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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.
Access to records maintained in the system is restricted to Census Bureau employees and certain individuals authorized by Title 13, U.S.
Code (designated as Special Sworn Status individuals). These individuals are subject to the same confidentiality requirements as regular
Census Bureau employees 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.
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Start Here
A3
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.
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)
We now have some follow-up questions to ask about:
b. Eating or swallowing because of
a health condition
c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea
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. Repeated or chronic physical pain,
including headaches or other back
or body pain
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.
e. Using their hands
f. Coordination or moving around
The survey should be completed by a parent or adult
caregiver who lives in this household and who is
familiar with this child’s health and health care.
g. Toothaches
h. Bleeding gums
Your participation is important. Thank you.
i.
A4
A. This Child’s Health
Decayed teeth or cavities
Does this child have any of the following?
a. Deafness or problems with hearing
b. Blindness or problems with seeing,
even when wearing glasses
A1 In general, how would you describe this child’s health
(the one named above)?
Has a doctor or other health care provider EVER told
you that this child has...
Excellent
Very good
A5
Allergies (including food, drug, insect, or other)?
Good
Yes
No
Fair
If yes, does this child CURRENTLY have the
condition?
Yes
Poor
No
If yes, is it:
A2 How would you describe the condition of this child’s
Mild
teeth?
This child does not have any teeth
Moderate
Severe
A6 Arthritis?
Excellent
Yes
No
Very good
If yes, does this child CURRENTLY have the
condition?
Yes
Good
No
If yes, is it:
Fair
Mild
Moderate
Severe
Poor
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Has a doctor or other health care provider EVER told
you that this child has...
A7 Asthma?
Has a doctor or other health care provider EVER told
you that this child has...
A12 Frequent or severe headaches, including migraine?
Yes
Yes
No
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
Yes
Yes
No
No
If yes, is it:
If yes, is it:
Mild
Moderate
Mild
Severe
Moderate
Severe
A13 Tourette Syndrome?
A8 Cerebral Palsy?
Yes
No
Yes
No
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
Yes
No
Yes
No
No
If yes, is it:
If yes, is it:
Mild
Moderate
Severe
A9 Diabetes?
Mild
Moderate
Severe
A14 Anxiety Problems?
Yes
No
Yes
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
Yes
Yes
No
Mild
Moderate
Mild
Severe
A10 Epilepsy or Seizure Disorder?
Yes
Severe
No
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
No
Yes
No
If yes, is it:
If yes, is it:
Mild
Moderate
Mild
Severe
A11 Heart Condition?
Yes
Moderate
A15 Depression?
No
Yes
No
If yes, is it:
If yes, is it:
Yes
No
Moderate
Severe
A16 Down Syndrome?
No
Yes
No
If yes, was this child born with the condition?
Yes
No
Does this child CURRENTLY have the condition?
Yes
No
If yes, is it:
Mild
Moderate
Severe
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Has a doctor or other health care provider EVER told
you that this child has...
A17 Blood Disorders (such as Sickle Cell Disease,
Thalassemia, or Hemophilia)?
Yes
Has a doctor, other health care provider, or educator
EVER told you that this child has...
Examples of educators are teachers and school nurses.
A20 Behavioral or Conduct Problems?
Yes
No
If yes, does this child CURRENTLY have the
condition?
If yes, is it:
Mild
Moderate
No
Severe
Yes
Was this child diagnosed with:
Sickle Cell Disease?
Yes
No
Thalassemia?
Yes
No
Hemophilia?
Yes
No
Other Blood
Disorders?
Yes
No
No
If yes, is it:
Mild
Moderate
Severe
A21 Developmental Delay?
Yes
If yes, does this child CURRENTLY have the
condition?
Were any of these blood disorders 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
Moderate
Severe
A18 Cystic Fibrosis?
Yes
A22 Intellectual Disability (formerly known as Mental
No
Retardation)?
If yes, is it:
Yes
Mild
Moderate
Severe
If yes, does this child CURRENTLY have the
disability?
Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Yes
No
Yes
If yes, is it:
No
Mild
A19 Other genetic or inherited condition?
Yes
No
Moderate
Severe
A23 Speech or other language disorder?
No
If yes, specify: C
Yes
No
If yes, does this child CURRENTLY have the
condition?
Is it:
Mild
Moderate
Yes
Severe
If yes, is it:
Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Yes
No
No
Mild
Moderate
Severe
A24 Learning Disability?
Yes
No
If yes, does this child CURRENTLY have the
disability?
Yes
No
If yes, is it:
Mild
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A25 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).
Yes
A30 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?
Yes
No ➔ SKIP to question A30
If yes, does this child CURRENTLY have the
condition?
If yes, does this child CURRENTLY have the
condition?
