6]

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

Shape123 Shape124 days (or)

Shape125 Shape126 weeks (or)

Shape127 Shape128 months (or)

Shape129 Shape130 years

Shape131 Child is still breastfeeding

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. 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.

Shape132 Shape133 days (or) Shape134 Shape135 weeks (or) Shape136 Shape137 months

Shape138 At birth

Shape139 Check this box if child has never been fed anything other than breast milk or formula

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

  1. Health Care Services

    1. 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?

      Shape140

      1. ☐ Yes

      2. ☐ No [Go to D2]

      1. ☐ Don’t Know [Go to D2]

      1. ☐ Prefer not to answer [Go to D2]

[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.

      1. ☐ 0 visits

      1. ☐ 1 visit

      2. ☐ 2 or more visits

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. Are you concerned about this child’s weight?

      1. ☐ Yes, it's too high

      2. ☐ Yes, it's too low

      3. ☐ No, I am not concerned

      1. ☐ Don't Know

      1. ☐ Prefer not to answer

    1. What is this child’s CURRENT height (or length)? Please provide your best estimate.

Shape141 Shape142 feet AND Shape143 Shape144 inches

Shape145 Shape146 meters AND Shape147 Shape148 centimeters

      1. ☐ Don't Know

      1. ☐ Prefer not to answer

    1. How much does this child CURRENTLY weigh? Please provide your best estimate.

Shape149 Shape150 pounds AND Shape151 Shape152 ounces

Shape153 Shape154 kilograms AND Shape155 Shape156 grams

      1. ☐ Don't Know

      1. ☐ Prefer not to answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

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?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

[If this child is YOUNGER THAN 9 MONTHS, GO to D7].

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.

Shape157

      1. ☐ Yes

      2. ☐ No [Go to D7]

      1. ☐ Don’t Know [Go to D7]

      1. ☐ Prefer not to answer [Go to D7]

[If this child is 9-23 Months]

Did the questionnaire ask about your concerns or observations about: Check all that apply.

      1. ☐ How this child talks or makes speech sounds?

      1. ☐ How this child interacts with you and others?

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

[If this child is 2-5 Years]

Did the questionnaire ask about your concerns or observations about: Check all that apply.

      1. ☐ Words and phrases this child uses and understands?

      1. ☐ How this child behaves and gets along with you and others?

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. 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?

      Shape158

      1. ☐ Yes

      2. ☐ No [Go to D8]

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

[If yes] where does this child USUALLY go?

      1. ☐ Doctor's Office

      1. ☐ Hospital Emergency Room

      2. ☐ Hospital Outpatient Department

      3. ☐ Clinic or Health Center

      4. ☐ School (Nurse's Office, Athletic Trainer's Office)

      5. ☐ Village Dispensary

      6. ☐ Some other place, please specify Shape159

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. Is there a place that this child USUALLY goes when he or she needs routine preventive care, such as a physical examination or well-child check-up?

      Shape160

      1. ☐ Yes

      2. ☐ No [If child is 0-5 years old, go to D9; else if child 6-17 years old, go to D10]

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

[If yes] is this the same place this child goes when he or she is sick?

      1. ☐ Yes

      1. ☐ No

    1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Has this child EVER had his or her vision tested?

Shape161

      1. ☐ Yes

      2. ☐ No [Go to D10]

      3. ☐ Don’t Know

      1. ☐ Prefer not to answer

[If yes] what kind of place or places did this child have his or her vision tested? Check all that apply.

      1. ☐ Eye doctor or eye specialist (ophthalmologist, optometrist) office

      1. ☐ Pediatrician or other general doctor’s office

      2. ☐ Clinic or health center

      3. ☐ School

      4. ☐ Another place, please specify Shape162

    1. 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?

      1. ☐ Yes, saw a dentist

      2. ☐ Yes, saw other oral health care provider

      3. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. 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, clinical social workers, and school counselors.

      1. ☐ Yes

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

      3. ☐ No, this child did not need to see a mental health professional

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. 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.

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. DURING THE PAST 12 MONTHS, was there any time when this child needed health care but it was not received or not available? By health care, we mean medical care as well as other kinds of care like dental care, vision care, and mental health services.

