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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
Not
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.
We now have some follow-up questions to ask about:
true
c. This child stays calm and
in control when faced with
a challenge
d. This child cares about
doing well in school
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.
e. This child does all
required homework
We have selected only one child per household in an
effort to minimize the amount of time necessary to
complete the follow-up questions.
f. This child is bullied,
picked on, or excluded by
other children
The survey should be completed by an adult who is
familiar with this child’s health and health care.
g. This child bullies others,
picks on them, or
excludes them
Your participation is important. Thank you.
h. This child argues too
much
A. This Child’s Health
true
a. This child shows interest
and curiosity in learning
new things
b. This child works to finish
tasks he or she starts
A4
A1 In general, how would you describe this child’s health
DURING THE PAST 12 MONTHS, has this child had
FREQUENT or CHRONIC difficulty with any of the
following?
Yes
No
Yes
No
a. Breathing or other respiratory
problems (such as wheezing or
shortness of breath)
b. Eating or swallowing because of
a health condition
(the one named above)?
Excellent
Very good
c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea
Good
Fair
d. Repeated or chronic physical pain,
including headaches or other back
or body pain
Poor
e. Toothaches
A2 How would you describe the condition of this child’s
f. Bleeding gums
teeth?
Excellent
Very good
g. Decayed teeth or cavities
A5
Good
Does this child have any of the following?
a. Serious difficulty concentrating,
remembering, or making decisions
because of a physical, mental, or
emotional condition
Fair
Poor
b. Serious difficulty walking or climbing
stairs
c. Difficulty dressing or bathing
d. Difficulty doing errands alone, such
as visiting a doctor’s office or shopping,
because of a physical, mental, or
emotional condition
e. Deafness or problems with hearing
f. Blindness or problems with seeing,
even when wearing glasses
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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 Substance Abuse 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
A18 Tourette Syndrome?
Yes
A24 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
A19 Anxiety Problems?
Yes
Moderate
Severe
A25 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:
No
If yes, is it:
Mild
Moderate
Severe
A20 Depression?
Mild
Moderate
Severe
A26 Speech or Other Language Disorder?
Yes
No
Yes
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:
Moderate
Severe
A21 Other Genetic or Inherited Condition?
Mild
Yes
If yes, does this child CURRENTLY have the condition?
Severe
No
If yes, does this child CURRENTLY have the condition?
No
Yes
If yes, is it:
Mild
Moderate
A27 Learning Disability?
No
Yes
No
If yes, is it:
Mild
Yes
No
No
If yes, is it:
Moderate
Severe
Mild
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A28 Has a doctor or other health care provider EVER told
A32
you that this child has...
Any Other Mental Health Condition?
Yes
Yes
No
A33
If yes, specify: C
If yes, does this child CURRENTLY have the
condition?
Yes
No
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?
No
A34 Has a doctor or other health care provider EVER told
you that this child has Attention Deficit Disorder or
Attention Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?
Moderate
Severe
No ➔ SKIP to question A37
Yes
A29 Has a doctor or other health care provider EVER told
you that this child has Autism or Autism Spectrum
Disorder (ASD)? Include diagnoses of Asperger’s Disorder
or Pervasive Developmental Disorder (PDD).
If yes, does this child CURRENTLY have the condition?
Yes
Mild
If yes, does this child CURRENTLY have the condition?
Yes
No
Moderate
Yes
Severe
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?
Yes
Don’t know
A31 What type of doctor or other health care provider was
No
A36 At any time DURING THE PAST 12 MONTHS, did this
care provider FIRST told you that he or she had Autism,
ASD, Asperger’s Disorder or PDD?
No
A37 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?
the FIRST to tell you that this child had Autism, ASD,
Asperger’s Disorder or PDD? Mark ONE only.
Primary Care Provider
This child does not have
any conditions ➔ SKIP to question B1
Specialist
Never
School Psychologist/Counselor
Sometimes
Other Psychologist (Non-School)
Usually
Psychiatrist
Always
Other, specify: C
Severe
ADHD?