Yes
Yes
No
Moderate
Mild
Severe
A26 How old was this child when a doctor or other health
Don’t know
Yes
No
A32 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 their behavior?
Yes
No
A33 Do you think this child has EVER had a concussion or
brain injury? A concussion or brain injury is when a blow
or jolt to the head causes problems such as headaches,
dizziness, being dazed or confused, difficulty remembering
or concentrating, vomiting, blurred vision, changes in mood
or behavior, or being knocked out.
Primary Care Provider
Specialist
School Psychologist/Counselor
Yes
Other Psychologist (Non-School)
No
If yes, did you seek medical care from a doctor or
other health care provider?
Psychiatrist
Other, specify:
Yes
C
Yes
child’s health conditions or problems affected their
ability to do things other children their age do?
No
This child does not have any
health conditions ➔ SKIP to question B1 on page 6
A29 At any time DURING THE PAST 12 MONTHS, did this
Never
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 their behavior?
Yes
No
A34 DURING THE PAST 12 MONTHS, how often have this
ASD, Asperger’s Disorder or PDD?
Yes
No
If yes, did a doctor or other health care
provider tell you that your child had a
concussion or brain injury?
Don’t know
A28 Is this child CURRENTLY taking medication for Autism,
Severe
ADHD?
A27 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.
Moderate
A31 Is this child CURRENTLY taking medication for ADD or
care provider FIRST told you that they had Autism, ASD,
Asperger’s Disorder or PDD?
Age in years
No
If yes, is it:
If yes, is it:
Mild
No ➔ SKIP to question A33
Sometimes
Usually
No
Always
A35 To what extent do this child’s health conditions or
problems affect their ability to do things?
Very little
Somewhat
A great deal
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B. This Child as an Infant
B7
B1 Was this child born more than 3 weeks before their
How old was this child when they were FIRST fed
formula? Your best estimate is fine.
This child has never been fed formula
due date?
OR
Yes
At birth
No
OR
B2 What month and year was this child born?
days
Birth Month / 4-Digit Birth Year
OR
/
2 0
weeks
B3 How much did they weigh when born? Answer in pounds
OR
and ounces OR kilograms and grams. Your best estimate
is fine.
months
pounds AND
ounces
B8
OR
kilograms AND
grams
How old was this child when they were FIRST fed
anything other than breast milk or formula? Include
water, juice, cow’s milk, sugar water, baby food, or
anything else that your child might have been given.
Your best estimate is fine.
This child has never been fed anything other than
breast milk or formula
OR
B4 What was the age of the mother when this child was
born? Your best estimate is fine.
At birth
Age in years
OR
B5 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 they COMPLETELY
stopped breastfeeding or being fed breast milk?
Your best estimate is fine.
OR
months
This child is still breastfeeding
OR
days
OR
weeks
OR
months
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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.
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?
0 visits
How this child interacts with you and others?
If yes, and this child is 2-5 Years:
Did the questionnaire ask about your concerns
or observations about:
Mark (X) ALL that apply.
1 visit
2 or more visits
Words and phrases this child uses and
understands?
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.
Less than 10 minutes
How this child behaves and gets along with
you and others?
C8
10-20 minutes
More than 20 minutes
Is there a place you or another caregiver USUALLY
take this child when they are sick or you need advice
about their health?
Yes
No ➔ SKIP to question C10
C4 Are you concerned about this child’s weight?
Yes, it’s too high
No
C9
Yes, it’s too low
If yes, where does this child USUALLY go first?
Mark (X) ONE box.
Doctor’s Office
No, I am not concerned
Hospital Emergency Room
C5
C6
Has a doctor or other health care provider ever told you
that this child is overweight?
Hospital Outpatient Department
Yes
Clinic or Health Center
No
Retail Store Clinic or “Minute Clinic”
School (Nurse’s Office, Athletic Trainer’s Office)
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
Some other place
C10 Is there a place that this child USUALLY goes when
they need routine preventive care, such as a physical
examination or well-child check-up?
No
Yes
No ➔ SKIP to question C12 on page 8
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C11 If yes, is this the same place this child goes when they
are sick?
C16 If yes, DURING THE PAST 12 MONTHS, what
PREVENTIVE dental service(s) did this child receive?
Mark (X) ALL that apply.
Yes
Check-up
No
Cleaning
C12 Has this child EVER received a vision screening from
Instruction on tooth brushing and oral health care
a provider other than an eye doctor? The screening
could have occurred in a school, preschool/child care
center, community setting, or a pediatrician’s office, using
pictures, shapes, letters, or a camera like tool.
Yes
X-Rays
Fluoride treatment
No ➔ SKIP to question C13
If yes, was it recommended that this child see an
eye doctor or other eye care provider for an eye
examination or additional vision services after the
vision screening? An eye doctor may be referred to
as an optometrist or ophthalmologist.