      Shape163

      1. ☐ Yes

      2. ☐ No [Go to D15]

      1. ☐ Don’t Know [Go to D15]

      1. ☐ Prefer not to answer [Go to D15]

[If yes] which types of care were not received or not available? Check all that apply.

      1. ☐ Medical Care

      1. ☐ Dental Care

      2. ☐ Vision Care

      3. ☐ Hearing Care

      4. ☐ Mental Health Services

      5. ☐ Another type, please specify Shape164

    1. Which of the following contributed to this child not receiving needed health services:

      YES

      NO

      Don’t Know

      Prefer Not to Answer

      D14a. This child was not eligible for the services?

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      D14b. The services this child needed were not available in your area?

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      D14c. There were problems getting an appointment when this child needed one?

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      D14d. There were problems with getting transportation or child care?

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      D14e. The (clinic/doctor’s) office wasn’t open when this child needed care?

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      D14f. There were issues related to cost?

      1 ☐

      2 ☐

      77 ☐

      99 ☐

    2. DURING THE PAST 12 MONTHS, how many times did this child visit a hospital emergency room?

      1. ☐ No visits

      2. ☐ 1 visit

      3. ☐ 2 or more visits

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

  1. Experience with This Child’s Health Care Providers

    1. 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.

      1. ☐ Yes, one person

      2. ☐ Yes, more than one person

      3. ☐ No

    2. DURING THE PAST 12 MONTHS, did this child need a referral to see any doctors or receive any services?

      Shape165

      1. ☐ Yes

      2. ☐ No [Go to E3]

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

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

      1. ☐ Not a problem

      1. ☐ Small problem

      2. ☐ Big problem

    1. [Answer the following questions only if this child had a health care visit IN THE PAST 12 MONTHS. Otherwise, go to E4.]

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

Always

Usually

Sometimes

Never

Don’t Know

Prefer Not to Answer

E3a. Spend enough time with this child?

1 ☐

2 ☐

3 ☐

4 ☐

77 ☐

99 ☐

E3b. Listen carefully to you?

1 ☐

2 ☐

3 ☐

4 ☐

77 ☐

99 ☐

E3c. Show sensitivity to your family’s values and customs?

1 ☐

2 ☐

3 ☐

4 ☐

77 ☐

99 ☐

E3d. Provide the specific information you needed concerning this child?

1 ☐

2 ☐

3 ☐

4 ☐

77 ☐

99 ☐

E3e. Help you feel like a partner in this child’s care?

1 ☐

2 ☐

3 ☐

4 ☐

77 ☐

99 ☐

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

      1. ☐ Yes

      2. ☐ No

      3. ☐ Did not see more than one health care provider in PAST 12 MONTHS [Go to E7]

    2. 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?

      Shape166

      1. ☐ Yes

      2. ☐ No [Go to E6]

[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?

      1. ☐ Usually

      1. ☐ Sometimes

      2. ☐ Never

    1. Overall, how satisfied are you with the communication among this child’s doctors and other health care providers?

      1. ☐ Very satisfied

      2. ☐ Somewhat satisfied

      3. ☐ Somewhat dissatisfied

      4. ☐ Very dissatisfied

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Do any of this child’s doctors or other health care providers treat only children?

Shape167

      1. ☐ Yes

      2. ☐ No [Go to E8]

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

[If yes] have they talked with you about having this child eventually see doctors or other health care providers who treat adults?

      1. ☐ Yes

      1. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Has this child’s doctor or other health care provider actively worked with this child to:

YES

NO

Don’t Know

Prefer Not to Answer

E8a. Think about and plan for his or her future. For example, by taking time to discuss future plans about education, work, relationships, and development of independent living skills?

1 ☐

2 ☐

77 ☐

99 ☐

E8b. Make positive choices about his or her health. For example, by eating healthy, getting regular exercise, not using tobacco, alcohol or other drugs, or delaying sexual activity?

1 ☐

2 ☐

77 ☐

99 ☐

E8c. Gain skills to manage his or her health and health care. For example, by understanding current health needs, knowing what to do in a medical emergency, or taking medications he or she may need?

1 ☐

2 ☐

77 ☐

99 ☐

E8d. 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?

1 ☐

2 ☐

77 ☐

99 ☐

    1. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Have this child’s doctors or other health care providers worked with you and this child to create a written plan to meet his or her health goals and needs?