A30 How old was this child when a doctor or other health
Age in years
Moderate
A35 Is this child CURRENTLY taking medication for ADD or
If yes, is it:
Mild
No
If yes, is it:
No ➔ SKIP to question A34
Yes
No
Yes
If yes, is it:
Mild
Is this child CURRENTLY taking medication for Autism,
ASD, Asperger’s Disorder or PDD?
A38 To what extent do this child’s health conditions or
problems affect his or her ability to do things?
Very little
Don’t know
Somewhat
A great deal
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B. This Child as an Infant
B1
C3
Was this child born more than 3 weeks before his or
her due date?
Less than 10 minutes
Yes
10-20 minutes
No
B2
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 much did he or she weigh when born?
Answer in pounds and ounces OR kilograms and grams.
Provide your best estimate.
pounds
AND
More than 20 minutes
C4
At his or her LAST preventive check-up, did this child
have a chance to speak with a doctor or other health
care provider privately, without you or another adult in
the room?
ounces
Yes
OR
No
kilograms
B3
AND
grams
C5
What is this child’s CURRENT height?
What was the age of the mother when this child was
born?
feet
AND
inches
OR
Age in years
meters
C. Health Care Services
C1
C6
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?
AND
centimeters
How much does this child CURRENTLY weigh?
pounds
OR
Yes
kilograms
No ➔ SKIP to question C5
C2
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.
C7
Are you concerned about this child’s weight?
Yes, it’s too high
Yes, it’s too low
No, I am not concerned
0 visits ➔ SKIP to question C5
1 visit
2 or more visits
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C8 Is there a place that this child USUALLY goes when
C14 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?
he or she is sick or you or another caregiver needs
advice about his or her health?
Yes
Yes, saw a dentist
No ➔ SKIP to question C10
Yes, saw other oral health care provider
No ➔ SKIP to question C17
C9 If yes, where does this child USUALLY go?
Mark ONE only.
C15 If yes, DURING THE PAST 12 MONTHS, did this child
Doctor’s Office
see a dentist or other oral health care provider for
preventive dental care, such as check-ups, dental
cleanings, dental sealants, or fluoride treatments?
Hospital Emergency Room
No preventive visits in
the past 12 months ➔ SKIP to question C17
Hospital Outpatient Department
Clinic or Health Center
Yes, 1 visit
Retail Store Clinic or “Minute Clinic”
School (Nurse’s Office, Athletic Trainer’s Office)
Yes, 2 or more visits
C16 If yes, DURING THE PAST 12 MONTHS, what
preventive dental services did this child receive?
Mark ALL that apply.
Some other place
C10 Is there a place that this child USUALLY goes when
Check-up
he or she needs routine preventive care, such as a
physical examination or well-child check-up?
Cleaning
Yes
Instruction on tooth brushing and oral health care
No ➔ SKIP to question C12
X-Rays
C11 If yes, is this the same place this child goes when he
Fluoride treatment
or she is sick?
Yes
Sealant (plastic coatings on back teeth)
No
Don’t know
C12 DURING THE PAST 2 YEARS, has this child had his or
her vision tested with pictures, shapes, or letters?
C17 DURING THE PAST 12 MONTHS, has this child
received any treatment or counseling from a mental
health professional? Mental health professionals include
psychiatrists, psychologists, psychiatric nurses, and clinical
social workers.
Yes
No ➔ SKIP to question C14
Yes
C13 If yes, what kind of place or places did this child have
his or her vision tested? Mark ALL that apply.
No, but this child needed to see a mental health
professional
Eye doctor or eye specialist (ophthalmologist,
optometrist) office
No, this child did not need to see a
mental health professional ➔ SKIP to question C19
Pediatrician or other general doctor’s office
Clinic or health center
C18 How much of a problem was it to get the mental health
treatment or counseling that this child needed?