Yes
Sealant (plastic coatings on back teeth)
Don’t know
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
C13 Has this child EVER seen an eye doctor? An eye doctor
Yes
may be referred to as an optometrist or ophthalmologist.
Yes
No, but this child needed to see a mental health
professional
No
If yes, what care did this child receive from the
eye doctor?
Mark (X) ALL that apply.
Received eye examination
No, this child did not need to see a
mental health professional ➔ SKIP to question C19
C18 How difficult was it to get the mental health treatment
or counseling that this child needed?
Prescribed eyeglasses or contact lenses
Not difficult
Diagnosis of a vision disorder other than
nearsighted, farsighted, or astigmatism
Somewhat difficult
Other
Very difficult
It was not possible to obtain care
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?
C19 DURING THE PAST 12 MONTHS, has this child taken
any medication because of difficulties with their
emotions, concentration, or behavior?
Yes, saw a dentist
Yes
Yes, saw other oral health care provider
No
No ➔ SKIP to question C17
C15 If yes, DURING THE PAST 12 MONTHS, did this child
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.
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 preventive visits in
the past 12 months ➔ SKIP to question C17
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
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C21 How difficult was it to get the specialist care that this
child needed?
C26 DURING THE PAST 12 MONTHS, how often were you
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
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.
C27 DURING THE PAST 12 MONTHS, how many times did
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.
Medical Care
No ➔ SKIP to question C32
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
not receiving needed health services?
Mark (X) Yes or No for EACH item.
meet their developmental needs such as speech,
occupational, or behavioral therapy?
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 they 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
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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
a. Discuss with you
the range of options
to consider for their
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 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
Usually Sometimes Never
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
It was not possible to get a referral
D8
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.
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?
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
c. Show sensitivity to
your family’s values
and customs?
d. Provide the specific
information you
needed concerning
this child?
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?
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
any decisions to be made regarding their health care,
such as whether to get prescriptions, referrals, or
procedures?
Somewhat satisfied
Somewhat dissatisfied
Yes
Very dissatisfied
No ➔ SKIP to question D7
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D11 DURING THE PAST 12 MONTHS, did this child’s health
care provider communicate with the child’s school, child
care provider, or special education program?
E3
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 them
to see the health care providers they need?
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
Always
g. Other, specify: C
Usually
Sometimes
Never
This child does not use mental or behavioral
health services
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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
G. This Child’s Learning
Sometimes
Never
F3
F4
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
Is this child able to do the following...
Mark (X) Yes or No for EACH item.
Yes
a. Say at least one word, such as "hi"
or "dog"?
No
b. Use 2 words together, such as
"car go"?
DURING THE PAST 12 MONTHS, have you or other
family members...
a. Left a job or taken a leave of
absence because of this child’s
health or health conditions?
Yes
Yes
c. Use 3 words together in a sentence,
such as, "Mommy come now."?
No
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"?
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."?
f. Tell a story with a beginning,
middle, and end?
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"?
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26011122
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
home schooling.
G9 How often can this child explain things they have seen
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 themselves?
No
G10 How often can this child write their first name, even 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
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G13 Can this child identify the colors red, yellow, blue,
and green by name?
G19 How often does this child become angry or anxious
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 they are 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 they
follow instructions to complete a simple task?
Sometimes
Always
Most of the time
Never
G22 How often does this child lose control of their temper
when things do not go their 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 their fist
This child cannot hold a pencil
G23 Compared to other children their 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
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G24 Compared to other children their age, how often is
H5
this child able to sit still?
Always
Less than 7 hours
Most of the time
7 hours
About half the time
8 hours
Sometimes
9 hours
Never
G25 How often...
DURING THE PAST WEEK, how many hours of sleep
did this child get during an average day (count both
nighttime sleep and naps)?
10 hours
Always
Usually Sometimes
11 hours
Never
a. Is this child
affectionate and
tender with you?
12 or more hours
H6
b. Does this child
bounce back
quickly when things
do not go their way?
c. Does this child
show interest and
curiosity in learning
new things?
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.
On their side
On their back
d. Does this child
smile and laugh?
On their stomach
H. About You and This
Child
H7
DURING THE PAST WEEK, how many times did this
child drink sugary drinks such as soda, fruit drinks,
sports drinks, or sweet tea?
This child did not drink sugary drinks
H1 Was this child born in the United States?
1-3 times during the past week
Yes ➔ SKIP to question
H3
4-6 times during the past week
No
1 time per day
H2 If no, how long has this child been living in the
United States?
years AND
2 or more times per day
3 or more times per day
months
H3 How many times has this child moved to a new address
H8
since they were born?