Shape168

      1. ☐ Yes

      2. ☐ No [Go to E10]

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

[If yes] does this plan identify specific health goals for this child and any health needs or problems this child may have and how to get these needs met?

      1. ☐ Yes

      1. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

Did you and this child receive a written copy of this plan of care?

      1. ☐ Yes

      1. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

Is this plan CURRENTLY up-to-date for this child?

      1. ☐ Yes

      1. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. Eligibility for health insurance often changes in young adulthood. Do you know how this child will be insured as he or she becomes an adult?

      1. ☐ Yes [Go to F]

        Shape169

      2. ☐ No

[If no] has anyone discussed with you how to obtain or keep some type of health insurance coverage as this child becomes an adult?

      1. ☐ Yes

      1. ☐ No

  1. This Child’s Health Insurance Coverage

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

      1. ☐ Yes, this child was covered all 12 months or, if under 1 year old, since birth [Go to F4]

      2. ☐ Yes, but this child had a gap in coverage

      3. ☐ No

    2. Please indicate whether each of the following is a reason this child was not covered by health insurance DURING THE PAST 12 MONTHS:

      Yes

      No

      F2a. Change in employer or employment status

      1 ☐

      2 ☐

      F2b. Cancellation due to overdue premiums

      1 ☐

      2 ☐

      F2c. Dropped coverage because it was unaffordable

      1 ☐

      2 ☐

      F2d. Dropped coverage because benefits were inadequate

      1 ☐

      2 ☐

      F2e. Dropped coverage because choice of health care providers was inadequate

      1 ☐

      2 ☐

      F2f. Problems with application or renewal process

      1 ☐

      2 ☐

      F2g. Another reason, please specify
      Shape170

      1 ☐

      2 ☐

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

      1. ☐ Yes

      2. ☐ No [Go to Section G]

      1. ☐ Don’t Know [Go to Section G]

      1. ☐ Prefer not to answer [Go to Section G]

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

      Yes

      No

      F4a. Insurance through a current or former employer or union

      1 ☐

      2 ☐

      F4b. Insurance purchased directly from an insurance company

      1 ☐

      2 ☐

      F4c. Medicaid, Medical Assistance, or any kind of government assistance plan for those with low incomes or a disability

      1 ☐

      2 ☐

      F4d. TRICARE or other military health care

      1 ☐

      2 ☐

      F4e. Indian Health Service

      1 ☐

      2 ☐

      F4f. Another type, please specify
      Shape171

      1 ☐

      2 ☐

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

      1. ☐ Always

      2. ☐ Usually

      3. ☐ Sometimes

      4. ☐ Never

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

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

      1. ☐ Always

      2. ☐ Usually

      3. ☐ Sometimes

      4. ☐ Never

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

  1. Providing for This Child’s Health

    1. 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.

      1. ☐ $0 (No medical or health-related expenses) [Go to G4]

      2. ☐ $1-$249

      3. ☐ $250-$499

      4. ☐ $500-$999

      5. ☐ $1,000-$5,000

      6. ☐ More than $5,000

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. How often are these costs reasonable?

      1. ☐ Always

      2. ☐ Usually

      3. ☐ Sometimes

      4. ☐ Never

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

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

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

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

      YES

      NO

      Don’t Know

      Prefer Not to Answer

      G4a. Stopped working because of this child’s health or health conditions?

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      G4b. Cut down on the hours you work because of this child’s health or health conditions?

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      G4c. Avoided changing jobs because of concerns about maintaining health insurance for this child?

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      G4d. Received help from extended family members?

      1 ☐

      2 ☐

      77 ☐

      99 ☐

    2. 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.

      1. ☐ This child does not need health care provided on a weekly basis

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

      3. ☐ Less than 1 hour per week

      4. ☐ 1-4 hours per week

      5. ☐ 5-10 hours per week

      6. ☐ 11 or more hours per week

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. 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. ☐ This child does not need health care provided on a weekly basis

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

      3. ☐ Less than 1 hour per week

      4. ☐ 1-4 hours per week

      5. ☐ 5-10 hours per week

      6. ☐ 11 or more hours per week

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

  1. This Child’s Learning

    1. 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?

      1. ☐ None

      2. ☐ Less than 1 hour

      3. ☐ 1 hour

      4. ☐ 2 hours

      5. ☐ 3 hours

      6. ☐ 4 or more hours

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. 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?

