Appendix 2: Questions to be cognitively tested
Form Approved
OMB No. 0920-0222
Exp. Date: 08/31/2021
Notice - CDC estimates the average public reporting burden for this collection of information as 55 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0222).
Assurance of confidentiality - We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347).
ACS Questions
1. What is Person [1-5]’s name?
Last name_________________
First Name__________________
2. How is this person related to Person 1?
Person 1
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
Same-sex husband/wife/spouse
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
Foster child
Other nonrelative
3. What is Person [1-5]’s sex? Mark X ONE box
Male
Female
4. What is Person 2’s age and what is Person 2’s date of birth? For babies less than 1 year old, do not write the age in months. Write 0 as the age.
Age (in years)____________
Month__
Day__
Year of birth_______
5. NOTE: Please answer BOTH Question 5 about Hispanic origin and Question 6 about race. For this survey, Hispanic origins are not races.
Is Person [1-5] of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for example, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc_____________
6. What is Person 2’s race? Mark (X) one or more boxes AND print origins
White – Print, for example, German, Irish, English, Italian, Lebanese, Egyptian, etc. ____________
Black or African Am. – Print, for example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. ______________
American Indian or Alaska Native – Print name of enrolled or principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, etc._____________
Chinese
Filipino
Asian Indian
Vietnamese
Korean
Japanese
Other Asian – Print, for example, Pakistani, Cambodian, Hmong, etc.___________
Native Hawaiian
Samoan
Chamorro
Other Pacific Islander – Print, for example, Tongan, Fijian, Marshallese, etc.____________
Some other race – Print race or origin.________________
7. Where was this person born?
In the United States—Print name of state._________________
Outside the United States—Print name of foreign country, or Puerto Rico, Guam, etc.________________
8. Is this person a citizen of the United States?
Yes, born in the United States (SKIP to question 10a)
Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents
Yes, U.S. citizen by naturalization—Print year of naturalization________________
No, not a U.S. citizen
9. When did this person come to live in the United States? If this person came to live in the United States more than once, print elates year.
Year____________
10a. At any time in the last 3 months, has this person attended school or college? Include only nursery or preschool, kindergarten, elementary school, home school, and schooling which leads to a high school diploma or a college degree.
No, has not attended in the last 3 months (SKIP to question 11)
Yes, public school, public college
Yes, private school, private college, home school
10b. What grade or level was this person attending? Mark (X) ONE box.
Nursery school, preschool
Kindergarten
Grade 1 through 12—Specify grade 1-12 _______________
College undergraduate
Graduate or professional school beyond a bachelor’s degree (for example: MA or PhD program, or medical or law school)
11. What is the highest grade of school or degree this person has completed? If currently enrolled, select the previous grade or highest degree received. Mark (X) ONE box.
Less than grade 1
Grade 1 through 11—Specify grade 1-11_____________
12th grade—NO DIPLOMA
Regular high school diploma
GED or alternative credential
Some college credit, but less than 1 year or college credit
11 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
Master’s degree (for example: MA, MS, MEng, Med, MSW, MBA)
Professional degree beyond a bachelor’s degree (for example: PhD, EdD)
12. This question focuses on the person’s BACHELOR’S DEGREE. Please print below the specific major(s) of any BACHELOR’S DEGREES this person has received. (For example: chemical engineering, elementary teacher education, organizational psychology)
_____________
13. What is this person’s ancestry or ethnic origin? (For example: Italian, Jamaican, African Am., Cambodia, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
______________
14a. Does this person speak a language other than English at home?
Yes
No (SKIP to question 15a)
14b. What is this language?
______________
14c. How well does this person speak English?
Very well
Well
Not well
Not at all
15a. Did this person live in this house or apartment 1 year ago?
Person is under 1 year old ➔ SKIP to question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and Puerto Rico – Print name of foreign country, or U.S. Virgin Islands, Guam, etc., below; then SKIP to question 16_______________________
No, different house in the United States or Puerto Rico
15b. Where did this person live 1 year ago?
Address (number and street name)____________________
Name of city, town, or post office ______________________
Name of U.S. country or municipio in Puerto Rico__________________________
Name of U.S. state or Puerto Rico______________________________
ZIP code_____________
16. Is this person CURRENTLY covered by any of the following types of health insurance or health coverage plans? Do NOT include plans that cover only one type of service, such as dental, drug, or vision plans.
