Appendix A-2019 Nsch Questionnaire

Appendix A – 2019 NSCH Questionnaire Content Revisions

2019 NSCH Questionnaire Content Revisions
Modifications or Additions to Existent Items
Questionnaire

Section

NSCH-T1,
NSCH-T2, &
NSCH-T3

Section B

Item
Number
(2018)
N/A

Item
Number
(2019)
B2
N/A

2018 Content

2019 Revised Content
What month and year was this child born?
__ /____
Birth Month/4-digit Birth Year

NSCH-T1,
NSCH-T2, &
NSCH-T3

Section C

C1

C1

DURING THE PAST 12 MONTHS, did this child see a doctor, nurse,
or other health care professional for medical care (for example,
preventive care, sick care, hospitalizations)?

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?

NSCH-T1

Section G

G4

G4

Are you concerned about how this child is learning to do things
for him or herself?

Are you concerned about how this child is learning to do things for him or
herself?

• Yes, very concerned
• Yes, somewhat concerned
• No
J5. When did you come to live in the United States?
___ Year

• No
• Yes, somewhat concerned
• Yes, very concerned
J5. When did you come to live in the United States? Indicate the 4-digit year in
which you came to live in the United States.
___ 4-Digit Year
J17. When did Caregiver 2 come to live in the United States? Indicate the 4digit year in which this caregiver came to live in the United States.
___ 4-Digit Year
For clarity, these sets of questions will reference “Caregiver 2” for 2019.

NSCH-T1,
NSCH-T2, &
NSCH-T3

Section J

NSCH-T1,
NSCH-T2, &
NSCH-T3

Section J

J5 & J17

J5 & J17

J17. When did this caregiver come to live in the United States?
___ Year
J13-J24

J13-J24

These questions referenced either “this adult primary caregiver”
or “primary caregiver”.

1

Questionnaire
NSCH-T1,
NSCH-T2, &
NSCH-T3

Section
Section D

Item
Number
(2018)
D7

NSCH-S1

Mailing
Instructions

N/A

NSCH-T1,
NSCH-T2, &
NSCH-T3

Mailing
Instructions

N/A

Item
2018 Content
Number
(2019)
D7
DURING THE PAST 12 MONTHS, did anyone help you arrange or
coordinate this child’s care among the different doctors or
services that this child uses?
• Yes
• No
• Did not see more than one health care provider in the
PAST 12 MONTHS
Public
reporting
burden for this collection of information is estimated
N/A

N/A

to average 5 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.
Public reporting burden for this collection of information is estimated
to average 33 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.

2

2019 Revised Content
DURING THE PAST 12 MONTHS, did anyone help you arrange or
coordinate this child’s care among the different doctors or services that this
child uses?
• Yes
• No
• Did not see more than one health care provider in the PAST 12
MONTHS -> Skip to question D11

We estimate that completing the National Survey of Children’s Health will take 5
minutes on average. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this
burden, to U.S. Department of Commerce, 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. This collection has been approved by the Office of Management and
Budget (OMB). The eight-digit OMB approval number that appears at the upper left of
the form confirms this approval. If this number were not displayed, we could not
conduct this survey.
We estimate that completing the National Survey of Children’s Health will take 33
minutes on average. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this
burden, to U.S. Department of Commerce, 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. This collection has been approved by the Office of Management and
Budget (OMB). The eight-digit OMB approval number that appears at the upper left of
the form confirms this approval. If this number were not displayed, we could not
conduct this survey.

Content Deletions
Questionnaire Section
NSCH-S1
NSCH-T1,
NSCH-T2, &
NSCH-T3

NSCH-T1,
NSCH-T2, &
NSCH-T3

Child 1Child 4
Section A

Section A

Item Number
(2018)
5

T1 - A18,
T2 & T3 – A20

T1 - A27,
T2 & T3 – A30

2018 Content

2019 with Removed Content

What is this child’s race? Mark (X) one or more boxes.

What is this child’s race? Mark (X) one or more boxes

[Includes response option of “Some other race”]
Has a doctor or other health care provider EVER told you that this child has...

[Remove response option “Some other race”]
Has a doctor or other health care provider EVER told you that this child has...

Down Syndrome?

Down Syndrome?

If yes, does this child CURRENTLY have the condition?
__Yes
__No

If yes, is it:
__ Mild __Moderate __Severe

__Yes

__No

__Yes

If yes, is it:
__ Mild __Moderate __Severe
Has a doctor or other health care provider EVER told you that this child has...

Any other mental health condition?
__Yes
__No

__No

This item has not proven useful for analytic purposes. The entire question
stem should be removed and questionnaire renumbered.

If yes, specify: _________________
If yes, does this child CURRENTLY have the condition?
__Yes
__No

NSCH-T1
NSCH-T1

Section C
Section C

C4
C5

If yes, is it:
__ Mild __Moderate __Severe
What is this child’s current height?
How much does this child currently weigh?

This item will be dropped (from T1 only) for 2019.
This item will be dropped (from T1 only) for 2019.

3

26009084

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 required by law to protect your information and is not permitted to publicly release your responses in
a way that could identify you or your household. The U.S. Census Bureau is conducting the National Survey of Children’s Health
on the behalf of the 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. Federal law protects your privacy and
keeps your answers confidential under 13 U.S.C. Section 9. Per the Federal Cybersecurity Enhancement Act of 2015, your data are
protected from cybersecurity risks through screening of the systems that transmit your data.
Any information you provide will be shared for the work-related purposes identified above and as permitted under the Privacy Act
of 1974 (5 U.S.C. Section 552a) and SORN COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame).
Participation in this survey is voluntary and there are no penalties for refusing to answer questions. However, your cooperation in
obtaining this much needed information is extremely important in order to ensure complete and accurate results.

NSCH-S1
(03/21/2019)

§;!{u¤

26009076

Start Here
Respond online today at: https://respond.census.gov/nsch
OR complete this form and mail it back as soon as possible.
Thank you for helping us learn about the health and well-being of America’s children.
If your household has children 0 - 17 years old, the questions on this form should be answered by an adult who is familiar with
their health and health care. If your household does not have any children, please answer question 1 below AND return the
questionnaire.
For help or questions about completing this form, please call 1-800-845-8241. The telephone call is free.
For Telephone Device for the Deaf (TDD) assistance, please call: 1-800-582-8330. The telephone call is free.
Si necesita ayuda o tiene preguntas sobre cómo completar este formulario, llame al 1-800-845-8241. La llamada es gratuita.
Para recibir ayuda relacionada con el Dispositivo Telefónico para Personas Sordas (TDD), llame al 1-800-582-8330. La llamada
es gratuita.

In Your Home
1

Are there any children 0-17 years old who usually live or stay at this address?
Yes
No – STOP HERE after marking “No” and return this survey to us in the enclosed envelope. It is important that we
receive a response from every household selected for this study.

2

How many children 0-17 years old usually live or stay at this address?

Number of children living or staying at this address
3

What is the primary language spoken in the household?
English
Spanish
Other Language, specify:

4

C

Is this house, apartment, or mobile home –
Mark (X) ONE box.
Owned by you or someone in this household with a mortgage or loan? Include home equity loans.
Owned by you or someone in this household free and clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?

➜

Answer the remaining questions for each of the children 0-17 years old who usually live or stay at this address.
Start with the YOUNGEST CHILD, who we will call “Child 1” and continue with the next youngest until you have
answered the questions for all children who usually live or stay at this address.

NSCH-S1

2

§;!{m¤

26009068

CHILD 1

7

(Youngest)
1

First name, initials, or nickname of the youngest child

2

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

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

No

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

No

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

Years OR
3

Months

8

What is this child’s sex?
Male

No

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

➜ NOTE: Answer BOTH question

4 about Hispanic
origin and question 5 about race.
For this survey, Hispanic origins are not races.

4

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

Female

Yes

No, not of Hispanic, Latino, or Spanish origin

Yes
9

Yes, Puerto Rican

5

No

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

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

Yes, Mexican, Mexican American, Chicano

No

No

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

Yes, Cuban

Yes

Yes, another Hispanic, Latino, or Spanish origin

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

What is this child’s race? Mark (X) one or more boxes.
White

Korean

Black or
African American

Vietnamese

American Indian or
Alaska Native

Other Asian

No

No

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

No

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

Native Hawaiian

Yes

Chinese

Guamanian or
Chamorro

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

Filipino

Samoan

Japanese

Other Pacific Islander

Asian Indian

No

Yes

No

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

6

Answer the following question only if this child is at
least 4 years old. Otherwise, SKIP to question 7 .
How well does this child speak English?

No

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

Very well

Yes

Well

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

No

Not well
Yes

No

Not at all
NSCH-S1

3

§;!{e¤

26009050

CHILD 2

7

(Next youngest)
1

First name, initials, or nickname of the next youngest
child

2

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

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

No

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

No

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

Years OR
3

Months

8

What is this child’s sex?
Male

No

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

➜ NOTE: Answer BOTH question

4 about Hispanic
origin and question 5 about race.
For this survey, Hispanic origins are not races.

4

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

Female

Yes

No, not of Hispanic, Latino, or Spanish origin

Yes
9

Yes, Puerto Rican

5

No

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

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

Yes, Mexican, Mexican American, Chicano

No

No

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

Yes, Cuban

Yes

Yes, another Hispanic, Latino, or Spanish origin

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

What is this child’s race? Mark (X) one or more boxes.
White

Korean

Black or
African American

Vietnamese

American Indian or
Alaska Native

Other Asian

No

No

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

No

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

Native Hawaiian

Yes

Chinese

Guamanian or
Chamorro

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

Filipino

Samoan

Japanese

Other Pacific Islander

Asian Indian

No

Yes

No

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

6

Answer the following question only if this child is at
least 4 years old. Otherwise, SKIP to question 7 .
How well does this child speak English?

No

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

Very well

Yes

Well

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

No

Not well
Yes

No

Not at all
NSCH-S1

4

§;!{S¤

26009043

CHILD 3

7

(Next youngest)
1

First name, initials, or nickname of the next youngest
child

2

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

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

No

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

No

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

Years OR
3

Months

8

What is this child’s sex?
Male

No

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

➜ NOTE: Answer BOTH question

4 about Hispanic
origin and question 5 about race.
For this survey, Hispanic origins are not races.

4

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

Female

Yes

No, not of Hispanic, Latino, or Spanish origin

Yes
9

Yes, Puerto Rican

5

No

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

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

Yes, Mexican, Mexican American, Chicano

No

No

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

Yes, Cuban

Yes

Yes, another Hispanic, Latino, or Spanish origin

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

What is this child’s race? Mark (X) one or more boxes.
White

Korean

Black or
African American

Vietnamese

American Indian or
Alaska Native

Other Asian

Yes

Filipino

Samoan

Japanese

Other Pacific Islander

No

10 Does this child need or get special therapy, such as
physical, occupational, or speech therapy?
Yes

Native Hawaiian
Guamanian or
Chamorro

No

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

Asian Indian
Chinese

No

No

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

No

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

6

Answer the following question only if this child is at
least 4 years old. Otherwise, SKIP to question 7 .
How well does this child speak English?

No

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

Very well

Yes

Well

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

No

Not well
Yes

No

Not at all
NSCH-S1

5

§;!{L¤

26009035

CHILD 4

7

(Next youngest)
1

First name, initials, or nickname of the next youngest
child

2

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

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

No

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

No

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

Years OR
3

Months

8

What is this child’s sex?
Male

No

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

➜ NOTE: Answer BOTH question

4 about Hispanic
origin and question 5 about race.
For this survey, Hispanic origins are not races.