      1. ☐ None

      2. ☐ Less than 1 hour

      3. ☐ 1 hour

      4. ☐ 2 hours

      5. ☐ 3 hours

      6. ☐ 4 or more hours

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

How well is this child learning to do things for him or herself?

      1. ☐ Very well

      2. ☐ Somewhat

      3. ☐ Poorly

      4. ☐ Not at all

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

How confident are you that this child will be successful in elementary or primary school?

      1. ☐ Very confident

      2. ☐ Mostly confident

      3. ☐ Somewhat confident

      4. ☐ Not confident at all

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

DURING THE PAST 12 MONTHS, about how many days did this child miss school because of illness or injury?

      1. ☐ No missed school days

      2. ☐ 1-3 days

      3. ☐ 4-6 days

      4. ☐ 7-10 days

      5. ☐ 11 or more days

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

DURING THE PAST 12 MONTHS, how many times has this child’s school contacted you or another adult in your household about any problems he or she is having with school?

      1. ☐ No times

      2. ☐ 1 time

      3. ☐ 2 or more times

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

SINCE STARTING KINDERGARTEN, has this child repeated any grades?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

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?

      1. ☐ 0 days

      2. ☐ 1-3 days

      3. ☐ 4-6 days

      4. ☐ Every day

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

  1. About You and This Child

    1. How many times has this child moved to a new address or location since he or she was born?

Shape172 Shape173 Number of times

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

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

      1. ☐ 0 days

      2. ☐ 1-3 days

      3. ☐ 4-6 days

      4. ☐ Every day

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

DURING THE PAST WEEK, how many days did you or other family members tell stories or sing songs to this child?

      1. ☐ 0 days

      2. ☐ 1-3 days

      3. ☐ 4-6 days

      4. ☐ Every day

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

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.

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

  1. About Your Family and Household

    1. Does anyone living in your household use cigarettes, cigars, pipe tobacco, or chew betel nut?

      1. ☐ Yes

      2. ☐ No [Go to J3]

      1. ☐ Don’t Know [Go to J3]

      1. ☐ Prefer Not to Answer [Go to J3]

    1. Does anyone smoke inside your home?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. Has your child ever chewed betel nut?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. Are you aware of the effects of chewing betel nut?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

The next three questions are about money.

    1. 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?

      1. ☐ Never

      2. ☐ Rarely

      3. ☐ Somewhat often

      4. ☐ Very often

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. 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?

      1. ☐ We could always afford to eat good nutritious meals.

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

      3. ☐ Sometimes we could not afford enough to eat.

      4. ☐ Often we could not afford enough to eat.

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

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

      YES

      NO

      Don’t Know

      Prefer Not to Answer

      J7a. Cash assistance from a government welfare program?

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      J7b. Food Stamps or Supplemental Nutrition Assistance Program benefits (SNAP)?

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      J7c. Free or reduced-cost breakfasts or lunches at school?

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      J7d. Benefits from the Woman, Infants, and Children (WIC) Program?

      1 ☐

      2 ☐

      77 ☐

      99 ☐

  1. About You

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.

    1. Adult 1

How are you related to this child?



      1. ☐ Biological or Adoptive Parent

      2. ☐ Step-parent

      3. ☐ Grandparent

      4. ☐ Foster Parent

      5. ☐ Aunt or Uncle

      6. ☐ Other: Relative

      7. ☐ Other: Non-Relative

    1. What is your sex?

      1. ☐ Male

      2. ☐ Female

    2. What is your age?

Shape174 Shape175 Age in years

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

      1. ☐ 8th grade or less

      2. ☐ 9th-12th grade; No diploma

      3. ☐ High School Graduate or GED Completed

      4. ☐ Completed a vocational, trade, or business school program

      5. ☐ Some College Credit, but no Degree

      6. ☐ Associate Degree (AA, AS)

      7. ☐ Bachelor’s Degree (BA, BS, AB)

      8. ☐ Master’s Degree (MA, MS, MSW, MBA)

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

    2. What is your marital status?

      1. ☐ Married [Go to K7]

      2. ☐ Never married

      3. ☐ Divorced

      4. ☐ Separated

      5. ☐ Widowed

      1. ☐ Prefer not to answer [Go to K7]

    1. Do you currently live with a romantic partner?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Prefer Not to Answer

    1. In general, how is your physical health?

      1. ☐ Excellent

      2. ☐ Very Good

      3. ☐ Good

      4. ☐ Fair

      5. ☐ Poor

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. In general, how is your mental or emotional health?