Mark "Yes" or "No" for EACH type of coverage in items a – h.
a. Insurance through a current or former employer or union (of this person or another family member)
b. Medicare, for people 65 and older, or people with certain disabilities
c. Medicaid, Children’s Health Insurance Program (CHIP), or any kind of government-assistance plan for those with low incomes or a disability
d. Insurance purchased directly from an insurance company or through a State or Federal Marketplace, HealthCare.gov, or a similar website (by this person or another family member)
e. TRICARE or other military health care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance or health coverage plan – Specify _________________
17a.Is there a premium for this plan? A premium is a fixed amount of money paid on a regular basis for health coverage. It does not include copays, deductibles, or other expenses such as prescription costs.
Yes
No (SKIP to question 18a)
17b. Does this person or another family member receive a tax credit or subsidy based on family income to help pay the premium?
Yes
No
18a. Does this person have difficulty seeing, even if wearing glasses?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
18b. Does this person have difficulty hearing, even if using a hearing aid?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Skip Instructions: Answer questions 19-20 if this person is 5 years or over.
Otherwise, SKIP to the questions for Person -2-5] on the next page.
19a. Does this person have difficulty walking or climbing stairs?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
19b. Does this person have difficulty remembering or concentrating?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
19c. Does this person have difficulty with self-care such as washing all over or dressing?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
20. Using your usual language, does this person have difficulty communicating, for example understanding or being understood?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
NHIS Questions
AGEOFONSET. You said that [YOU or NAME if proxy] have difficulty with [fill: seeing, hearing, walking or climbing steps, remembering or concentrating, self-care, communicating]. Did [if one: this difficulty / if more than one: any of these difficulties] begin before age 18?
Yes
No
Don’t know
Refused
CHILD SLEEP
SLEEP1. In a typical week during the school year, how often does [CHILD’S NAME] wake up well-rested? Would you say every day, most days, some days, few days, or no days? Would you say never, some days, most days, or every day?
Never
Some days
Most days
Every day
Refused
Don’t know
SLEEP2. In a typical week during the school year, how often does [CHILD’S NAME] have difficulty getting out of bed in the morning? Would you say never, some days, most days, or every day?
Never
Some days
Most days
Every day
Refused
Don’t know
SLEEP3. In a typical week during the school year, how often does [CHILD’S NAME] complain about being tired during the day? Would you say never, some days, most days, or every day?
Never
Some days
Most days
Every day
Refused
Don’t know
SLEEP4. In a typical week during the school year, how often does [CHILD’S NAME] nap or fall asleep during the day, such as in school, watching TV, or riding in a car? Would you say never, some days, most days, or every day?
Never
Some days
Most days
Every day
Refused
Don’t know
SLEEP5. In a typical week during the school year, on nights [CHILD’S NAME] had school the next day, how often did he/she go to bed at the same time? Would you say never, some days, most days, or every day?
Never
Some days
Most days
Every day
Refused
Don’t know
SLEEP6. In a typical week during the school year, on school days, how often did [CHILD’S NAME] wake up at the same time? Would you say never, some days, most days, or every day?
Never
Some days
Most days
Every day
Refused
Don’t know
CHILD SCREEN TIME
SCREENTIME1. “In a typical week during the school year, how often does [CHILD’S NAME] spend at least 60 minutes a day in front of a TV, computer, cellphone or other electronic device watching programs, playing games, or accessing the internet or using social media? Would you say never, some days, most days, or every day? Read-if-necessary: Do not include time spent doing schoolwork.
Never
Some days
Most days
Every day
Refused
Don’t know
CHILD PHYSICAL EDUCATION
PHYSED1. In the past 12 months, did [CHILD’S NAME] take a Physical Education, PE, or gym class?
Yes
No
Don’t know
Refused
WALK1. In a typical week during the school year, how often does [CHILD’S NAME] walk for at least 10 minutes at a time? Would you say never, some days, most days, or every day?
Never
Some days
Most days
Every day
Refused
Don’t know
BIKE1. In a typical week during the school year, how often does [CHILD’S NAME] bike for at least 10 minutes at a time? Would you say never, some days, most days, or every day?
Never
Some days
Most days
Every day
Refused
Don’t know
STRENGTH1. In a typical week during the school year, how often does [CHILD’S NAME] lift weights or use weights while they play or exercise? Would you say never, some days, most days, or every day?