School
Other, specify:
Not a problem
C
Small problem
Big problem
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C19 DURING THE PAST 12 MONTHS, has this child taken
C25 Which of the following contributed to this child not
receiving needed health services:
any medication because of difficulties with his or her
emotions, concentration, or behavior?
Yes
Yes
a. This child was not eligible for the
services?
No
b. The services this child needed were
not available in your area?
c. There were problems getting an
appointment when this child needed
one?
C20 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.
d. There were problems with getting
transportation or child care?
Yes
e. The (clinic/doctor’s) office wasn’t
open when this child needed care?
No, but this child needed to see a specialist
f. There were issues related to cost?
No, this child did not need to
see a specialist ➔ SKIP to question C22
C26 DURING THE PAST 12 MONTHS, how often were you
frustrated in your efforts to get services for this child?
C21 How much of a problem was it to get the specialist
Never
care that this child needed?
Not a problem
Sometimes
Small problem
Usually
Big problem
Always
C22 DURING THE PAST 12 MONTHS, did this child use any
No
C27 DURING THE PAST 12 MONTHS, how many times did
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.
this child visit a hospital emergency room?
No visits
1 visit
Yes
2 or more visits
No
C28 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).
C23 DURING THE PAST 12 MONTHS, was there any time
when this child needed health care but it was not
received? By health care, we mean medical care as well
as other kinds of care like dental care, vision care, and
mental health services.
Yes
No ➔ SKIP to question C31
Yes
No ➔ SKIP to question C26
C29 If yes, how old was this child at the time of the FIRST
plan?
C24 If yes, which types of care were not received?
Mark ALL that apply.
Medical Care
Years
AND
Months
Dental Care
C30 Is this child CURRENTLY receiving services under one
of these plans?
Vision Care
Hearing Care
Yes
Mental Health Services
No
Other, specify:
C
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C31 Has this child EVER received special services to meet
D4
his or her developmental needs such as speech,
occupational, or behavioral therapy?
Yes
Answer the following questions only if this child had a
health care visit IN THE PAST 12 MONTHS. Otherwise,
SKIP to question D13 .
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers:
No ➔ SKIP to question D1
Always
Usually Sometimes
Never
a. Spend enough time
with this child?
C32 If yes, how old was this child when he or she began
receiving these special services?
b. Listen carefully to
you?
Years
AND
c. Show sensitivity to
your family’s values
and customs?
Months
C33 Is this child CURRENTLY receiving these special
d. Provide the specific
information you
needed concerning
this child?
services?
Yes
e. Help you feel like a
partner in this
child’s care?
No
D. Experience with This
Child’s Health Care
Providers
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.
D5
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?
Yes
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:
Yes, one person
Always
Yes, more than one person
No
D2
b. Make it easy for you
to raise concerns or
disagree with
recommendations
for this child’s health
care?
DURING THE PAST 12 MONTHS, did this child need a
referral to see any doctors or receive any services?
Yes
No ➔ SKIP to question D4
D3
Usually Sometimes Never
a. Discuss with you
the range of options
to consider for his
or her health care or
treatment?
c. Work with you to
decide together
which health care
and treatment
choices would be
best for this child?
If yes, how much of a problem was it to get referrals?
Not a problem
Small problem
Big problem
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D7 Does anyone help you arrange or coordinate this
D13 Do any of this child’s doctors or other health care
providers treat only children?
child’s care among the different doctors or services
that this child uses?
Yes
Yes
No ➔ SKIP to question D15
No
Did not see more than one
health care provider in
PAST 12 MONTHS ➔ SKIP to question D11
D14 If yes, have they talked with you about having this child
eventually see doctors or other health care providers
who treat adults?
Yes
D8 DURING THE PAST 12 MONTHS, have you felt that you
could have used extra help arranging or coordinating
this child’s care among the different health care
providers or services?
No
D15 Has this child’s doctor or other health care provider
actively worked with this child to:
Yes
Yes
No ➔ SKIP to question D10
No
Don’t
know
a. 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?