4

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

Female

Yes

No, not of Hispanic, Latino, or Spanish origin

Yes
9

Yes, Puerto Rican

5

No

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

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

Yes, Mexican, Mexican American, Chicano

No

No

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

Yes, Cuban

Yes

Yes, another Hispanic, Latino, or Spanish origin

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

What is this child’s race? Mark (X) one or more boxes.
White

Korean

Black or
African American

Vietnamese

American Indian or
Alaska Native

Other Asian

No

No

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

No

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

Native Hawaiian

Yes

Chinese

Guamanian or
Chamorro

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

Filipino

Samoan

Japanese

Other Pacific Islander

Asian Indian

No

Yes

No

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

6

Answer the following question only if this child is at
least 4 years old. Otherwise, SKIP to question 7 .
How well does this child speak English?

No

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

Very well

Yes

Well

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

No

Not well
Yes

No

Not at all
NSCH-S1

6

§;!{D¤

26009027

➜

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

First name, initials, or nickname

CHILD 5
▲

(Next youngest)

Age

Years OR

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

First name, initials, or nickname

CHILD 6
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

CHILD 7
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

CHILD 8
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

CHILD 9
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

CHILD 10
▲

(Next youngest)

Age

Years OR

NSCH-S1

7

§;!{<¤

26009019

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 your household and the children of this household.
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.

➜ Make sure you have:
• Listed all first names, initials, or nicknames of children 0-17 years old in the household
• Answered all questions for each child reported

➜ Place the completed questionnaire in the postage-paid return envelope. If the envelope has been
misplaced, please 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.

We estimate that completing the National Survey of Children’s Health will take 5 minutes on average. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to U.S. Department of Commerce, 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. This collection has been
approved by the Office of Management and Budget (OMB). The eight-digit OMB approval number that appears
at the upper left of the form confirms this approval. If this number were not displayed, we could not conduct this
survey.

NSCH-S1

8

§;!{4¤

26019208

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 required by law to protect your information and is not permitted to publicly release your responses in
a way that could identify you or your household. The U.S. Census Bureau is conducting the National Survey of Children’s Health
on the behalf of the 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. Federal law protects your privacy and
keeps your answers confidential under 13 U.S.C. Section 9. Per the Federal Cybersecurity Enhancement Act of 2015, your data are
protected from cybersecurity risks through screening of the systems that transmit your data.
Any information you provide will be shared for the work-related purposes identified above and as permitted under the Privacy Act
of 1974 (5 U.S.C. Section 552a) and SORN COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame).
Participation in this survey is voluntary and there are no penalties for refusing to answer questions. However, your cooperation in
obtaining this much needed information is extremely important in order to ensure complete and accurate results.

NSCH-T1
(04/15/2019) Draft 6

§;"})¤

26019190

Start Here

A3

How often...
Always

Usually Sometimes

Never

a. Is this child
affectionate and
tender with you?

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.

b. Does this child
bounce back
quickly when
things do not go
his or her way?

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

c. Does this child
show interest
and curiosity in
learning new
things?

If the name listed above is not correct or does not
correspond to a child living in this household, please
call 1-800-845-8241 for assistance.

d. Does this child
smile and laugh?

We have selected only one child per household in an
effort to minimize the amount of time you will need to
complete the follow-up questions.
A4

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

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

A. This Child’s Health

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

i.

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

A5

Decayed teeth or cavities

Does this child have any of the following?

teeth?
This child does not have any teeth

a. Deafness or problems with hearing

Excellent

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

Very good
Good
Fair
Poor

NSCH-T1

2

§;"|{¤

26019182

Has a doctor or other health care provider EVER told
you that this child has...
A6

Allergies (including food, drug, insect, or other)?
Yes

Has a doctor or other health care provider EVER told
you that this child has...
A12 Epilepsy or Seizure 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

No

If yes, is it:

If yes, is it:
Mild

Moderate

Severe

A7 Arthritis?

Mild

Moderate

Severe

A13 Heart Condition?

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

A8 Asthma?

Mild

Moderate

Severe

A14 Frequent or severe headaches, including migraine?

Yes

No

Yes

Yes

No

Yes

Mild

Moderate

Severe

Mild

Yes

No

Severe

No

If yes, does this child CURRENTLY have the
condition?

If yes, does this child CURRENTLY have the
condition?

Yes

No

No

If yes, is it:

If yes, is it:
Mild

Moderate

Mild

Severe

A10 Cerebral Palsy?

Yes

Moderate

A15 Tourette Syndrome?

A9 Brain injury, concussion or head injury?

Yes

No

If yes, is it:

If yes, is it:

Yes

No

If yes, does this child CURRENTLY have the
condition?

If yes, does this child CURRENTLY have the
condition?

Moderate

Severe

A16 Anxiety Problems?

No

Yes

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

No

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

No

No

If yes, is it:

If yes, is it:
Mild

Moderate

Mild

Severe

A11 Diabetes?

Moderate

Severe

A17 Depression?

Yes

No

Yes

If yes, does this child CURRENTLY have the
condition?

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

No

Yes

No

If yes, is it:

If yes, is it:
Mild

No

Moderate

Mild

Severe

NSCH-T1

3

Moderate

Severe

§;"|s¤

26019174

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

Has a doctor, other health care provider, or educator
EVER told you that this child has...
Examples of educators are teachers and school nurses.

A18 Down Syndrome?

A22 Behavioral or Conduct Problems?

Yes

No
Yes

If yes, is it:
Mild

Moderate

If yes, does this child CURRENTLY have the
condition?

Severe

Yes

A19 Blood Disorders (such as Sickle Cell Disease,

Thalassemia, or Hemophilia)?
Yes

No

No

If yes, is it:
Mild

No

If yes, is it:

Moderate

Severe

A23 Developmental Delay?

Mild

Moderate

Severe

Yes

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Yes

No

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

No

No

If yes, is it:

If yes, was this child diagnosed with:

Mild

Moderate

Severe

Sickle Cell Disease?

Yes

No

Thalassemia?

Yes

No

Hemophilia?

Yes

No

Yes

Other Blood Disorders?

Yes

No

If yes, does this child CURRENTLY have the
disability?

A24 Intellectual Disability (formerly known as Mental

Retardation)?

A20 Cystic Fibrosis?

Yes

No

Yes
No

No

If yes, is it:

If yes, is it:

Mild

Mild

Moderate

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Yes

Moderate

Severe

Severe
A25 Speech or other language disorder?

Yes

No

If yes, does this child CURRENTLY have the
condition?

No

Yes

A21 Other genetic or inherited condition?

No

If yes, is it:
Yes

No
Mild

If yes, specify: C

Moderate

Severe

A26 Learning Disability?

Yes

Is it:
Mild

Moderate

If yes, does this child CURRENTLY have the
disability?

Severe

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Yes

No

Yes

No

If yes, is it:

No

Mild

NSCH-T1

4

Moderate

Severe

§;"|k¤

26019166

A27 Has a doctor or other health care provider EVER told

A32 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?

you that this child has Autism or Autism Spectrum
Disorder (ASD)? Include diagnoses of Asperger’s Disorder
or Pervasive Developmental Disorder (PDD).
No ➔ SKIP to question A32

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:
Mild

No ➔ SKIP to question A35

Yes

No

If yes, is it:
Moderate

Severe

A28 How old was this child when a doctor or other health

Mild

Severe

A33 Is this child CURRENTLY taking medication for ADD or

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

ADHD?
Yes

Age in years

Moderate

No

Don’t know
A34 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?

A29 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 (X) ONE box.

Yes

Primary Care Provider
Specialist

No

A35 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?

School Psychologist/Counselor
Other Psychologist (Non-School)

This child does not have any
health conditions ➔ SKIP to question B1 on page 6

Psychiatrist

Never

Other, specify:

C

Sometimes
Usually

Don’t know

Always

A30 Is this child CURRENTLY taking medication for Autism,

ASD, Asperger’s Disorder or PDD?
Yes

A36 To what extent do this child’s health conditions or

problems affect his or her ability to do things?

No

Very little

A31 At any time DURING THE PAST 12 MONTHS, did this

Somewhat

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?
Yes

A great deal

No

NSCH-T1

5

§;"|c¤

26019158

B. This Child as an Infant
B1

B7

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?
Check this box if child has never been fed formula
OR

Yes

At birth

No
B2

OR

What month and year was this child born?

days

Birth Month / 4-Digit Birth Year
OR

/

2 0
weeks

B3

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

OR
months

pounds AND

ounces
B8

OR
kilograms AND
B4

grams

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

What was the age of the mother when this child was
born? Your best estimate is fine.

At birth
Age in years
B5

OR

Was this child EVER breastfed or fed breast milk?

days

Yes

OR

No ➔ SKIP to question B7
B6

weeks

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

OR
months

days
OR
weeks
OR

months
OR
Check this box if child is still breastfeeding

NSCH-T1

6

§;"|[¤

26019141

C. Health Care Services

C7

DURING THE PAST 12 MONTHS, did a doctor or other
health care provider have you or another caregiver fill
out a questionnaire about observations or concerns 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.

C1 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
No ➔ SKIP to question C4
C2

Answer the following question only if this child is at
least 9 months old. Otherwise skip to question C8 .

Yes

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.

No

If yes, and this child is 9-23 Months:
Did the questionnaire ask about your concerns
or observations about: Mark (X) ALL that apply.
How this child talks or makes speech sounds?
How this child interacts with you and others?

0 visits

If yes, and this child is 2-5 Years:
Did the questionnaire ask about your concerns
or observations about: Mark (X) ALL that apply.
Words and phrases this child uses and
understands?

1 visit
2 or more visits
C3

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 behaves and gets along with
you and others?
C8

Less than 10 minutes

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

10-20 minutes
No ➔ SKIP to question C10 on page 8
More than 20 minutes
C9
C4 Are you concerned about this child’s weight?

If yes, where does this child USUALLY go first?
Mark (X) ONE box.

Yes, it’s too high

Doctor’s Office

Yes, it’s too low

Hospital Emergency Room

No, I am not concerned

Hospital Outpatient Department
Clinic or Health Center

C5

C6

Has a doctor or other health care provider ever told you
that this child is overweight?

Retail Store Clinic or “Minute Clinic”

Yes

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

No

Some other place

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?
Yes
No

NSCH-T1

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§;"|J¤

26019133

C10 Is there a place that this child USUALLY goes when

C16 If yes, DURING THE PAST 12 MONTHS, what

PREVENTIVE dental service(s) did this child receive?
Mark (X) ALL that apply.

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

Check-up

No ➔ SKIP to question C12

Cleaning
Instruction on tooth brushing and oral health care

C11 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)
C12 DURING THE PAST 12 MONTHS, has this child had his

or her vision tested, such as with pictures, shapes, or
letters?

Don’t know
C17 DURING THE PAST 12 MONTHS, has this child

Yes

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 C14
C13 If yes, where was this child’s vision tested?

Yes

Mark (X) ALL that apply.
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 C19

Clinic or health center

C18 How difficult was it to get the mental health treatment

or counseling that this child needed?
School
Not difficult
Other, specify:

C

Somewhat difficult
Very difficult

C14 DURING THE PAST 12 MONTHS, did this child see a

It was not possible to obtain care

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

C19 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 C17
C15 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?

No
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.

No preventive visits in
the past 12 months ➔ SKIP to question C19

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 C22 on page 9

NSCH-T1

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26019125

C21 How difficult was it to get the specialist care that this

C26 DURING THE PAST 12 MONTHS, how often were you

child needed?

frustrated in your efforts to get services for this child?

