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OMB No. 0607-0990: Approval Expires 04/30/2019
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.
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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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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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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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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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Total Amount
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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 0607-0990,
U.S. Census Bureau, 4600 Silver Hill Road, Room 8H590, Washington, DC 20233. You may e-mail comments to
[email protected]; use "Paperwork Project 0607-0990" as the subject.
NSCH-T1
20
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| File Type | application/pdf |
| File Modified | 2016-06-16 |
| File Created | 2016-04-11 |