      1. ☐ Excellent

      2. ☐ Very Good

      3. ☐ Good

      4. ☐ Fair

      5. ☐ Poor

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

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

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. Is there another adult in this household who is this child’s caregiver or guardian?

      1. ☐ Yes

      2. ☐ No [Go to Section L]

      1. ☐ Prefer not to answer [Go to Section L]

This other caregiver or guardian will now be referred to as Adult 2.

    1. How is Adult 2 related to this child?

      1. ☐ Biological or Adoptive Parent

      2. ☐ Step-parent

      3. ☐ Grandparent

      4. ☐ Foster Parent

      5. ☐ Aunt or Uncle

      6. ☐ Other: Relative

      7. ☐ Other: Non-Relative

    2. What is Adult 2’s sex?

      1. ☐ Male

      2. ☐ Female

    3. What is Adult 2’s age?

Shape176 Shape177 Age in years

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

      1. ☐ 8th grade or less

      2. ☐ 9th-12th grade; No diploma

      3. ☐ High School Graduate or GED Completed

      4. ☐ Completed a vocational, trade, or business school program

      5. ☐ Some College Credit, but no Degree

      6. ☐ Associate Degree (AA, AS)

      7. ☐ Bachelor’s Degree (BA, BS, AB)

      8. ☐ Master’s Degree (MA, MS, MSW, MBA)

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

    2. What is Adult 2’s marital status?

      1. ☐ Married [Go to K17]

      2. ☐ Never married

      3. ☐ Divorced

      4. ☐ Separated

      5. ☐ Widowed

      1. ☐ Prefer not to answer

    1. Does Adult 2 currently live with a romantic partner?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

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

      1. ☐ Excellent

      2. ☐ Very Good

      3. ☐ Good

      4. ☐ Fair

      5. ☐ Poor

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

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

      1. ☐ Excellent

      2. ☐ Very Good

      3. ☐ Good

      4. ☐ Fair

      5. ☐ Poor

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. Was Adult 2 employed at least 50 out of the past 52 weeks?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

  1. Your Health

    1. A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition. About how long has it been since you last visited a doctor for a routine checkup?

      1. ☐ Within the past year (anytime less than 12 months ago)

      2. ☐ Within the past 2 years (1 year but less than 2 years ago)

      3. ☐ Within the past 5 years (2 years but less than 5 years ago)

      4. ☐ 5 or more years ago

      5. ☐ Never

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. DURING THE PAST 12 MONTHS, have you received any treatment or counseling from a mental health professional? Mental health professionals include psychiatrists, psychologists, psychiatric nurses, and clinical social workers.

      1. ☐ Yes

      2. ☐ No, but I needed to see a mental health professional

      3. ☐ No, I did not need to see a mental health professional [Go to L4]

      1. ☐ Don’t Know [Go to L4]

      1. ☐ Prefer Not to Answer [Go to L4]

    1. How much of a problem was it to get the mental health treatment or counseling that you needed?

      1. ☐ Not a problem

      2. ☐ Small problem

      3. ☐ Big problem

    2. During your most recent pregnancy, did you have your teeth cleaned by a dentist or dental hygienist?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. Who makes the healthcare decisions for your health?

      1. ☐ You

      2. ☐ Your spouse

      3. ☐ You and your spouse/partner together

      4. ☐ Your parents

      5. ☐ Someone else, please specify Shape178

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. Who makes the healthcare decisions for your child(ren)?

      1. ☐ You

      2. ☐ Your spouse

      3. ☐ You and your spouse/partner together

      4. ☐ Your parents

      5. ☐ Another person, please specify Shape179

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

The next questions ask about smoking, drinking, and drug use.