D9 If yes, DURING THE PAST 12 MONTHS, how often
did you get as much help as you wanted with
arranging or coordinating this child’s health care?
Usually
b. 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?
Sometimes
Never
D10 Overall, how satisfied are you with the communication
c. 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?
among this child’s doctors and other health care
providers?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
d. Understand the changes in
health care that happen at
age 18. For example, by
understanding changes in privacy,
consent, access to information, or
decision-making?
Very dissatisfied
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?
D16 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?
Yes
No ➔ SKIP to question D13
Yes
Did not need health care
provider to communicate
with these providers ➔ SKIP to question D13
No ➔ SKIP to question D20
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?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
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E. This Child’s Health
Insurance Coverage
D17 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?
Yes
E1
No
DURING THE PAST 12 MONTHS, was this child EVER
covered by ANY kind of health insurance or health
coverage plan?
Yes, this child was covered
all 12 months ➔ SKIP to question E4
D18 Did you and this child receive a written copy of this
plan of care?
Yes, but this child had a gap in coverage
Yes
No
No
E2
D19 Is this plan CURRENTLY up-to-date for this child?
Indicate whether any of the following is a reason this
child was not covered by health insurance DURING
THE PAST 12 MONTHS:
Yes
Yes
No
a. Change in employer or employment
status
No
b. Cancellation due to overdue
premiums
D20 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?
c. Dropped coverage because it was
unaffordable
Yes ➔ SKIP to question E1
d. Dropped coverage because benefits
were inadequate
No
e. Dropped coverage because choice
of health care providers was
inadequate
D21 If no, has anyone discussed with you how to obtain or
keep some type of health insurance coverage as this
child becomes an adult?
f. Problems with application or
renewal process
Yes
g. Other, specify: C
No
E3
Is this child CURRENTLY covered by ANY kind of
health insurance or health coverage plan?
Yes
No ➔ SKIP to question F1
E4
Is this child covered by any of the following types of
health insurance or health coverage plans?
Yes
a. Insurance through a current or
former employer or union
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
d. TRICARE or other military
health care
e. Indian Health Service
f. Other, specify: C
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E5
How often does this child’s health insurance offer
benefits or cover services that meet this child’s needs?
F2
How often are these costs reasonable?
Always
Always
Usually
Usually
Sometimes
Sometimes
Never
Never
F3
E6
How often does this child’s health insurance allow him
or her to see the health care providers he or she needs?
Always
Yes
Usually
No
Sometimes
F4
Never
E7
DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?
DURING THE PAST 12 MONTHS, have you or other
family members:
Yes
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?
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
Usually
Sometimes
This child does not need health care provided
on a weekly basis
Never
No at home care was provided by me or other family
members
F. Providing for This
Child’s Health
F1
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.
Less than 1 hour per week
1-4 hours 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.
5-10 hours per week
11 or more hours per week
$0 (No medical or health-related
expenses) ➔ SKIP to question F4
$1-$249
$250-$499
$500-$999
$1,000-$5,000
More than $5,000
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F6
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?
G4 DURING THE PAST 12 MONTHS, did this child
participate in:
Yes
This child does not need health care coordinated
on a weekly basis
b. Any clubs or organizations after
school or on weekends?
No health or medical care was arranged or coordinated
by me or other family members
c. Any other organized activities or
lessons, such as music, dance,
language, or other arts?
Less than 1 hour per week
1-4 hours per week
d. Any type of community service or
volunteer work at school, church, or
in the community?
5-10 hours per week
e. Any paid work, including regular
jobs as well as babysitting, cutting
grass, or other occasional work?
11 or more hours per week
G. This Child’s Schooling
and Activities
G5 DURING THE PAST 12 MONTHS, how often did you
attend events or activities that this child participated in?
Always
G1 DURING THE PAST 12 MONTHS, about how many days
did this child miss school because of illness or injury?