Never
Some days
Most days
Every day
Refused
Don’t know
CHILD INJURY
INJURY_INTRO: The next set of questions asks about injuries. People can be injured accidentally, or on purpose. They may hurt themselves or others may cause them to be hurt.
INJURY1. DURING THE PAST 3 MONTHS, did [CHILD’S NAME] have an accident or an injury where any part of his/her body was hurt?
1. Yes
2. No
7. Don’t know
9. Refused
Skip Instructions: If Yes: go to INJURY2
If No, DK, or Refused: End Questionnaire
INJURY2. Did any of these injuries limit [CHILD’S NAME]’s usual activities for at least 24 hours after the injury occurred?
1. Yes
2. No
7. Don’t know
9. Refused
INJURY3. Did any of these injuries cause [CHILD’S NAME] to miss at least one day of
[FILL (if age 5-17): school; (if age 3-4): school or daycare; (if age 0-2): daycare]?
1. Yes
2. No
7. Don’t know
9. Refused
Skip Instructions: If Yes to INJURY2 or INJURY3 and Child’s age is 3 or older: go to INJURY4.
If Yes to INJURY2 or INJURY3 and Child’s age <3; go to INJURY7
If No, DK, or Refused to INJURY2 and INJUR3: End Questionnaire.
INJURY4. [age 3-17] Please think only about the injuries that occurred IN THE PAST 3 MONTHS that caused [child’s name] to miss at least one day of [FILL (if age 5-17): school; (if age 3-4): school or daycare], or that made it difficult for him/her to do things that he/she usually does for one day or more.
Did any of these injuries occur while [CHILD’S NAME] was playing sports or exercising, including walking, biking, or running, playing baseball, basketball, football or doing any other physical activity?
Read if necessary: Include recreational sports such as skating, skiing, tennis, golf, bowling, or fishing.
1. Yes
2. No
7. Don’t know
9. Refused
INJURY5. [age 3-17] Did any of these injuries occur while [CHILD’S NAME] was doing household activities, such as housework, cooking, chores, or yardwork?
1. Yes
2. No
7. Don’t know
9. Refused
INJURY6. [If age 3-17] Did any of these injuries occur while [CHILD’S NAME] was engaged in leisure activities, such as playing, hanging out with friends, doing a hobby, or just relaxing?
1. Yes
2. No
7. Don’t know
9. Refused
INJURY7. The next two questions are about where [CHILD’S NAME] was when s/he was injured. Please continue to only consider those injuries that happened IN THE PAST 3 MONTHS that caused him/her to miss at least one day of [FILL (if age 5-17): school; (if age 3-4): school or daycare; (if age 0-2): daycare], or that made it difficult for him/her to do things that he/she usually does for one day or more.
Did any injury occur while [CHILD’S NAME] was at his/her home?
Read if necessary: Include the yards, garage, basement, and other places on the home property.
1. Yes
2. No
7. Don’t know
9. Refused
INJURY8. Did any injury occur while [CHILD’S NAME] was at [FILL (if age 5-17): school; (if age 3-4): school or a daycare center; (if age 0-2): a daycare center]?
Read if necessary: Include classrooms, playgrounds, sports fields, swimming pools, parking lots and other places on school or daycare property.
1. Yes
2. No
7. Don’t know
9. Refused
INJURY9. The next questions are about two ways that [CHILD’S NAME] might have been injured.
Did [CHILD’S NAME] have any injury as a result of a fall or falling?
1. Yes
2. No
7. Don’t know
9. Refused
Skip Instructions: If Yes to INJURY7: go to INJURY10
Else If Yes to INJURY8; go to INJURY11
Else; go to INJURY12
INJURY10. Did any fall occur while [CHILD’S NAME] was at his/her HOME?
1. Yes
2. No
7. Don’t know
9. Refused
INJURY11. Did any fall occur while [CHILD’S NAME] was at [FILL (if age 5-17): school; (if age 3-4): school or daycare; (if age 0-2): daycare]?
1. Yes
2. No
7. Don’t know
9. Refused
INJURY12. Did [CHILD’S NAME] have any injury as a result of being in a motor vehicle crash or being hit by a motor vehicle, while not in a vehicle, such as while walking or biking?