    1. During the past 30 days, on how many days did you smoke cigarettes?

      1. ☐ 0 days

      2. ☐ 1 or 2 days

      3. ☐ 3 to 5 days

      4. ☐ 6 to 9 days

      5. ☐ 10 to 19 days

      6. ☐ 20 to 29 days

      7. ☐ All 30 days

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. Do you drink alcohol, including drinks you brew or make at home?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. During your life, have you ever used any of the following:

Yes

No

Don’t Know

Prefer Not to Answer

L9a. Betel nut

1 ☐

2 ☐

77 ☐

99 ☐

L9b. Vape or e-cigarette

1 ☐

2 ☐

77 ☐

99 ☐

L9c. Funta

1 ☐

2 ☐

77 ☐

99 ☐

L9d. Marijuana (also called grass, pot, weed, or reefer)

1 ☐

2 ☐

77 ☐

99 ☐

L9e. Cocaine, including powder, crack, or freebase

1 ☐

2 ☐

77 ☐

99 ☐

L9f. Heroin (also called smack, junk, or China White)

1 ☐

2 ☐

77 ☐

99 ☐

L9g. Methamphetamines (also called speed, crystal, crank, or ice)

1 ☐

2 ☐

77 ☐

99 ☐

L9h. Ecstasy (also called MDMA)

1 ☐

2 ☐

77 ☐

99 ☐

L9i. Synthetic marijuana (also called K2, Spice, fake weed, King Kong, Yucatan Fire, Skunk, or Moon Rocks)

1 ☐

2 ☐

77 ☐

99 ☐

L9j. Steroid pills or shots without a doctor's prescription

1 ☐

2 ☐

77 ☐

99 ☐

L9k. Prescription pain medicine without a doctor's prescription or differently than how a doctor told you to use it? (Count drugs such as codeine, Vicodin, OxyContin, Hydrocodone, and Percocet)

1 ☐

2 ☐

77 ☐

99 ☐

If respondent never chewed betel nut, go to L11.

    1. During the past 30 days, on how many days did you chew betel nut?

      1. ☐ 0 days

      2. ☐ 1 or 2 days

      3. ☐ 3 to 5 days

      4. ☐ 6 to 9 days

      5. ☐ 10 to 19 days

      6. ☐ 20 to 29 days

      7. ☐ All 30 days

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. Have you been referred to, or did you receive, any form of intervention/counseling/treatment for substance use issues?

      1. ☐ Yes

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. Has your doctor or health care professional told you that you had type 1 or type 2 diabetes?

      1. ☐ Type 1 diabetes

      2. ☐ Type 2 diabetes

      3. ☐ Neither [Go to L14]

      1. ☐ Don’t Know [Go to L14]

      1. ☐ Prefer Not to Answer [Go to L14]

    1. Are you taking medication for this?

      1. ☐ Insulin

      2. ☐ Pills

      3. ☐ Insulin and Pills

      4. ☐ I do not take medication

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. Has a doctor or other health care provider EVER told you that you have any of the following conditions…?

      YES

      NO

      Don’t Know

      Prefer Not to Answer

      L14a. Rheumatic heart disease

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      L14b. Rheumatic fever

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      L14c. Cervical cancer

      1 ☐

      2 ☐

      77 ☐

      99 ☐

      L14d. Anemia

      1 ☐

      2 ☐

      77 ☐

      99 ☐

    2. How do you describe your weight?

      1. ☐ Very underweight

      2. ☐ Slightly underweight

      3. ☐ About the right weight

      4. ☐ Slightly overweight

      5. ☐ Very overweight

    3. Which of the following are you trying to do about your weight?

      1. ☐ Lose weight

      2. ☐ Gain weight

      3. ☐ Stay the same weight

      4. ☐ I am not trying to do anything about my weight

    4. During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.

      1. ☐ 0 days

      2. ☐ 1 day

      3. ☐ 2 days

      4. ☐ 3 days

      5. ☐ 4 days

      6. ☐ 5 days

      7. ☐ 6 days

      8. ☐ 7 days

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. We would like to confirm, do you have an infant 12-months or younger and/or are you currently pregnant.

      1. ☐ I have an infant 12-months or younger and I am not currently pregnant

      2. ☐ I have a young infant and I am currently pregnant

      3. ☐ I am currently pregnant but do not have another infant [Go to Section M]

      4. ☐ No [Go to M]

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

These next questions are about Zika virus. Zika virus infection is an illness that is most often spread by the bite of a mosquito but may also be spread by having sex with a man who has the Zika virus.

