Survey Content for Participants with a Child Aged 6-17
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?
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
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?
DURING THE PAST 12 MONTHS, how often was {Child’s Name} 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
1-2
times per week
Almost
every day
(If any response other than “Never” is selected above)
Who were you thinking of bullying {Child’s Name} when you answered the question above?
DURING THE PAST 12 MONTHS, how often did {Child’s Name} 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)
1-2
times (in the past 12 months)
1-2
times per month
1-2
times per week
Almost
every day
(If any response other than “Never” is selected above)
What were you thinking of when you answered the question above?
Was it easy or hard for you to answer the questions above about bullying?
Easy
Hard
(If “Easy” is selected)
Please tell us about why it was easy to answer the questions about bullying.
(If “Hard” is selected)
Please tell us about why it was hard to answer the questions about bullying.
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
To the best of your knowledge, has {Child’s Name} EVER experienced the following?
Treated or judged unfairly because of their sexual orientation or gender identity.
Yes
No
Treated or judged unfairly because of their race or ethnic group.
Yes
No
How did you feel about answering the question about sexual orientation and gender identity?
In your own words, what does "sexual orientation" mean?
In your own words, what does "gender identity" mean?
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?
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Sarah S Vetting (CENSUS/DSMD FED) |
File Modified | 0000-00-00 |
File Created | 2021-01-14 |