Not difficult

Never

Somewhat difficult

Sometimes

Very difficult

Usually

It was not possible to obtain care

Always

C22 DURING THE PAST 12 MONTHS, did this child use any

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?
None
1 time

Yes

2 or more times

No

C28 DURING THE PAST 12 MONTHS, was this child

admitted to the hospital to stay for at least one night?

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
C29 Has this child EVER had a special education or early

Yes

intervention plan? Children receiving these services often
have an Individualized Family Service Plan (IFSP) or
Individualized Education Plan (IEP).

No ➔ SKIP to question C26
C24 If yes, which types of care were not received?

Yes

Mark (X) ALL that apply.

No ➔ SKIP to question C32

Medical Care
Dental Care

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

plan?
Vision Care
Years AND

Hearing Care

C31 Is this child CURRENTLY receiving services under one

Mental Health Services
Other, specify:

Months

of these plans?
Yes

C

No
C25 Did any of the following reasons contribute to this child C32 Has this child EVER received special services to meet

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

not receiving needed health services? Mark (X) Yes or No
for each item.
Yes

No

Yes

a. This child was not eligible for the
services
b. The services this child needed were
not available in your area

No ➔ SKIP to question D1 on page 10
C33 If yes, how old was this child when he or she began

receiving these special services?

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 or doctor’s office wasn’t
open when this child needed care

Yes

f. There were issues related to cost

No

NSCH-T1

9

§;"|:¤

26019117

D. Experience with This
Child’s Health Care
Providers

D6

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

Usually Sometimes Never

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

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.

b. Make it easy for you
to raise concerns or
disagree with
recommendations
for this child’s health
care?

Yes, one person
Yes, more than one person

c. Work with you to
decide together
which health care
and treatment
choices would be
best for this child?

No
D2 DURING THE PAST 12 MONTHS, did this child need a

referral to see any doctors or receive any services?
Yes
D7

No ➔ SKIP to question D4

DURING THE PAST 12 MONTHS, did anyone help you
arrange or coordinate this child’s care among the
different doctors or services that this child uses?

D3 How difficult was it to get referrals?

Yes
Not difficult
No
Somewhat difficult

Did not see more than one health
care provider in the PAST 12
MONTHS ➔ SKIP to question D11 on page 11

Very difficult
D8

It was not possible to get a referral
D4 Answer the following questions only if this child had a

health care visit IN THE PAST 12 MONTHS. Otherwise
skip to question E1 on page 11.

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

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

Usually Sometimes

No ➔ SKIP to question D10

Never

a. Spend enough time
with this child?

D9

b. Listen carefully to
you?

Usually

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

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?

Sometimes
Never
D10 DURING THE PAST 12 MONTHS, how satisfied were

you with the communication between this child’s
doctors and other health care providers?

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

Very satisfied

D5 DURING THE PAST 12 MONTHS, did this child need

Somewhat satisfied

any decisions to be made regarding his or her health
care, such as whether to get prescriptions, referrals,
or procedures?

Somewhat dissatisfied

Yes

Very dissatisfied

No ➔ SKIP to question D7
NSCH-T1

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§;"|2¤

26019109

D11 DURING THE PAST 12 MONTHS, did this child’s health

E3

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

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

Yes

No ➔ SKIP to question F1 on page 12

No ➔ SKIP to question E1
E4

Did not need health care
provider to communicate
with these providers ➔ SKIP to question E1

Is this child CURRENTLY covered by any of the
following types of health insurance or health coverage
plans? Mark (X) Yes or No for EACH item.
Yes

No

a. Insurance through a current or
former employer or union

D12 If yes, during this time, how satisfied were you with the

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

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

Very satisfied
Somewhat satisfied
Somewhat dissatisfied

d. TRICARE or other military
health care

Very dissatisfied

e. Indian Health Service

E. This Child’s Health
Insurance Coverage
E1

E2

f. Other, specify: C

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

E5

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

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

Always

Yes, but this child had a gap in coverage

Usually

No

Sometimes

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

Never
E6

No

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

a. Change in employer or employment
status

Always

b. Cancellation due to overdue
premiums

Usually

c. Dropped coverage because it was
unaffordable

Sometimes

d. Dropped coverage because benefits
were inadequate

Never

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

E7

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?

f. Problems with application or
renewal process

This child does not use mental or behavioral
health services

g. Other, specify: C

Always
Usually
Sometimes
Never

NSCH-T1

11

§;"|*¤

26019091

F. Providing for This
Child’s Health
F1

F5

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 at home
on a weekly basis

Including co-pays and amounts reimbursed 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.

Less than 1 hour per week
1-4 hours per week
5-10 hours per week

$0 (No medical or health-related
expenses) ➔ SKIP to question F4

11 or more hours per week
$1-$249
F6

$250-$499
$500-$999

F2

IN AN AVERAGE WEEK, how many hours do you or
other family members spend arranging or coordinating
health or medical care for this child, such as making
appointments or locating services?

$1,000-$5,000

This child does not need health care coordinated
on a weekly basis

More than $5,000

Less than 1 hour per week
1-4 hours per week

How often are these costs reasonable?
Always

5-10 hours per week

Usually

11 or more hours per week

Sometimes

G. This Child’s Learning

Never
F3

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

Answer the following question only if this child is at
least 1 year old. Otherwise skip to H1 on page 15.
G1

Yes

Yes

a. Say at least one word, such as "hi"
or "dog"?

No
F4

Is this child able to do the following...
Mark (X) Yes or No for each item.

b. Use 2 words together, such as
"car go"?

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

c. Use 3 words together in a sentence,
such as, "Mommy come now."?

No

a. Left a job or taken a leave of
absence because of this child’s
health or health conditions?

d. Ask questions like "who," "what,"
"when," "where"?

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

e. Ask questions like "why" and "how"?
f. Tell a story with a beginning,
middle, and end?

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

g. Understand the meaning of the
word "no"?
h. Follow a verbal direction without
hand gestures, such as "Wash your
hands."?
i.

Point to things in a book when
asked?
j. Follow 2-step directions, such as
"Get your shoes and put them in the
basket."?
k. Understand words such as "in,"
"on," and "under"?

NSCH-T1

12

§;"{|¤

No

26019083

G2 Is this child 3 years old or older?

G8 Can this child rhyme words?

Yes

Yes

No ➔ SKIP to question H1 on page 15

No

G3 Has this child started school? Include any formal

G9 How often can this child explain things he or she has seen

home schooling.

or done so that you get a very good idea what happened?

Yes, preschool

Always

Yes, kindergarten

Most of the time

Yes, first grade

About half the time

No

Sometimes
Never

G4 Are you concerned about how this child is learning to

do things for him or herself?
G10 How often can this child write his or her first name, even

No

if some of the letters aren’t quite right or are backwards?

Yes, somewhat concerned

Always

Yes, very concerned

Most of the time
About half the time

G5 How confident are you that this child is ready to be in

school?
Sometimes
Completely confident
Never
Mostly confident
G11 How high can this child count?

Somewhat confident
This child cannot count
Not at all confident
Up to five
G6 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 ten
Up to 20

Always

Up to 50

Most of the time

Up to 100 or more

About half the time
Sometimes

G12 How often can this child identify basic shapes such as

a triangle, circle, or square?

Never

Always

G7 About how many letters of the alphabet can this child

Most of the time

recognize?

About half the time

All of them

Sometimes

Most of them

Never

About half of them
Some of them
None of them

NSCH-T1

13

§;"{t¤

26019075

G13 Can this child identify the colors red, yellow, blue,

G19 How often does this child become angry or anxious

and green by name?

when going from one activity to another?

Yes, all of them

Always

Yes, some of them

Most of the time

No, none of them

About half the time

G14 How often is this child easily distracted?

Sometimes

Always
Most of the time

Never
G20 How often does this child show concern when others

are hurt or unhappy?

About half the time

Always
Sometimes
Most of the time
Never
About half the time
G15 How often does this child keep working at something

until he or she is finished?

Sometimes

Always
Most of the time

Never
G21 When excited or all wound up, how often can this child

calm down quickly?

About half the time

Always
Sometimes
Most of the time
Never
About half the time
G16 When this child is paying attention, how often can he

Sometimes

or she follow instructions to complete a simple task?
Always
Most of the time

Never
G22 How often does this child lose control of his or her

temper when things do not go his or her way?

About half the time

Always
Sometimes
Most of the time
Never
About half the time
G17 How does this child usually hold a pencil?

Sometimes

Uses fingers to hold the pencil

Never

Grips the pencil in his or her fist
This child cannot hold a pencil

G23 Compared to other children his or her age, how much

difficulty does this child have making or keeping
friends?

G18 How often does this child play well with others?

No difficulty

Always

A little difficulty

Most of the time

A lot of difficulty

About half the time
Sometimes
Never
NSCH-T1

14

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26019067

G24 Compared to other children his or her age, how often

H6

is this child able to sit still?

Answer the next question only if this child is LESS THAN
12 MONTHS OLD. Otherwise, SKIP to question H7 .
In which position do you most often lay this baby down
to sleep now? Mark (X) ONE box.

Always
Most of the time

On his or her side

About half the time

On his or her back

Sometimes

On his or her stomach

Never

H7

H. About You and This
Child

ON MOST WEEKDAYS, about how much time did this
child spend in front of a TV, computer, cellphone or
other electronic device watching programs, playing
games, accessing the internet or using social media?
Do not include time spent doing schoolwork.
Less than 1 hour

H1 Was this child born in the United States?

Yes ➔ SKIP to question

1 hour
H3

2 hours

No

3 hours
H2 If no, how long has this child been living in the

United States?
Years AND

4 or more hours
Months

H8

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

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

since he or she was born?

1-3 days
Number of times
4-6 days
H4 How often does this child go to bed at about the same

Every day

time on weeknights?
Always

H9

Usually

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

Sometimes

0 days

Rarely

1-3 days

Never

4-6 days
Every day

H5 DURING THE PAST WEEK, how many hours of sleep

did this child get during an average day (count both
nighttime sleep and naps)?

H10 How well do you think you are handling the day-to-day

demands of raising children?

Less than 7 hours

Very well
7 hours
Somewhat well
8 hours
Not very well
9 hours
Not well at all
10 hours
11 hours
12 or more hours

NSCH-T1

15

§;"{d¤

26019059

I. About Your Family and
Household

H11 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

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

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

1-3 days
4-6 days

c. Angry with
this child?

Every day

H12 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 I4

No ➔ SKIP to question

H14

H13 If yes, did you receive emotional support from...
Yes

I3

If yes, does anyone smoke inside your home?
Yes

No

No

a. Spouse or domestic partner?
b. Other family member or close friend?

I4

c. Health care provider?

DURING THE PAST 12 MONTHS, how often were
pesticides used inside your residence to control for
insects? If the frequency changed throughout the year,
report the highest frequency.

d. Place of worship or religious leader?

More than once a week

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

Once a week

f. Peer support group?

Once a month

g. Counselor or other mental health
professional?

Once every 2-5 months

h. Other person, specify:

Once every 6 months
C

Once during the past 12 months
Never
H14 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.

Don’t know
I5

Yes

DURING THE PAST 12 MONTHS, other than in a shower
or bathtub, have you seen any mold, mildew or other
signs of water damage on walls or other surfaces inside
your home?
Yes

No

No

H15 DURING THE PAST 12 MONTHS, did you or anyone in

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?
Yes
No

NSCH-T1

16

§;"{\¤

26019042

I6

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

Most of
the time

Some of
the time

I10 In your neighborhood, is/are there...

Yes

None of
the time

No

a. Sidewalks or walking paths?

a. Talk together
about what to do

b. A park or playground?

b. Work together to
solve our problems

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

c. Know we have
strengths to draw on

d. A library or bookmobile?

d. Stay hopeful
even in difficult
times

e. Litter or garbage on the street
or sidewalk?
f. Poorly kept or rundown housing?

I7

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

g. Vandalism such as broken
windows or graffiti?
I11 To what extent do you agree with these statements

about your neighborhood or community?
Rarely

Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

Somewhat often

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

Very often
I8

Which of these statements best describes your
household’s ability to afford the food you need
DURING THE PAST 12 MONTHS?
We could always afford to eat good nutritious meals.

c. This child is
safe in our
neighborhood

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

d. When we
encounter
difficulties, we
know where to
go for help in
our community

Sometimes we could not afford enough to eat.
Often we could not afford enough to eat.
I9

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

I12 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.

No

a. Cash assistance from a government
welfare program?

To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated

b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?
c. Free or reduced-cost breakfasts or
lunches at school?

b. Parent or guardian died

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

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 his or her
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
NSCH-T1

17

§;"{K¤

26019034

J. Child’s Caregivers

J7

➜ Complete the questions for UP TO TWO ADULTS

Married

in the household who are this child’s primary
caregivers.

Not married, but living with a partner
Never Married

CAREGIVER 1 (You)
J1

Divorced

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

Separated

Step-parent

Widowed

Grandparent

J2

What is your marital status?

J8

In general, how is your physical health?

Foster Parent

Excellent

Other: Relative

Very good

Other: Non-Relative

Good
Fair

What is your sex?
Male

Poor

Female
J9
J3

What is your age?

Excellent

Age in years
J4

J5

Very good

Where were you born?

Good

In the United States ➔ SKIP to question J6

Fair

Outside of the United States

Poor

When did you come to live in the United States?
Indicate the 4-digit year in which you came to live in the
United States.

J10

What is the highest grade or level of school you have
completed? Mark (X) ONE box.

Were you employed at least 50 out of the past 52 weeks?
Yes
No

4-Digit Year
J6

In general, how is your mental or emotional health?

J11

8th grade or less

Have you ever served on active duty in the
U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
Never served in the
military ➔ SKIP to question J13 on page 19

9th-12th grade; No diploma
High School Graduate or GED Completed

Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question J13 on page 19

Completed a vocational, trade, or business school
program

Now on active duty

Some College Credit, but no Degree

On active duty in the past, but not now

Associate Degree (AA, AS)

J12

Were you deployed at any time during this child’s life?

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)
NSCH-T1

18

§;"{C¤

26019026

➜ If this child has another primary adult caregiver

J19 What is Caregiver 2’s marital status?

who lives in this household, complete Questions
J13-J24. Otherwise, skip to Question K1 on page 20.

Married

CAREGIVER 2

Not married, but living with a partner

J13 How is Caregiver 2 related to this child?

Never Married

There is only one primary adult caregiver in the
household for this child ➔ SKIP to question K1 on
page 20

Divorced

Biological or Adoptive Parent

Separated

Step-parent

Widowed

Grandparent

J20 In general, how is Caregiver 2’s physical health?

Foster Parent

Excellent

Other: Relative

Very good

Other: Non-Relative

Good
Fair

J14 What is Caregiver 2’s sex?

Male

Poor

Female

J21 In general, how is Caregiver 2’s mental or emotional

health?
J15 What is Caregiver 2’s age?

Excellent

Age in years

Very good

J16 Where was Caregiver 2 born?

Good

In the United States ➔ SKIP to question J18

Fair

Outside of the United States

Poor

J17 When did Caregiver 2 come to live in the United States?

Indicate the 4-digit year in which Caregiver 2 came to live
in the United States.

J22 Was Caregiver 2 employed at least 50 out of the past 52

weeks?
Yes

4-Digit Year

No
J18 What is the highest grade or level of school Caregiver 2

has completed? Mark (X) ONE box.

J23 Has Caregiver 2 ever served on active duty in the U.S.

Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
Never served in the
military ➔ SKIP to question K1 on page 20

8th grade or less
9th-12th grade; No diploma
High School Graduate or GED Completed

Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question K1 on page 20

Completed a vocational, trade, or business school
program

Now on active duty

Some College Credit, but no Degree

On active duty in the past, but not now

Associate Degree (AA, AS)
J24 Was Caregiver 2 deployed at any time during this child’s

life?

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)
NSCH-T1

19

§;"{;¤

26019018

K. Household Information
K1

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

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 ➔

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.

Yes ➔

Number of people

$

,

$

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

$

,

.00

,

No

$

,

.00

,

.00

,

,

.00

TOTAL AMOUNT
in the last calendar year

The following question is about your 2018 income.
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 businesses, farm or rent, and any other money income
received.

$

,

.00

,

TOTAL AMOUNT
in the last calendar year

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

,

Loss

TOTAL AMOUNT
in the last calendar year

No

$

No
K4

.00

,

,

TOTAL AMOUNT
in the last calendar year

Yes ➔

TOTAL AMOUNT
in the last calendar year

No

.00

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

Income in 2018
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 for
all jobs.
Yes ➔

,

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

No

K3

,

TOTAL AMOUNT
in the last calendar year

No

Number of people
K2

$

Loss

TOTAL AMOUNT
in the last calendar year

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.
We estimate that completing the National Survey of Children’s Health will take 33 minutes on average. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to U.S. Department of Commerce, 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. This collection has been
approved by the Office of Management and Budget (OMB). The eight-digit OMB approval number that appears at the upper left of the form confirms this approval. If this number
were not displayed, we could not conduct this survey.

NSCH-T1

20

§;"{3¤

26029207

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 required by law to protect your information and is not permitted to publicly release your responses in
a way that could identify you or your household. The U.S. Census Bureau is conducting the National Survey of Children’s Health
on the behalf of the 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. Federal law protects your privacy and
keeps your answers confidential under 13 U.S.C. Section 9. Per the Federal Cybersecurity Enhancement Act of 2015, your data are
protected from cybersecurity risks through screening of the systems that transmit your data.
Any information you provide will be shared for the work-related purposes identified above and as permitted under the Privacy Act
of 1974 (5 U.S.C. Section 552a) and SORN COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame).
Participation in this survey is voluntary and there are no penalties for refusing to answer questions. However, your cooperation in
obtaining this much needed information is extremely important in order to ensure complete and accurate results.

NSCH-T2
(04/15/2019) Draft 4

§;#}(¤

26029199

Start Here

A3

How often does this child...
Always

Usually Sometimes

Never

a. Show interest and
curiosity in learning
new things?

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.

b. Work to finish tasks
he or she starts?

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

c. Stay calm and in
control when faced
with a challenge?
d. Care about doing
well in school?

If the name listed above is not correct or does not
correspond to a child living in this household, please
call 1-800-845-8241 for assistance.

e. Do all required
homework?

We have selected only one child per household in an
effort to minimize the amount of time you will need to
complete the follow-up questions.
The survey should be completed by an adult who is
familiar with this child’s health and health care.

f. Argue too much?

A4

Your participation is important. Thank you.

DURING THE PAST 12 MONTHS, how often was this
child bullied, picked on, or excluded by other children?
If the frequency changed throughout the year, report the
highest frequency.
Never (in the past 12 months)
1-2 times (in the past 12 months)
1-2 times per month

A. This Child’s Health

1-2 times per week
Almost every day

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

(the one named above)?
Excellent

A5

Very good
Good

DURING THE PAST 12 MONTHS, how often did this
child bully others, pick on them, or exclude them?
If the frequency changed throughout the year, report the
highest frequency.
Never (in the past 12 months)

Fair

1-2 times (in the past 12 months)

Poor

1-2 times per month

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

1-2 times per week

teeth?

Almost every day

Excellent
Very good
Good
Fair
Poor

NSCH-T2

2

§;#|ƒ¤

26029181

A6 DURING THE PAST 12 MONTHS, has this child had

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

FREQUENT or CHRONIC difficulty with any of the
following?
Yes

No

A10 Asthma?

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

Yes

No

If yes, does this child CURRENTLY have the
condition?

b. Eating or swallowing because of
a health condition

Yes

No

If yes, is it:

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

Mild

Moderate

Severe

A11 Brain injury, concussion or head injury?

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

Yes

No

If yes, does this child CURRENTLY have the
condition?

e. Toothaches
f. Bleeding gums

Yes

No

If yes, is it:

g. Decayed teeth or cavities

Mild
A7 Does this child have any of the following?
Yes

No

Yes

No

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

b. Serious difficulty walking or climbing
stairs

Mild

Moderate

Yes

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

No

If yes, does this child CURRENTLY have the
condition?

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

Yes

No

If yes, does this child CURRENTLY have the
condition?

No

If yes, is it:

A8 Allergies (including food, drug, insect, or other)?

Mild

Moderate

Yes

No

If yes, does this child CURRENTLY have the
condition?

If yes, is it:
Moderate

Yes

Severe

No

If yes, is it:

A9 Arthritis?

Mild
No

Moderate

Severe

A15 Heart Condition?

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

Severe

A14 Epilepsy or Seizure Disorder?

No

Yes

Severe

A13 Diabetes?

d. Deafness or problems with hearing

Mild

No

If yes, is it:

c. Difficulty dressing or bathing

Yes

Severe

A12 Cerebral Palsy?

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

Yes

Moderate

Yes

No

If yes, does this child CURRENTLY have the
condition?

No

If yes, is it:
Yes
Mild

Moderate

Severe

No

If yes, is it:
Mild

NSCH-T2

3

Moderate

Severe

§;#|r¤

26029173

Has a doctor or other health care provider EVER told
you that this child has...
A16 Frequent or severe headaches, including migraine?

Has a doctor or other health care provider EVER told
you that this child has...
A21 Blood Disorders (such as Sickle Cell Disease,

Thalassemia, or Hemophilia)?
Yes

No
Yes

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

If yes, is it:

No

Mild

If yes, is it:
Mild

Moderate

Severe

Yes

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

Severe

No

If yes, was this child diagnosed with:

No

Sickle Cell Disease?

Yes

No

Thalassemia?

Yes

No

Hemophilia?

Yes

No

Other Blood
Disorders?

Yes

No

No

If yes, is it:
Mild

Moderate

Severe

A22 Cystic Fibrosis?

A18 Anxiety Problems?

Yes

Yes

No

Yes

Mild

No

Moderate

Severe

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.

If yes, is it:
Mild

No

If yes, is it:

If yes, does this child CURRENTLY have the
condition?

Moderate

Severe

A19 Depression?

Yes

No

A23 Other genetic or inherited condition?

Yes

No

Yes

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

No

If yes, specify: C

No

If yes, is it:
Mild

Is it:
Moderate

Severe

Mild

Yes

Moderate

Severe

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.

A20 Down Syndrome?

No

If yes, is it:
Mild

Moderate

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.

A17 Tourette Syndrome?

Yes

No

Yes
Moderate

Severe

No

A24 Substance Use Disorder?

Yes

No

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

No

If yes, is it:
Mild

NSCH-T2

4

Moderate

Severe

§;#|j¤

26029165

Has a doctor, other health care provider, or educator
EVER told you that this child has...
Examples of educators are teachers and school nurses.

A30 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).

A25 Behavioral or Conduct Problems?

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

A26 Developmental Delay?

Yes

No ➔ SKIP to question A35 on page 6

Yes

Mild

Moderate

Severe

A31 How old was this child when a doctor or other health

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

No

If yes, does this child CURRENTLY have the
condition?
Don’t know

Age in years
Yes

No
A32 What type of doctor or other health care provider was

If yes, is it:
Mild

Moderate

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

Severe

Primary Care Provider

A27 Intellectual Disability (formerly known as Mental

Retardation)?
Yes

Specialist

No

School Psychologist/Counselor

If yes, does this child CURRENTLY have the
disability?

Other Psychologist (Non-School)
Yes

No
Psychiatrist

If yes, is it:
Mild

Moderate

Other, specify: C

Severe

A28 Speech or other language disorder?

Yes

No

Don’t know

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

A33 Is this child CURRENTLY taking medication for Autism,

ASD, Asperger’s Disorder or PDD?

No

If yes, is it:

Yes

Mild

Moderate

Severe

A34 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?

A29 Learning Disability?

Yes

No

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

No

Yes

No

No

If yes, is it:
Mild

Moderate

Severe

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26029157

A35 Has a doctor or other health care provider EVER told

B2

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

What month and year was this child born?
Birth Month / 4-Digit Birth Year

/

No ➔ SKIP to question A38

Yes

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

B3

No

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

If yes, is it:
Mild

pounds AND
Moderate

Severe

kilograms AND

ADHD?
No

ounces

OR

A36 Is this child CURRENTLY taking medication for ADD or

Yes

2 0

B4

grams

What was the age of the mother when this child was
born? Your best estimate is fine.

A37 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?
Yes

Age in years

No

C. Health Care Services
A38 DURING THE PAST 12 MONTHS, how often have this

child’s health conditions or problems affected his or her C1 DURING THE PAST 12 MONTHS, did this child see a
ability to do things other children his or her age do?
doctor, nurse, or other health care professional for
sick-child care, well-child check-ups, physical exams,
This child does not have any
hospitalizations or any other kind of medical care?
health conditions ➔ SKIP to question B1
Never

Yes

Sometimes

No ➔ SKIP to question C4 on page 7

Usually

C2

Always
A39 To what extent do this child’s health conditions or

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.

problems affect his or her ability to do things?
0 visits

Very little

1 visit

Somewhat

2 or more visits

A great deal
C3

B. This Child as an Infant
B1

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.
Less than 10 minutes

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

10-20 minutes
Yes
More than 20 minutes
No

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26029140

C4 What is this child’s CURRENT height?

C10 Is there a place that this child USUALLY goes when

Your best estimate is fine.
feet AND

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

Yes

OR

No ➔ SKIP to question C12
meters AND

centimeters

C11 If yes, is this the same place this child goes when he

or she is sick?
C5 How much does this child CURRENTLY weigh?

Yes

Your best estimate is fine.

No
pounds
C12 DURING THE PAST 12 MONTHS, has this child had his

OR

or her vision tested, such as with pictures, shapes, or
letters?
kilograms

C6

Yes

Are you concerned about this child’s weight?
Yes, it’s too high

No ➔ SKIP to question C14
C13 If yes, where was this child’s vision tested?

Mark (X) ALL that apply.

Yes, it’s too low

Eye doctor or eye specialist (ophthalmologist,
optometrist) office

No, I am not concerned

Pediatrician or other general doctor’s office
C7

C8

Has a doctor or other health care provider ever told
you that this child is overweight?

Clinic or health center

Yes

School

No

Other, specify:

Is there a place you or another caregiver USUALLY
take this child when he or she is sick or you need
advice about his or her health?

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?

Yes
No ➔ SKIP to question C10
C9

C

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

If yes, where does this child USUALLY go first?
Mark (X) ONE box.

No ➔ SKIP to question C17 on page 8
Doctor’s Office
C15 If yes, DURING THE PAST 12 MONTHS, did this child

Hospital Emergency Room

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 Outpatient Department
Clinic or Health Center

No preventive visits in the past
12 months ➔ SKIP to question C17 on page 8

Retail Store Clinic or “Minute Clinic”

Yes, 1 visit

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

Yes, 2 or more visits

Some other place

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26029132

C16 If yes, DURING THE PAST 12 MONTHS, what

C21 How difficult was it to get the specialist care that this

child needed?

PREVENTIVE dental service(s) did this child receive?
Mark (X) ALL that apply.

Not difficult
Check-up
Somewhat difficult
Cleaning
Very difficult
Instruction on tooth brushing and oral health care
It was not possible to obtain care
X-Rays
C22 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.

Fluoride treatment
Sealant (plastic coatings on back teeth)
Don’t know

Yes
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.

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

Yes

No, this child did not need to see a
mental health professional ➔ SKIP to question C19

No ➔ SKIP to question C26 on page 9
C24 If yes, which types of care were not received?

C18 How difficult was it to get the mental health treatment

Mark (X) ALL that apply.

or counseling that this child needed?
Medical Care
Not difficult
Dental Care
Somewhat difficult
Vision Care
Very difficult
Hearing Care
It was not possible to obtain care
Mental Health Services
C19 DURING THE PAST 12 MONTHS, has this child taken

Other, specify: C

any medication because of difficulties with his or her
emotions, concentration, or behavior?
Yes
No

C25 Did any of the following reasons contribute to this child

not receiving needed health services? Mark (X) Yes or No
for each item.
Yes

C20 DURING THE PAST 12 MONTHS, did this child see a

a. This child was not eligible for the
services

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.

b. The services this child needed were
not available in your area
c. There were problems getting an
appointment when this child needed
one

Yes
No, but this child needed to see a specialist

d. There were problems with getting
transportation or child care

No, this child did not need to
see a specialist ➔ SKIP to question C22

e. The clinic or doctor’s office wasn’t
open when this child needed care
f. There were issues related to cost

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No

26029124

D. Experience with This
Child’s Health Care
Providers

C26 DURING THE PAST 12 MONTHS, how often were you

frustrated in your efforts to get services for this child?
Never
Sometimes
D1

Usually
Always
C27 DURING THE PAST 12 MONTHS, how many times did

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.

this child visit a hospital emergency room?
Yes, one person

None

Yes, more than one person

1 time

No

2 or more times
C28 DURING THE PAST 12 MONTHS, was this child

D2

admitted to the hospital to stay for at least one night?

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

Yes

Yes

No

No ➔ SKIP to question D4

C29 Has this child EVER had a special education or early

D3

intervention plan? Children receiving these services often
have an Individualized Family Service Plan (IFSP) or
Individualized Education Plan (IEP).

How difficult was it to get referrals?
Not difficult

Yes

Somewhat difficult

No ➔ SKIP to question C32

Very difficult
It was not possible to get a referral

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

plan?
D4

Years AND

Months

C31 Is this child CURRENTLY receiving services under one

Answer the following questions only if this child had a
health care visit IN THE PAST 12 MONTHS. Otherwise
skip to question E1 on page 11.
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers...

of these plans?
Yes

Always

Usually Sometimes

a. Spend enough time
with this child?

No

b. Listen carefully to
you?

C32 Has this child EVER received special services to meet

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

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

Yes

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

No ➔ SKIP to question D1
C33 If yes, how old was this child when he or she began

receiving these special services?
Years AND

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

Months

C34 Is this child CURRENTLY receiving these special

services?
Yes
No
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Never

26029116

D5 DURING THE PAST 12 MONTHS, did this child need

D10 DURING THE PAST 12 MONTHS, how satisfied were

any decisions to be made regarding his or her health
care, such as whether to get prescriptions, referrals,
or procedures?

you with the communication between this child’s
doctors and other health care providers?
Very satisfied

Yes
Somewhat satisfied
No ➔ SKIP to question D7
Somewhat dissatisfied
D6 If yes, DURING THE PAST 12 MONTHS, how often did

this child’s doctors or other health care providers...
Always

Very dissatisfied

Usually Sometimes Never

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

D11 DURING THE PAST 12 MONTHS, did this child’s health

b. Make it easy for you
to raise concerns or
disagree with
recommendations
for this child’s health
care?

No ➔ SKIP to question E1 on page 11

c. Work with you to
decide together
which health care
and treatment
choices would be
best for this child?

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

Did not need health care provider to communicate
with these providers ➔ SKIP to question E1 on
page 11
D12 If yes, during this time, how satisfied were you with the

health care provider’s communication with the school,
child care provider, or special education program?
Very satisfied
Somewhat satisfied

D7 DURING THE PAST 12 MONTHS, did anyone help you

arrange or coordinate this child’s care among the
different doctors or services that this child uses?

Somewhat dissatisfied
Very dissatisfied

Yes
No
Did not see more than one health care provider
in the PAST 12 MONTHS ➔ SKIP to question D11
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?
Yes
No ➔ SKIP to question D10
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
Sometimes
Never

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26029108

E. This Child’s Health
Insurance Coverage

E4

Is this child CURRENTLY covered by any of the
following types of health insurance or health coverage
plans? Mark (X) Yes or No for EACH item.
Yes

E1

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

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

Yes, this child was covered
all 12 months ➔ SKIP to question E4
Yes, but this child had a gap in coverage
No
E2

No

a. Insurance through a current or
former employer or union

d. TRICARE or other military
health care

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

e. Indian Health Service
f. Other, specify: C

No

a. Change in employer or employment
status
b. Cancellation due to overdue
premiums

E5

c. Dropped coverage because it was
unaffordable

Always

d. Dropped coverage because benefits
were inadequate

Usually

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

Sometimes
Never

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

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

E6

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

E3

Usually

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

Sometimes

Yes

Never

No ➔ SKIP to question F1 on page 12
E7

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?
This child does not use mental or behavioral
health services
Always
Usually
Sometimes
Never

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26029090

F. Providing for This
Child’s Health
F1

F5

Including co-pays and amounts reimbursed 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.

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 at home
on a weekly basis
Less than 1 hour per week
1-4 hours per week
5-10 hours per week

$0 (No medical or health-related
expenses) ➔ SKIP to question F4

11 or more hours per week
$1-$249
F6

$250-$499
$500-$999

F2

IN AN AVERAGE WEEK, how many hours do you or
other family members spend arranging or coordinating
health or medical care for this child, such as making
appointments or locating services?

$1,000-$5,000

This child does not need health care coordinated
on a weekly basis

More than $5,000

Less than 1 hour per week
1-4 hours per week

How often are these costs reasonable?
Always

5-10 hours per week

Usually

11 or more hours per week

Sometimes
Never
F3

DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?
Yes
No

F4

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

No

a. Left a job or taken a leave of
absence because of this child’s
health or health conditions?
b. Cut down on the hours you work
because of this child’s health or
health conditions?
c. Avoided changing jobs because of
concerns about maintaining health
insurance for this child?

NSCH-T2

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26029082

G. This Child’s Schooling
and Activities

G5

DURING THE PAST 12 MONTHS, did this child
participate in...
Yes

No

a. A sports team or did he or she
take sports lessons after school
or on weekends?

G1 DURING THE PAST 12 MONTHS, about how many days

did this child miss school because of illness or injury?
Include days missed from any formal home schooling.

b. Any clubs or organizations after
school or on weekends?

No missed school days

c. Any other organized activities or
lessons, such as music, dance,
language, or other arts?

1-3 days
4-6 days

d. Any type of community service or
volunteer work at school, place of
worship, or in the community?

7-10 days

e. Any paid work, including regular
jobs as well as babysitting, cutting
grass, or other occasional work?

11 or more days
This child was not enrolled in school
G2

G6

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

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

None

1-3 days

1 time

4-6 days

2 or more times

Every day

G3 SINCE STARTING KINDERGARTEN, has this child

repeated any grades?

G7

Yes

Compared to other children his or her age, how much
difficulty does this child have making or keeping
friends?
No difficulty

No

A little difficulty
G4 DURING THE PAST 12 MONTHS, how often did you

attend events or activities that this child participated in?

A lot of difficulty

Always
Usually
Sometimes
Rarely
Never

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26029074

H. About You and This
Child
H1

H7

How well can you and this child share ideas or talk
about things that really matter?
Very well

Was this child born in the United States?

Somewhat well

Yes ➔ SKIP to question H3
Not very well
No
Not well at all
H2

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

H3

H8

Months

How well do you think you are handling the day-to-day
demands of raising children?
Very well

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

Somewhat well
Not very well

Number of times
Not well at all
H4

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

H9

Never

Always

Sometimes

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

Rarely
Never
DURING THE PAST WEEK, how many hours of sleep
did this child get on most weeknights?
Less than 6 hours

Rarely Sometimes Usually Always

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

Usually

H5

DURING THE PAST MONTH, how often have you felt...

c. Angry with
this child?
H10 DURING THE PAST 12 MONTHS, was there someone

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

6 hours
7 hours

Yes

8 hours

No ➔ SKIP to question I1 on page 15

9 hours
10 hours

H11 If yes, did you receive emotional support from...
Yes

a. Spouse or domestic partner?
11 or more hours
b. Other family member or close friend?
H6

ON MOST WEEKDAYS, about how much time did this
child spend in front of a TV, computer, cellphone or
other electronic device watching programs, playing
games, accessing the internet or using social media?
Do not include time spent doing schoolwork.

c. Health care provider?
d. Place of worship or religious leader?

Less than 1 hour

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

1 hour

f. Peer support group?

2 hours

g. Counselor or other mental health
professional?

3 hours

h. Other person, specify:

C

4 or more hours
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No

26029066

I. About Your Family and
Household
I1

I6

All of
the time

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

Some of
the time

None of
the time

b. Work together to
solve our problems

1-3 days

c. Know we have
strengths to draw on

4-6 days

d. Stay hopeful even
in difficult times

Every day

Most of
the time

a. Talk together
about what to do

0 days

I2

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

I7

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

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

Yes

Rarely

No ➔ SKIP to question I4
I3

Somewhat often

If yes, does anyone smoke inside your home?
Yes

Very often
I8

No
I4

Which of these statements best describes your
household’s ability to afford the food you need DURING
THE PAST 12 MONTHS?
We could always afford to eat good nutritious meals.

DURING THE PAST 12 MONTHS, how often were
pesticides used inside your residence to control for
insects? If the frequency changed throughout the year,
report the highest frequency.

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

More than once a week

Sometimes we could not afford enough to eat.

Once a week

Often we could not afford enough to eat.

Once a month

I9

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

Once every 2-5 months

Yes

Once every 6 months

a. Cash assistance from a government
welfare program?

Once during the past 12 months

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

Never

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

Don’t know
I5

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

DURING THE PAST 12 MONTHS, other than in a shower
or bathtub, have you seen any mold, mildew or other
signs of water damage on walls or other surfaces inside
your home?
Yes
No

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No

26029058

I10 In your neighborhood, is/are there...

Yes

No

I13 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.

a. Sidewalks or walking paths?
b. A park or playground?

To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated

c. A recreation center, community
center, or boys’ and girls’ club?
d. A library or bookmobile?

b. Parent or guardian died

e. Litter or garbage on the street
or sidewalk?

c. Parent or guardian served time in jail
f. Poorly kept or rundown housing?
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home

g. Vandalism such as broken
windows or graffiti?

e. Was a victim of violence or
witnessed violence in his or her
neighborhood

I11 To what extent do you agree with these statements

about your neighborhood or community?
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

f. Lived with anyone who was mentally
ill, suicidal, or severely depressed

a. People in this
neighborhood
help each other
out

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

b. We watch out for
each other’s
children in this
neighborhood
c. This child is
safe in our
neighborhood
d. When we
encounter
difficulties, we
know where to
go for help in
our community
e. This child is safe
at school
I12 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?
Yes
No

NSCH-T2

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26029041

J. Child’s Caregivers

J6

➜ Complete the questions for UP TO TWO ADULTS

8th grade or less

in the household who are this child’s primary
caregivers.

9th-12th grade; No diploma

CAREGIVER 1 (You)
J1

High School Graduate or GED Completed
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)

Other: Relative

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

Other: Non-Relative
J7
J2

What is the highest grade or level of school you have
completed? Mark (X) ONE box.

What is your marital status?

What is your sex?
Married
Male
Not married, but living with a partner
Female
Never Married

J3

What is your age?

Divorced

Age in years
J4

Separated
Widowed

Where were you born?
In the United States ➔ SKIP to question J6

J8

Excellent

Outside of the United States
J5

In general, how is your physical health?

Very good

When did you come to live in the United States?
Indicate the 4-digit year in which you came to live in the
United States.

Good
Fair

4-Digit Year
Poor
J9

In general, how is your mental or emotional health?
Excellent
Very good
Good
Fair
Poor

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26029033

J10 Were you employed at least 50 out of the past

J16 Where was Caregiver 2 born?

52 weeks?
In the United States ➔ SKIP to question J18
Yes
Outside of the United States
No
J17 When did Caregiver 2 come to live in the United States?

Indicate the 4-digit year in which Caregiver 2 came to live in
the United States.

J11 Have you ever served on active duty in the

U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.

4-Digit Year

Never served in the military ➔ SKIP to question J13
Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question J13

J18 What is the highest grade or level of school Caregiver 2

has completed? Mark (X) ONE box.

Now on active duty

8th grade or less

On active duty in the past, but not now

9th-12th grade; No diploma

J12 Were you deployed at any time during this child’s life?

High School Graduate or GED Completed

Yes

Completed a vocational, trade, or business school
program

No
Some College Credit, but no Degree

➜ If this child has another primary adult caregiver

Associate Degree (AA, AS)

who lives in this household, complete Questions
J13-J24. Otherwise, skip to Question K1 on page
19.

Bachelor’s Degree (BA, BS, AB)
Master’s Degree (MA, MS, MSW, MBA)

CAREGIVER 2

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

J13 How is Caregiver 2 related to this child?

There is only one primary adult caregiver in the
household for this child ➔ SKIP to question K1 on
page 19

J19 What is Caregiver 2’s marital status?

Biological or Adoptive Parent

Married

Step-parent

Not married, but living with a partner

Grandparent

Never Married

Foster Parent

Divorced

Other: Relative

Separated

Other: Non-Relative

Widowed

J14 What is Caregiver 2’s sex?

J20 In general, how is Caregiver 2’s physical health?

Male

Excellent

Female

Very good
Good

J15 What is Caregiver 2’s age?

Fair
Age in years

Poor

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18

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26029025

J21 In general, how is Caregiver 2’s mental or emotional

K3

health?
Excellent
Very good

Income in 2018
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 for
all jobs.

Good

Yes ➔

Fair

$

,

.00

TOTAL AMOUNT
in the last calendar year

No

Poor

,

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

J22 Was Caregiver 2 employed at least 50 out of the past 52

weeks?
Yes

Yes ➔

No

No

$

,

,

.00

Loss

TOTAL AMOUNT
in the last calendar year

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

J23 Has Caregiver 2 ever served on active duty in the U.S.

Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.

Yes ➔

Never served in the military ➔ SKIP to question K1

$

,

.00

Loss

TOTAL AMOUNT
in the last calendar year

No

Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question K1

,

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

Now on active duty
Yes ➔

On active duty in the past, but not now

$

Yes ➔

No

,

,

.00

TOTAL AMOUNT
in the last calendar year

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.
Number of people

$

No

K. Household Information

K2

.00

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

Yes

K1

,

TOTAL AMOUNT
in the last calendar year

No
J24 Was Caregiver 2 deployed at any time during this child’s

life?

,

Yes ➔

$

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.
Number of people

,

.00

TOTAL AMOUNT
in the last calendar year

No
K4

,

The following question is about your 2018 income.
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 businesses, farm or rent, and any other money income
received.

$

,

.00

,

TOTAL AMOUNT
in the last calendar year

NSCH-T2

19

§;#{:¤

26029017

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.

We estimate that completing the National Survey of Children’s Health will take 33 minutes on average. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to U.S. Department of Commerce, 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. This collection has been approved by the Office of Management and Budget (OMB).
The eight-digit OMB approval number that appears at the upper left of the form confirms this approval. If this number
were not displayed, we could not conduct this survey.

NSCH-T2

20

§;#{2¤

26039206

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 required by law to protect your information and is not permitted to publicly release your responses in
a way that could identify you or your household. The U.S. Census Bureau is conducting the National Survey of Children’s Health
on the behalf of the 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. Federal law protects your privacy and
keeps your answers confidential under 13 U.S.C. Section 9. Per the Federal Cybersecurity Enhancement Act of 2015, your data are
protected from cybersecurity risks through screening of the systems that transmit your data.
Any information you provide will be shared for the work-related purposes identified above and as permitted under the Privacy Act
of 1974 (5 U.S.C. Section 552a) and SORN COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame).
Participation in this survey is voluntary and there are no penalties for refusing to answer questions. However, your cooperation in
obtaining this much needed information is extremely important in order to ensure complete and accurate results.

NSCH-T3
(04/15/2019) Draft 5

§;$}’¤

26039198

Start Here

A3

How often does this child...
Always

Usually Sometimes

Never

a. Show interest and
curiosity in learning
new things?

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.

b. Work to finish tasks
he or she starts?

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

c. Stay calm and in
control when faced
with a challenge?
d. Care about doing
well in school?

If the name listed above is not correct or does not
correspond to a child living in this household, please
call 1-800-845-8241 for assistance.

e. Do all required
homework?

We have selected only one child per household in an
effort to minimize the amount of time you will need to
complete the follow-up questions.
The survey should be completed by an adult who is
familiar with this child’s health and health care.

f. Argue too much?

A4

Your participation is important. Thank you.

DURING THE PAST 12 MONTHS, how often was this
child bullied, picked on, or excluded by other children?
If the frequency changed throughout the year, report the
highest frequency.
Never (in the past 12 months)
1-2 times (in the past 12 months)
1-2 times per month

A. This Child’s Health

1-2 times per week
Almost every day

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

(the one named above)?
Excellent

A5

Very good
Good

DURING THE PAST 12 MONTHS, how often did this
child bully others, pick on them, or exclude them?
If the frequency changed throughout the year, report the
highest frequency.
Never (in the past 12 months)

Fair

1-2 times (in the past 12 months)

Poor

1-2 times per month

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

1-2 times per week

teeth?

Almost every day

Excellent
Very good
Good
Fair
Poor

NSCH-T3

2

§;$|¥¤

26039180

A6 DURING THE PAST 12 MONTHS, has this child had

FREQUENT or CHRONIC difficulty with any of the
following?
Yes

Has a doctor or other health care provider EVER told
you that this child has...
No

A10 Asthma?

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

Yes

No

If yes, does this child CURRENTLY have the
condition?

b. Eating or swallowing because of
a health condition

Yes

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

No

If yes, is it:
Mild

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

Moderate

Severe

A11 Brain injury, concussion or head injury?

Yes

No

If yes, does this child CURRENTLY have the
condition?

e. Toothaches
f. Bleeding gums

Yes

g. Decayed teeth or cavities

If yes, is it:

No

Mild

A7 Does this child have any of the following?
Yes

No

Moderate

Severe

A12 Cerebral Palsy?

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

Yes

No

If yes, does this child CURRENTLY have the
condition?

b. Serious difficulty walking or climbing
stairs

Yes

No

If yes, is it:

c. Difficulty dressing or bathing
Mild

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

Yes

No

If yes, does this child CURRENTLY have the
condition?

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

Yes

A8 Allergies (including food, drug, insect, or other)?

No

If yes, is it:

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

Mild

Moderate

Severe

A14 Epilepsy or Seizure Disorder?

No

Yes

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

Severe

A13 Diabetes?

e. Deafness or problems with hearing

Yes

Moderate

No

If yes, does this child CURRENTLY have the
condition?

No

Yes

If yes, is it:

No

If yes, is it:

Mild

Moderate

Severe

A9 Arthritis?

Mild

Moderate

Severe

A15 Heart Condition?

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:
Mild

No

No

If yes, is it:
Moderate

Severe

Mild

NSCH-T3

3

Moderate

Severe

§;$|q¤

26039172

Has a doctor or other health care provider EVER told
you that this child has...
A16 Frequent or severe headaches, including migraine?

Has a doctor or other health care provider EVER told
you that this child has...
A21 Blood Disorders (such as Sickle Cell Disease,

Thalassemia, or Hemophilia)?
Yes

No
Yes

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

If yes, is it:

No

Mild

If yes, is it:
Mild

Moderate

Severe

Yes

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

Severe

No

If yes, was this child diagnosed with:

No

Sickle Cell Disease?

Yes

No

Thalassemia?

Yes

No

Hemophilia?

Yes

No

Other Blood
Disorders?

Yes

No

No

If yes, is it:
Mild

Moderate

Severe

A22 Cystic Fibrosis?

A18 Anxiety Problems?

Yes

Yes

No

Yes

Mild

No

Moderate

Severe

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.

If yes, is it:
Mild

No

If yes, is it:

If yes, does this child CURRENTLY have the
condition?

Moderate

Severe

A19 Depression?

Yes

No

A23 Other genetic or inherited condition?

Yes

No

Yes

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

No

If yes, specify: C

No

If yes, is it:
Mild

Is it:
Moderate

Severe

Mild

Yes

Moderate

Severe

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.

A20 Down Syndrome?

No

If yes, is it:
Mild

Moderate

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.

A17 Tourette Syndrome?

Yes

No

Yes
Moderate

Severe

No

A24 Substance Use Disorder?

Yes

No

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

No

If yes, is it:
Mild

NSCH-T3

4

Moderate

Severe

§;$|i¤

26039164

Has a doctor, other health care provider, or educator
EVER told you that this child has...
Examples of educators are teachers and school nurses.

A30 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).

A25 Behavioral or Conduct Problems?

Yes

No

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

No ➔ SKIP to question A35 on page 6

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

Moderate

Severe

A26 Developmental Delay?

Yes

A31 How old was this child when a doctor or other health

No

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

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

A32 What type of doctor or other health care provider was

Mild

Moderate

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

Severe

A27 Intellectual Disability (formerly known as Mental

Primary Care Provider

Retardation)?
Yes

No

Specialist

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

Don’t know

Age in years

No

School Psychologist/Counselor
Other Psychologist (Non-School)

No

If yes, is it:

Psychiatrist

Mild

Moderate

Severe

Other, specify: C

A28 Speech or other language disorder?

Yes

No
Don’t know

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

A33 Is this child CURRENTLY taking medication for Autism,

No

ASD, Asperger’s Disorder or PDD?

If yes, is it:
Yes
Mild

Moderate

A34 At any time DURING THE PAST 12 MONTHS, did this

A29 Learning Disability?

Yes

No

Severe
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

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

Yes

No

No

If yes, is it:
Mild

Moderate

Severe

NSCH-T3

5

§;$|a¤

26039156

A35 Has a doctor or other health care provider EVER told

B2

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

What month and year was this child born?
Birth Month / 4-Digit Birth Year

/

No ➔ SKIP to question A38

Yes

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

B3

No

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

If yes, is it:
Mild

2 0

pounds AND
Moderate

Severe

ounces

OR

A36 Is this child CURRENTLY taking medication for ADD or

ADHD?
Yes

kilograms AND
No
B4

A37 At any time DURING THE PAST 12 MONTHS, did this

What was the age of the mother when this child was
born? Your best estimate is fine.

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

grams

Age in years

No

C. Health Care Services

A38 DURING THE PAST 12 MONTHS, how often have this

child’s health conditions or problems affected his or her
C1 DURING THE PAST 12 MONTHS, did this child see a
ability to do things other children his or her age do?
doctor, nurse, or other health care professional for
This child does not have any
sick-child care, well-child check-ups, physical exams,
health conditions ➔ SKIP to question B1
hospitalizations or any other kind of medical care?
Never

Yes

Sometimes

No ➔ SKIP to question C5 on page 7

Usually
C2

Always
A39 To what extent do this child’s health conditions or

problems affect his or her ability to do things?

If yes, at his or her LAST medical care visit, did this
child have a chance to speak with a doctor or other
health care provider privately, without you or another
caregiver in the room?
Yes

Very little

No

Somewhat
A great deal

C3

B. This Child as an Infant
B1

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

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

1 visit
Yes
2 or more visits
No

NSCH-T3

6

§;$|Y¤

26039149

C4

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.

C10 If yes, where does this child USUALLY go first?

Mark (X) ONE box.
Doctor’s Office

Less than 10 minutes

Hospital Emergency Room

10-20 minutes

Hospital Outpatient Department

More than 20 minutes

Clinic or Health Center
Retail Store Clinic or “Minute Clinic”

C5 What is this child’s CURRENT height?

Your best estimate is fine.
School (Nurse’s Office, Athletic Trainer’s Office)
feet AND

inches

Some other place

OR
C11 Is there a place that this child USUALLY goes when

meters AND

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

centimeters

Yes

C6 How much does this child CURRENTLY weigh?

Your best estimate is fine.
pounds

No ➔ SKIP to question C13
C12 If yes, is this the same place this child goes when he

or she is sick?

OR

Yes
kilograms
C7 Are you concerned about this child’s weight?

No
C13 DURING THE PAST 12 MONTHS, has this child had his

or her vision tested, such as with pictures, shapes, or
letters?

Yes, it’s too high
Yes, it’s too low

Yes

No, I am not concerned

No ➔ SKIP to question C15 on page 8

C8 Has a doctor or other health care provider ever told

C14 If yes, where was this child’s vision tested? Mark (X)

you that this child is overweight?

ALL that apply.

Yes

Eye doctor or eye specialist (ophthalmologist,
optometrist) office

No

Pediatrician or other general doctor’s office
Clinic or health center

C9 Is there a place you or another caregiver USUALLY

take this child when he or she is sick or you need
advice about his or her health?

School

Yes

Other, specify:

C

No ➔ SKIP to question C11

NSCH-T3

7

§;$|R¤

26039131

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

C20 DURING THE PAST 12 MONTHS, has this child taken

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

dentist or other oral health care provider for any kind
of dental or oral health care?
Yes, saw a dentist

Yes

Yes, saw other oral health care provider

No

No ➔ SKIP to question C18

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.

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?

Yes

No preventive visits in
the past 12 months ➔ SKIP to question C18

No, but this child needed to see a specialist

Yes, 1 visit

No, this child did not need to
see a specialist ➔ SKIP to question C23

Yes, 2 or more visits

C22 How difficult was it to get the specialist care that this

child needed?
C17 If yes, DURING THE PAST 12 MONTHS, what

Not difficult

PREVENTIVE dental service(s) did this child receive?
Mark (X) ALL that apply.

Somewhat difficult

Check-up

Very difficult

Cleaning

It was not possible to obtain care

Instruction on tooth brushing and oral health care
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.

X-Rays
Fluoride treatment
Sealant (plastic coatings on back teeth)

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
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.

Yes

Yes

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

No ➔ SKIP to question C27 on page 9
C25 If yes, which types of care were not received?

No, this child did not need to see a
mental health professional ➔ SKIP to question C20

Mark (X) ALL that apply.
Medical Care

C19 How difficult was it to get the mental health treatment

or counseling that this child needed?

Dental Care

Not difficult

Vision Care

Somewhat difficult

Hearing Care

Very difficult

Mental Health Services

It was not possible to obtain care

Other, specify:

NSCH-T3

8

C

§;$|@¤

26039123

C26 Did any of the following reasons contribute to this child C32 Is this child CURRENTLY receiving services under one

not receiving needed health services? Mark (X) Yes or No
for each item.
Yes

of these plans?

No

Yes

a. This child was not eligible for the
services

No

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

C33 Has this child EVER received special services to meet

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

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

d. There were problems with getting
transportation or child care
e. The clinic or doctor’s office wasn’t
open when this child needed care

No ➔ SKIP to question D1
C34 If yes, how old was this child when he or she began

receiving these special services?

f. There were issues related to cost
C27 DURING THE PAST 12 MONTHS, how often were you

Years AND

frustrated in your efforts to get services for this child?

Months

C35 Is this child CURRENTLY receiving these special

Never

services?

Sometimes

Yes

Usually

No

Always

D. Experience with This
Child’s Health Care
Providers

C28 DURING THE PAST 12 MONTHS, how many times did

this child visit a hospital emergency room?
None
D1

1 time
2 or more times
C29 DURING THE PAST 12 MONTHS, was this child admitted

to the hospital to stay for at least one night?

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.

Yes, one person

Yes

Yes, more than one person

No

No

C30 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).

D2

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

Yes

Yes

No ➔ SKIP to question C33

No ➔ SKIP to question D4 on page 10

C31 If yes, how old was this child at the time of the FIRST

D3

plan?

How difficult was it to get referrals?
Not difficult

Years AND

Somewhat difficult

Months

Very difficult
It was not possible to get a referral

NSCH-T3

9

§;$|8¤

26039115

D4 Answer the following questions only if this child had a

D8

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...
Always

Usually Sometimes

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

Never

No ➔ SKIP to question D10

a. Spend enough time
with this child?
D9

b. Listen carefully to
you?
c. Show sensitivity to
your family’s values
and customs?

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

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

Never

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

D10 DURING THE PAST 12 MONTHS, how satisfied were

you with the communication between this child’s
doctors and other health care providers?

D5 DURING THE PAST 12 MONTHS, did this child need

Very satisfied

any decisions to be made regarding his or her health
care, such as whether to get prescriptions, referrals,
or procedures?

Somewhat satisfied
Somewhat dissatisfied

Yes

Very dissatisfied

No ➔ SKIP to question D7

D11 DURING THE PAST 12 MONTHS, did this child’s health
D6 If yes, DURING THE PAST 12 MONTHS, how often did

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

this child’s doctors or other health care providers...
Always

Usually Sometimes Never

Yes

a. Discuss with you
the range of options
to consider for his
or her health care or
treatment?
b. Make it easy for you
to raise concerns or
disagree with
recommendations
for this child’s health
care?

No ➔ SKIP to question D13
Did not need health care
provider to communicate
with these providers ➔ SKIP to question D13
D12 If yes, during this time, how satisfied were you with the

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

c. Work with you to
decide together
which health care
and treatment
choices would be
best for this child?

Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

D7 DURING THE PAST 12 MONTHS, did anyone help you

arrange or coordinate this child’s care among the
different doctors or services that this child uses?

D13 Do any of this child’s doctors or other health care

providers treat only children?

Yes

Yes

No

No ➔ SKIP to question D15 on page 11

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

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26039107

D14 If yes, have they talked with you about when this child

D20 Eligibility for health insurance often changes in young

will need to see doctors or other health care providers
who treat adults?

adulthood. Do you know how this child will be insured
as he or she becomes an adult?

Yes

Yes ➔ SKIP to question E1

No

No

D15 Has this child’s doctor or other health care provider

actively worked with this child to:
Yes

No

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?

Don’t
know

a. 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?
b. 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?