Usually
No missed school days
Sometimes
1-3 days
Rarely
4-6 days
Never
7-10 days
G6
11 or more days
G2 DURING THE PAST 12 MONTHS, how many times has
DURING THE PAST WEEK, on how many days did
this child exercise, play a sport, or participate in
physical activity for at least 60 minutes?
0 days
this child’s school contacted you or another adult in
your household about any problems he or she is
having with school?
1-3 days
4-6 days
No times
Every day
1 time
2 or more times
No
a. A sports team or did he or she
take sports lessons after school
or on weekends?
G7
Compared to other children his or her age, how much
difficulty does this child have making or keeping
friends?
G3 SINCE STARTING KINDERGARTEN, has this child
repeated any grades?
No difficulty
Yes
A little difficulty
No
A lot of difficulty
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H. About You and This
Child
H1
H2
H6 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?
None
Was this child born in the United States?
Yes ➔ SKIP to question H3
Less than 1 hour
No
1 hour
If no, how long has this child been living in the
United States?
2 hours
3 hours
Years
H3
AND
4 or more hours
Months
How many times has this child moved to a new address
since he or she was born?
H7 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?
None
Number of times
H4
Less than 1 hour
How often does this child go to bed at about the same
time on weeknights?
1 hour
Always
2 hours
Usually
3 hours
Sometimes
4 or more hours
Rarely
H8
Never
H5
How well can you and this child share ideas or talk
about things that really matter?
Very well
DURING THE PAST WEEK, how many hours of sleep
did this child get on an average weeknight?
Somewhat well
Less than 6 hours
Not very well
6 hours
Not at all
7 hours
H9
8 hours
How well do you think you are handling the day-to-day
demands of raising children?
9 hours
Very well
10 hours
Somewhat well
11 or more hours
Not very well
Not at all
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I. About Your Family and
Household
H10 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?
I1
b. That this
child does
things that
really bother
you a lot?
DURING THE PAST WEEK, on how many days did all the
family members who live in the household eat a meal
together?
0 days
1-3 days
4-6 days
c. Angry with
this child?
Every day
H11 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?
Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?
Yes
Yes
No ➔ SKIP to question
No ➔ SKIP to question I4
I1
I3
H12 If yes, did you receive emotional support from:
Yes
If yes, does anyone smoke inside your home?
Yes
No
No
a. Spouse?
b. Other family member or close friend?
I4
When your family faces problems, how often are you
likely to do each of the following?
c. Health care provider?
All of
the time
d. Place of worship or religious leader?
a. Talk together
about what to do
e. Support or advocacy group related
to specific health condition?
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?
h. Other person, specify:
Most of
the time
Some of None of
the time the time
d. Stay hopeful
even in difficult
times
C
I5
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
Somewhat often
Very often
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I6
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?
I9
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree
a. People in this
neighborhood
help each other
out
We could always afford to eat good nutritious meals.
We could always afford enough to eat but not always
the kinds of food we should eat.
b. We watch out for
each other’s
children in this
neighborhood
Sometimes we could not afford enough to eat.
Often we could not afford enough to eat.
I7
c. This child is
safe in our
neighborhood
At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive:
Yes
d. When we
encounter
difficulties, we
know where to
go for help in
our community
No
a. Cash assistance from a government
welfare program?
b. Food Stamps or Supplemental Nutrition
Assistance Program benefits (SNAP)?
e. This child is safe
at school
c. Free or reduced-cost breakfasts or
lunches at school?
I10
d. Benefits from the Woman, Infants,
and Children (WIC) Program?
I8
To what extent do you agree with these statements
about your neighborhood or community?
Other than you or other adults in your home, is there at
least one other adult in this child’s school, neighborhood,
or community who knows this child well and who he or
she can rely on for advice or guidance?
In your neighborhood, is/are there:
Yes
Yes
No
a. Sidewalks or walking paths?
b. A park or playground?
No
I11
c. A recreation center, community
center, or boys’ and girls’ club?
d. A library or bookmobile?