Read if necessary: Motor vehicles include cars, trucks, vans, buses, motorcycles, motorized scooters, motorized carts, tractors, ATVs, snowmobiles, dune buggies, and other motorized vehicles.
1. Yes
2. No
7. Don’t know
9. Refused
INJURY13. Was [CHILD’S NAME] a [if age>=6: a driver,] passenger, bicyclist, a pedestrian, or doing something else when this occurred?
Read if necessary: Motor vehicles include cars, trucks, vans, buses, motorcycles, motorized scooters, motorized carts, tractors, ATVs, snowmobiles, dune buggies, and other motorized vehicles.
(MARK ALL THAT APPLY)
1. Driver
2. Passenger
3. Bicyclist
4. Pedestrian
5. Something else
7. Don’t know
9. Refused
INJURY14. Did any of [CHILD’S NAME’s] injuries result in broken bones?
1. Yes
2. No
7. Don’t know
9. Refused
INJURY15. Did any of [CHILD’S NAME’s] injuries require stitches or staples?
1. Yes
2. No
7. Don’t know
9. Refused
INJURY16. Were any of [CHILD’S NAME’s] injuries a sprain or strain?
1. Yes
2. No
7. Don’t know
9. Refused
INJURY17. The next questions are about the impact of [CHILD’S NAME]’s injuries. Please continue to only consider those injuries that happened IN THE PAST 3 MONTHS that caused him/her to miss at least one day of [FILL (if age 5-17): school; (if age 3-4): school or daycare; (if age 0-2): daycare], or that made it difficult for him/her to do things that he/she usually does for one day or more.
DURING THE PAST 3 MONTHS, how many days of [FILL (if age 5-17): school; (if age 3-4): school or daycare; (if age 0-2): daycare], did [child’s name] miss because of injuries?
_________Number of days
Skip Instructions: If 0: go to INJURY19
If 1-90; go to INJURY18
INJURY18. Do you expect [CHILD’S NAME] to miss any more days of [FILL (if age 5-17): school; (if age 3-4): school or daycare; (if age 0-2): daycare], because of injuries that occurred DURING THE PAST 3 MONTHS?
1. Yes
2. No
7. Don’t know
9. Refused
INJURY19. Did [CHILD’S NAME] see a doctor or other health professional about any of these injuries?
1. Yes
2. No
7. Don’t know
9. Refused
Skip Instructions: If Yes: go to INJURY20.
If No, DK, or Refused; go to INJURY22
INJURY20. Did [CHILD’S NAME] go to an emergency room for any of these injuries?
1. Yes
2. No
7. Don’t know
9. Refused
INJURY21. Was [CHILD’S NAME] hospitalized overnight for any of these injuries?
1. Yes
2. No
7. Don’t know
9. Refused
CONCINTRO_C: The next questions are about head injuries that may have occurred anytime in [CHILD’S NAME]’s life. Please think about all head injuries, for example, from playing sports, car accidents, falls, or being hit by something or someone.
INJLOSTCON_C. As a result of a blow or jolt to the head, has [CHILD’S NAME] ever been knocked out or lost consciousness?
1. Yes
2. No
7. Don’t know
9. Refused
Skip Instructions: If Yes: go to INJCHKCONC_C
If No, DK, or Refused; go to INJDAZED_C
INJDAZED_C. As a result of a blow or jolt to the head, has [CHILD’S NAME] ever been dazed or had a gap in his/her memory?
1. Yes
2. No
7. Don’t know
9. Refused
INJHEADSYM_C. As a result of a blow or jolt to the head, has [CHILD’S NAME] ever had headaches, vomiting, blurred vision, or changes in mood or behavior?
1. Yes
2. No
7. Don’t know
9. Refused
INJCHKCONC_C. Has [CHILD’S NAME] ever been checked for a concussion or brain injury by a doctor, nurse, athletic trainer, or other health care professional?
1. Yes
2. No
7. Don’t know
9. Refused
Skip Instructions: If Yes: go to INJDRCONC_C
If No, DK, or Refused; End Questionnaire
INJDRCONC_C. Did a doctor, nurse, athletic trainer, or other health care provider ever say that [CHILD’S NAME] had a concussion or brain injury?
1. Yes
2. No
7. Don’t know
9. Refused
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Vickers, Jonathan (CDC/DDPHSS/NCHS/DRM) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |