1 Survey Content for Participants with a Child Aged 0-5

Survey Content for Participants with a Child Aged 0-5

The US Census Bureau is testing questions for a survey on children’s health topics. We would like you to answer the questions and then answer some follow-up questions about how you came up with your answers and how you interpret some of the questions.  There are no right or wrong answers. Please do not go back and change your original answers. 

 

Thank you for participating in our research. 

 

The survey questions will appear in bold.
The follow-up questions will appear in italics.

The U.S. Census Bureau is required by law to protect your information. We are conducting this voluntary survey under 13 U.S.C 8(b) to study possible improvements to the questionnaire. Federal law protects your privacy and keeps your answers confidential (The Confidential Information Protection and Statistical Efficiency Act). Per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems that transmit your data.

Your privacy is also protected by the Privacy Act, Title 5 U.S. Code. Routine uses of these data are limited to those identified in the Privacy Act System of Record Notice titled, “SORN COMMERCE/Census-7, Demographic Survey Collection (non-Census Bureau Sampling Frame).” The Census Bureau can use your responses only to produce statistics, and is not permitted to publicly release your responses in a way that could identify you.

We estimate that completing this survey will take 15 minutes on average. Send comments regarding this estimate or any other aspect of this survey, including suggestions for reducing the time it takes to complete this survey to [email protected]. This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-0725, confirms this approval. We are required to display this number to conduct this survey. By proceeding, you give your consent to participate in this study.

Are there any children 0-17 years old who usually live or stay at your address?

Yes

No (survey terminates)

To begin, read the instructions below:

 

If you have one child age 0-17 years old, think of that child when answering the questions in this survey.

  

 

If you have two or more children 0-17 years old, think of whichever child uses more medical, behavioral, or mental health services when answering the questions in the survey.  If none of your children use medical, behavioral, or mental health services, think of the one whose birthday was most recent.

What is this child's name? Instead of this child's name, you may use an identifying phrase, such as "Child 1, Child 2, etc..." This identifying phrase will be used throughout the remainder of the survey.

How old is this child? 

If less than 1 year old, enter 0.

Where do you or another caregiver USUALLY take {Child’s Name} when they are sick or you need advice about their health?

Doctor's Office

Hospital Emergency Room

Hospital Outpatient Department

Urgent Care

Clinic or Health Center

Retail Store Clinic or "Minute Clinic"

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

Some Other Place

No Usual Place

Did you have any trouble choosing just one place when answering the question above?

Yes

No

(If Yes)

Tell us more about why you had trouble choosing just one place.

In your own words, how would you describe each of the following:

 

Urgent care

Clinic or health center

Retail or minute clinic

Where does {Child’s Name} USUALLY go when they need routine PREVENTIVE care, such as a physical examination or well-child check-up?

Doctor's Office

Hospital Emergency Room

Hospital Outpatient Department

Urgent Care

Clinic or Health Center

Retail Store Clinic or "Minute Clinic"

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

Some Other Place

No Usual Place

Did you have any trouble choosing just one place when answering the question above?

Yes

No

(If Yes)

Tell us more about why you had trouble choosing just one place.

DURING THE PAST 12 MONTHS, did {Child’s Name} see a dentist or other health care provider for any kind of dental or oral health care?

Yes, saw a dentist or other oral health care provider

Yes, saw another kind of health care provider

No

(If Yes)

Were you thinking of any other health care provider besides a dentist when you answered the previous question?

Yes

No

(If Yes)

What types of health care providers were you thinking of?

DURING THE PAST 12 MONTHS, how many times did {Child’s Name} visit a hospital emergency room?

None

1 time

2 or more times

Were you considering visits to urgent care when you answered the previous question?

Yes

No

(If the “Child’s age” text response is less than or equal to 1)

DURING THE PAST 12 MONTHS, was {Child’s Name} admitted to the hospital to stay for at least one night?

Yes

No

What were you thinking of when you answered the question above?

DURING THE PAST 12 MONTHS, did {Child’s Name} need any decisions to be made regarding their health care, such as whether to get prescriptions, referrals, or procedures?

Yes

No

What do you think the question above is asking?

What types of decisions were you thinking of when answering this question?

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

Yes

No

Did not see more than one health care provider in the PAST 12 MONTHS

(If Yes)

Who helped you coordinate your child's care?

(If Yes or No is selected in response to the “had help arranging care” survey question)

DURING THE PAST 12 MONTHS, have you felt that you could have used extra help arranging or coordinating {Child’s Name}’s care among the different health care providers or services? 

Yes

No

(If Yes is selected in response to “Needed help arranging care” )

What type of help were you thinking of?

IN AN AVERAGE WEEK, how many hours do you or other family members spend providing health care at home for {Child’s Name}? 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

11 or more hours per week

What types of care were you thinking about when you answered the above question?

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

Yes

No

Did you think about vaping when answering the previous question?

Yes

No

Does anyone living in your household use vaping products or e-cigarettes?

Yes

No

How are you related to {Child’s Name}?

Biological or Adoptive Parent

Step-parent

Grandparent

Foster Parent

Other: Relative

Other: Non-Relative

What is your sex?

Male

Female

What is your age?

What is the highest grade or level of school you have completed?

8th grade or less

9th-12th grade; No diploma

High School Graduate or GED Completed

Completed a vocational, trade, or business school program

Some College Credit, but no Degree

Associate Degree (AA, AS)

Bachelor’s Degree (BA, BS, AB)

Master’s Degree (MA, MS, MSW, MBA)

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

Does {Child’s Name} have another parent or adult caregiver who lives in this household?

Yes

No

What do you think is meant by "parent or adult caregiver"?

How many people did you consider when thinking about your answer?

Here's another way we might ask this question:

Does {Child’s Name} have another primary adult caregiver who lives in the household?

 

Which version of the question do you think is easier to understand?

Does {Child’s Name} have another primary adult caregiver who lives in the household?

Does {Child’s Name} have another parent or adult caregiver who lives in the household?

Tell us more about why you think this question is easier to understand when asked as "{Fills with respondent selection}".

(If No is selected for “Does {Child’s Name} have another parent or adult caregiver who lives in this household?”)

Are there any other adults in the household besides you?

Yes

No

(If Yes)

Tell us why you chose not to count these other adults as parents or caregivers.

(If Yes is selected for “Does {Child’s Name} have another parent or adult caregiver who lives in this household?”)

How did you decide who to list as this other caregiver?

How is this other caregiver related to {Child’s Name}?

Biological or Adoptive Parent

Step-parent

Grandparent

Foster Parent

Other: Relative

Other: Non-Relative

What is this caregiver's sex?

Male

Female

What is this caregiver's age?

What is the highest grade or level of school this caregiver has completed?

8th grade or less

9th-12th grade; No diploma

High School Graduate or GED Completed

Completed a vocational, trade, or business school program

Some College Credit, but no Degree

Associate Degree (AA, AS)

Bachelor’s Degree (BA, BS, AB)

Master’s Degree (MA, MS, MSW, MBA)

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

Overall, what would you say about the survey questions you looked at today?

Is there anything else you would like to tell us that you haven't already mentioned?