Yes
No

E. This Child’s Health
Insurance Coverage
E1

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

c. 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?
D16 Did you and this child receive a summary of your

child’s medical history (for example, medical conditions,
allergies, medications, immunizations)?

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

Yes, but this child had a gap in coverage
No
E2

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

Yes

a. Change in employer or employment
status

No

b. Cancellation due to overdue
premiums

D17 Have this child’s doctors or other health care providers

worked with you and this child to create a plan of care
to meet his or her health goals and needs?

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

Yes

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

No ➔ SKIP to question D20
D18 If yes, do you and this child have access to this plan of

care?

f. Problems with application or
renewal process

Yes

g. Other, specify: C

No
D19 Does this plan of care address transition to doctors and

other health care providers who treat adults?

E3

Yes

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

No

No ➔ SKIP to question F1 on page 12

No, child already sees providers who treat adults

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No

26039099

E4

F. Providing for This
Child’s Health

Is this child CURRENTLY covered by any of the
following types of health insurance or health coverage
plans? Mark (X) Yes or No for EACH item.
Yes

No

a. Insurance through a current or
former employer or union

F1

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

Including co-pays and amounts reimbursed 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

d. TRICARE or other military
health care

$1-$249

e. Indian Health Service
$250-$499
f. Other, specify: C
$500-$999
$1,000-$5,000
E5

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

More than $5,000
F2

Always

Usually

Usually

Sometimes

Sometimes

Never
E6

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

Never
F3

Always

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

Usually

Yes

Sometimes

No

Never
E7

How often are these costs reasonable?

F4

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?

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

a. Left a job or taken a leave of
absence because of this child’s
health or health conditions?

This child does not use mental or behavioral
health services

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

Always

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

Usually
Sometimes
Never

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No

26039081

F5

IN AN AVERAGE WEEK, how many hours do you or
G3 SINCE STARTING KINDERGARTEN, has this child
other family members spend providing health care at
repeated any grades?
home for this child? Care might include changing
bandages, or giving medication and therapies when needed.
Yes
This child does not need health care provided at home
No
on a weekly basis
Less than 1 hour per week

G4 DURING THE PAST 12 MONTHS, how often did you

attend events or activities that this child participated in?
1-4 hours per week
Always
5-10 hours per week
Usually
11 or more hours per week
Sometimes
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?
This child does not need health care coordinated
on a weekly basis

Rarely
Never
G5 DURING THE PAST 12 MONTHS, did this child

participate in...

Less than 1 hour per week

Yes

1-4 hours per week
5-10 hours per week

b. Any clubs or organizations after
school or on weekends?

11 or more hours per week

c. Any other organized activities or
lessons, such as music, dance,
language, or other arts?

G. This Child’s Schooling
and Activities

d. Any type of community service or
volunteer work at school, place of
worship, or in the community?

G1 DURING THE PAST 12 MONTHS, about how many days

e. Any paid work, including regular
jobs as well as babysitting, cutting
grass, or other occasional work?

did this child miss school because of illness or injury?
Include days missed from any formal home schooling.
No missed school days

G6

1-3 days

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?

4-6 days

0 days

7-10 days

1-3 days

11 or more days

4-6 days

This child was not enrolled in school

Every day

G2 DURING THE PAST 12 MONTHS, how many times has

No

a. A sports team or did he or she
take sports lessons after school
or on weekends?

G7

this child’s school contacted you or another adult in
your household about any problems he or she is
having with school?

Compared to other children his or her age, how much
difficulty does this child have making or keeping
friends?
No difficulty

None
A little difficulty
1 time
A lot of difficulty
2 or more times

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26039073

H. About You and This
Child
H1

H7

How well can you and this child share ideas or talk
about things that really matter?
Very well

Was this child born in the United States?

Somewhat well

Yes ➔ SKIP to question H3
Not very well
No
Not well at all
H2

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

H3

H8

Months

How well do you think you are handling the day-to-day
demands of raising children?
Very well

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

Somewhat well
Not very well

Number of times
Not well at all
H4

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

H9

Never

Always

Sometimes

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

Rarely
Never
DURING THE PAST WEEK, how many hours of sleep
did this child get on most weeknights?
Less than 6 hours

Rarely Sometimes Usually Always

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

Usually

H5

DURING THE PAST MONTH, how often have you felt...

c. Angry with
this child?
H10 DURING THE PAST 12 MONTHS, was there someone

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

6 hours
7 hours

Yes

8 hours

No ➔ SKIP to question I1 on page 15

9 hours
10 hours

H11 If yes, did you receive emotional support from...
Yes

a. Spouse or domestic partner?
11 or more hours
b. Other family member or close friend?
H6

ON MOST WEEKDAYS, about how much time did this
child spend in front of a TV, computer, cellphone or
other electronic device watching programs, playing
games, accessing the internet or using social media?
Do not include time spent doing schoolwork.

c. Health care provider?
d. Place of worship or religious leader?

Less than 1 hour

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

1 hour

f. Peer support group?

2 hours

g. Counselor or other mental health
professional?

3 hours

h. Other person, specify:

C

4 or more hours
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No

26039065

I. About Your Family and
Household
I1

I6

All of
the time

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

Some of
the time

None of
the time

b. Work together to
solve our problems

1-3 days

c. Know we have
strengths to draw on

4-6 days

d. Stay hopeful even
in difficult times

Every day

Most of
the time

a. Talk together
about what to do

0 days

I2

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

I7

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

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

Yes

Rarely

No ➔ SKIP to question I4
I3

Somewhat often

If yes, does anyone smoke inside your home?
Yes

Very often
I8

No
I4

Which of these statements best describes your
household’s ability to afford the food you need DURING
THE PAST 12 MONTHS?
We could always afford to eat good nutritious meals.

DURING THE PAST 12 MONTHS, how often were
pesticides used inside your residence to control for
insects? If the frequency changed throughout the year,
report the highest frequency.

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

More than once a week

Sometimes we could not afford enough to eat.

Once a week

Often we could not afford enough to eat.

Once a month

I9

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

Once every 2-5 months

Yes

Once every 6 months

a. Cash assistance from a government
welfare program?

Once during the past 12 months

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

Never

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

Don’t know
I5

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

DURING THE PAST 12 MONTHS, other than in a shower
or bathtub, have you seen any mold, mildew or other
signs of water damage on walls or other surfaces inside
your home?
Yes
No

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No

26039057

I10 In your neighborhood, is/are there:

Yes

No

I13 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.

a. Sidewalks or walking paths?
b. A park or playground?

To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated

c. A recreation center, community
center, or boys’ and girls’ club?
d. A library or bookmobile?

b. Parent or guardian died

e. Litter or garbage on the street
or sidewalk?

c. Parent or guardian served time in jail
f. Poorly kept or rundown housing?
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home

g. Vandalism such as broken
windows or graffiti?

e. Was a victim of violence or
witnessed violence in his or her
neighborhood

I11 To what extent do you agree with these statements

about your neighborhood or community?
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

f. Lived with anyone who was mentally
ill, suicidal, or severely depressed

a. People in this
neighborhood
help each other
out

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

b. We watch out for
each other’s
children in this
neighborhood
c. This child is
safe in our
neighborhood
d. When we
encounter
difficulties, we
know where to
go for help in
our community
e. This child is safe
at school
I12 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?
Yes
No

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26039040

J. Child’s Caregivers

J6

➜ Complete the questions for UP TO TWO ADULTS

8th grade or less

in the household who are this child’s primary
caregivers.

9th-12th grade; No diploma

CAREGIVER 1 (You)
J1

High School Graduate or GED Completed
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)

Other: Relative

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

Other: Non-Relative
J7
J2

What is the highest grade or level of school you have
completed? Mark (X) ONE box.

What is your marital status?

What is your sex?
Married
Male
Not married, but living with a partner
Female
Never Married

J3

What is your age?

Divorced

Age in years
J4

Separated
Widowed

Where were you born?
In the United States ➔ SKIP to question J6

J8

Excellent

Outside of the United States
J5

In general, how is your physical health?

Very good

When did you come to live in the United States?
Indicate the 4-digit year in which you came to live in the
United States.

Good
Fair

4-Digit Year
Poor
J9

In general, how is your mental or emotional health?
Excellent
Very good
Good
Fair
Poor

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26039032

J10 Were you employed at least 50 out of the past

J16 Where was Caregiver 2 born?

52 weeks?
In the United States ➔ SKIP to question J18
Yes
Outside of the United States
No
J17 When did Caregiver 2 come to live in the United States?

Indicate the 4-digit year in which Caregiver 2 came to live in
the United States.

J11 Have you ever served on active duty in the

U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.

4-Digit Year

Never served in the military ➔ SKIP to question J13
Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question J13

J18 What is the highest grade or level of school Caregiver 2

has completed? Mark (X) ONE box.

Now on active duty

8th grade or less

On active duty in the past, but not now

9th-12th grade; No diploma

J12 Were you deployed at any time during this child’s life?

High School Graduate or GED Completed

Yes

Completed a vocational, trade, or business school
program

No
Some College Credit, but no Degree

➜ If this child has another primary adult caregiver

Associate Degree (AA, AS)

who lives in this household, complete Questions
J13-J24. Otherwise, skip to Question K1 on page
19.

Bachelor’s Degree (BA, BS, AB)
Master’s Degree (MA, MS, MSW, MBA)

CAREGIVER 2

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

J13 How is Caregiver 2 related to this child?

There is only one primary adult caregiver in the
household for this child ➔ SKIP to question K1 on
page 19

J19 What is Caregiver 2’s marital status?

Biological or Adoptive Parent

Married

Step-parent

Not married, but living with a partner

Grandparent

Never Married

Foster Parent

Divorced

Other: Relative

Separated

Other: Non-Relative

Widowed

J14 What is Caregiver 2’s sex?

J20 In general, how is Caregiver 2’s physical health?

Male

Excellent

Female

Very good
Good

J15 What is Caregiver 2’s age?

Fair
Age in years

Poor

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26039024

J21 In general, how is Caregiver 2’s mental or emotional

K3

health?
Excellent
Very good

Income in 2018
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 for
all jobs.

Good

Yes ➔

Fair

$

,

.00

TOTAL AMOUNT
in the last calendar year

No

Poor

,

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

J22 Was Caregiver 2 employed at least 50 out of the past 52

weeks?
Yes

Yes ➔

No

No

$

,

,

.00

Loss

TOTAL AMOUNT
in the last calendar year

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

J23 Has Caregiver 2 ever served on active duty in the U.S.

Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.

Yes ➔

Never served in the military ➔ SKIP to question K1

$

,

.00

Loss

TOTAL AMOUNT
in the last calendar year

No

Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question K1

,

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

Now on active duty
Yes ➔

On active duty in the past, but not now

$

Yes ➔

No

,

,

.00

TOTAL AMOUNT
in the last calendar year

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.
Number of people

$

No

K. Household Information

K2

.00

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

Yes

K1

,

TOTAL AMOUNT
in the last calendar year

No
J24 Was Caregiver 2 deployed at any time during this child’s

life?

,

Yes ➔

$

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.
Number of people

,

.00

TOTAL AMOUNT
in the last calendar year

No
K4

,

The following question is about your 2018 income.
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 businesses, farm or rent, and any other money income
received.

$

,

.00

,

TOTAL AMOUNT
in the last calendar year

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26039016

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.

We estimate that completing the National Survey of Children’s Health will take 33 minutes on average. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to U.S. Department of Commerce, 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. This collection has been approved by the Office of Management and Budget (OMB).
The eight-digit OMB approval number that appears at the upper left of the form confirms this approval. If this number
were not displayed, we could not conduct this survey.

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