The next questions are about events that may have
happened during this child’s life. These things can
happen in any family, but some people may feel
uncomfortable with these questions. You may skip any
questions you do not want to answer.
To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated
e. Litter or garbage on the street
or sidewalk?
f. Poorly kept or rundown housing?
g. Vandalism such as broken
windows or graffiti?
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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J. About You
J6
➜ Complete the questions for each of the two adults
8th grade or less
in the household who are this child’s primary
caregivers. If there is just one adult, provide
answers for that adult.
9th-12th grade; No diploma
High School Graduate or GED Completed
ADULT 1 (Respondent)
J1
Completed a vocational, trade, or business school
program
How are you related to this child?
Biological or Adoptive Parent
Some College Credit, but no Degree
Step-parent
Associate Degree (AA, AS)
Grandparent
Bachelor’s Degree (BA, BS, AB)
Foster Parent
Master’s Degree (MA, MS, MSW, MBA)
Aunt or Uncle
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
Other: Relative
J7
J3
What is your marital status?
Married
Other: Non-Relative
J2
What is the highest grade or year of school you have
completed? Mark ONE only.
Not married, but living with a partner
What is your sex?
Male
Never Married
Female
Divorced
Separated
What is your age?
Widowed
Age in years
J4
J5
J8
In general, how is your physical health?
Excellent
Where were you born?
In the United States ➔ SKIP to question J6
Very Good
Outside of the United States
Good
When did you come to live in the United States?
Fair
Year
Poor
J9
In general, how is your mental or emotional health?
Excellent
Very Good
Good
Fair
Poor
J10
Were you employed at least 50 out of the past 52 weeks?
Yes
No
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ADULT 2
J17 What is Adult 2’s marital status?
Married
J11 How is Adult 2 related to this child?
Biological or Adoptive Parent
Not married, but living with a partner
Step-parent
Never Married
Grandparent
Divorced
Foster Parent
Separated
Aunt or Uncle
Widowed
Other: Relative
J18 In general, how is Adult 2’s physical health?
Other: Non-Relative
Excellent
There is only one primary adult
caregiver for this child ➔ SKIP to question K1
Very Good
Good
J12 What is Adult 2’s sex?
Male
Fair
Female
Poor
J13 What is Adult 2’s age?
J19 In general, how is Adult 2’s mental or emotional health?
Excellent
Age in years
Very Good
J14 Where was Adult 2 born?
Good
In the United States ➔ SKIP to question J16
Fair
Outside of the United States
Poor
J15 When did Adult 2 come to live in the United States?
J20 Was Adult 2 employed at least 50 out of the past 52
weeks?
Year
Yes
No
J16 What is the highest grade or year of school Adult 2 has
completed? Mark ONE only.
K. Household Information
8th grade or less
K1
9th-12th grade; No diploma
High School Graduate or GED Completed
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.
Completed a vocational, trade, or business school
program
Number of people
Some College Credit, but no Degree
Associate Degree (AA, AS)
K2
Bachelor’s Degree (BA, BS, AB)
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.
Master’s Degree (MA, MS, MSW, MBA)
Number of people
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
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26036020
K3
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.
K4
a. Wages, salary, commissions, bonuses, or tips from all
jobs?
Yes
C
No
$
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.
$
Total Amount
Total Amount
b. Self-employment income from own nonfarm businesses
or farm business, including proprietorships and
partnerships?
Yes
C
No
$
Total Amount
c. Interest, dividends, net rental income, royalty income,
or income from estates and trusts?
Yes
C
No
$
Total Amount
d. Social security or railroad retirement; retirement,
survivor, or disability pensions?
Yes
C
No
$
Total Amount
e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office?
Yes
C
No
$
Total Amount
f. Any other sources of income received regularly such as
Veterans’ (VA) payments, unemployment compensation,
child support, or alimony?
Yes
$
C
No
Total Amount
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26036012
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.
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| File Type | application/pdf |
| File Modified | 2016-06-16 |
| File Created | 2016-04-13 |