    1. During your most recent pregnancy, how worried were you about getting infected with Zika virus? Check ONE answer.

      1. ☐ Very worried

      2. ☐ Somewhat worried

      3. ☐ Not at all worried

      4. ☐ I had never heard of Zika virus during my most recent pregnancy

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. At any time during your most recent pregnancy, did you talk with a doctor, nurse, or other healthcare worker about Zika virus?

      1. ☐ No

      2. ☐ Yes, a healthcare worker talked with me without my asking about it

      3. ☐ Yes, a healthcare worker talked with me, but only AFTER I asked about it

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. During your most recent pregnancy, did you get a blood test for Zika virus?

      1. ☐ Yes

      2. ☐ No [Go to L23]

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

    1. Were you diagnosed with Zika during your most recent pregnancy?

      1. ☐ Yes

      2. ☐ No [Go to M1]

      1. ☐ Don’t Know [Go to M1]

      1. ☐ Prefer Not to Answer [Go to M1]

[If yes] which child were you carrying?

Shape180

The next questions are about travel during your most recent pregnancy.

    1. During your most recent pregnancy, did you travel to areas with the Zika virus?

      Shape181

      1. ☐ Yes

        Shape182

      2. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

[If yes] During your most recent pregnancy, were you aware of recommendations that pregnant women should avoid travel to areas with Zika virus?

      1. ☐ Yes

      1. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

[If no] During your most recent pregnancy, did you avoid travel to areas with the Zika virus because of recommendations that pregnant women should avoid travel to areas those areas?

      1. ☐ Yes

      1. ☐ No

      1. ☐ Don’t Know

      1. ☐ Prefer Not to Answer

  1. Household Information

    1. 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.

Shape183 Shape184 Number of people

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. 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.

Shape185 Shape186 Number of people

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer

    1. Now we are going to ask about your family’s income IN THE LAST CALENDAR YEAR (January 1 - December 31, 2017) For each type of income, please mention if your family received it then give me your best estimate of the TOTAL AMOUNT IN THE LAST CALENDAR YEAR.

      YES

      NO

      If yes, total amount received

      Don’t Know

      Prefer Not to Answer

      M3a. Wages, salary, commissions, bonuses, or tips from all jobs?

      1 ☐

      2 ☐

      Shape187 Shape188 ,Shape189 Shape190 Shape191 ,Shape192 Shape193 Shape194

      77 ☐

      99 ☐

      M3b. Self-employment income from own nonfarm businesses or farm business, including proprietorships and partnerships?

      1 ☐

      2 ☐

      Shape195 Shape196 ,Shape197 Shape198 Shape199 ,Shape200 Shape201 Shape202

      77 ☐

      99 ☐

      M3c. Interest, dividends, net rental income, royalty income, or income from estates and trusts?

      1 ☐

      2 ☐

      Shape203 Shape204 ,Shape205 Shape206 Shape207 ,Shape208 Shape209 Shape210

      77 ☐

      99 ☐

      M3d. Social security or railroad retirement; retirement, survivor, or disability pensions?

      1 ☐

      2 ☐

      Shape211 Shape212 ,Shape213 Shape214 Shape215 ,Shape216 Shape217 Shape218

      77 ☐

      99 ☐

      M3e. Supplemental security income (SSI); any public assistance or welfare payments from the state or local welfare office?

      1 ☐

      2 ☐

      Shape219 Shape220 ,Shape221 Shape222 Shape223 ,Shape224 Shape225 Shape226

      77 ☐

      99 ☐

      M3f. Any other sources of income received regularly such as Veterans’ (VA) payments, unemployment compensation, child support, or alimony?

      1 ☐

      2 ☐

      Shape227 Shape228 ,Shape229 Shape230 Shape231 ,Shape232 Shape233 Shape234

      77 ☐

      99 ☐

    2. The following question is about your income and is very important. Think about your total combined family income in 2017 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.

Shape235 Shape236 ,Shape237 Shape238 Shape239 ,Shape240 Shape241 Shape242 Total amount ($)

      1. ☐ Don’t Know

      1. ☐ Prefer not to answer



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, you, 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





File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBeckmann, Allan G. EOP/OMB
File Modified0000-00-00
File Created2021-01-20
© 2024 OMB.report | Privacy Policy