DURING THE PAST WEEK, how many times did this
child eat vegetables? Include any that were fresh,
frozen, or canned. Do not include French fries, fried
potatoes, or potato chips.
Number of times
Number of times
H4 How often does this child go to bed at about the same
time on weeknights?
Always
Usually
Sometimes
Rarely
Never
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H9 DURING THE PAST WEEK, how many times did this
child eat fruit? Include any that were fresh, frozen,
canned, or dried. Do NOT include juice.
H13 DURING THE PAST WEEK, how many days did you or
other family members read to this child?
0 days
This child did not eat fruit
1-3 days
1-3 times during the past week
4-6 days
4-6 times during the past week
Every day
1 time per day
2 times per day
H14 DURING THE PAST WEEK, how many days did you or
other family members tell stories or sing songs to this
child?
3 or more times per day
0 days
H10 ON MOST WEEKDAYS, how much time does this
1-3 days
child spend playing outdoors? Include time spent
playing in your yard or neighborhood, outside at school
or child care, in a park, playground or other outdoor
recreation area. Your best estimate is fine.
4-6 days
Every day
Less than 1 hour
1 hour
H15 How well do you think you are handling the day-to-day
demands of raising children?
2 hours
Very well
3 hours
Somewhat well
4 or more hours
Not very well
H11 ON AN AVERAGE WEEKEND DAY, how much time
does this child spend playing outdoors? Include time
spent playing in your yard or neighborhood, in a park,
playground or other outdoor recreation area. Your best
estimate is fine.
Not well at all
H16 DURING THE PAST MONTH, how often have you felt...
Never
Less than 1 hour
1 hour
2 hours
3 hours
4 or more hours
H12 ON MOST WEEKDAYS, about how much time does
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.
Rarely Sometimes Usually Always
a. That this child
is much harder
to care for than
most children
their age?
b. That this child
does things
that really
bother you a
lot?
c. Angry with
this child?
H17 DURING THE PAST 12 MONTHS, was there someone
that you could turn to for day-to-day emotional support
with parenting or raising children?
Yes
Less than 1 hour
No ➔ SKIP to question H19 on page 17
1 hour
2 hours
3 hours
4 or more hours
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H18 If yes, did you receive emotional support from...
Yes
I3
Yes
a. Spouse or domestic partner?
No
b. Other family member or close friend?
c. Health care provider?
I4
d. Place of worship or religious leader?
Rarely
f. Peer support group?
Somewhat often
g. Counselor or other mental health
professional?
Very often
C
I5
H19 Does this child receive care for at least 10 hours per
We could always afford enough to eat but not always
the kinds of food we should eat.
Yes
Sometimes we could not afford enough to eat.
No
Often we could not afford enough to eat.
H20 DURING THE PAST 12 MONTHS, did you or anyone in
I6
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?
At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive...
No
Yes
No
b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?
No
c. Free or reduced-cost breakfasts or
lunches at school?
I. About Your Family and
Household
DURING THE PAST WEEK, on how many days did all
the family members who live in the household eat a
meal together?
d. Benefits from the Women, Infants,
and Children (WIC) Program?
I7
In your neighborhood, is/are there...
a. Sidewalks or walking paths?
0 days
b. A park or playground?
1-3 days
c. A recreation center, community
center, or boys’ and girls’ club?
4-6 days
d. A library or bookmobile?
Every day
e. Litter or garbage on the street
or sidewalk?
Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?
f. Poorly kept or rundown housing?
g. Vandalism such as broken
windows or graffiti?
Yes
No ➔ SKIP to question
Yes
a. Cash assistance from a government
welfare program?
Yes
I2
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.
week from someone other than their parent or guardian?
This could be a day care center, preschool, Head Start
program, family child care home, nanny, au pair, babysitter
or relative.
I1
SINCE THIS CHILD WAS BORN, how often has it been
very hard to cover the basics, like food or housing,
on your family’s income?
Never
e. Support or advocacy group related
to specific health condition?
h. Other person, specify:
If yes, does anyone smoke inside your home?
No
I4
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26011072
I8
To what extent do you agree with these statements
about your neighborhood or community?
I11
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree
Yes
a. People in this
neighborhood
help each other
out
No
I12
b. We watch out for
each other’s
children in this
neighborhood
Has anyone living in your household EVER tried to get
tested for COVID-19?
Yes
c. This child is
safe in our
neighborhood
No
I13
d. When we
encounter
difficulties, we
know where to
go for help in
our community
I9
Has a doctor or other health care provider EVER told
anyone living in your household that they had or likely
had COVID-19, also known as the Coronavirus?
Has anyone living in your household EVER been tested
for COVID-19?
Yes
No
The next questions are about events that may have
happened during this child’s life. These things can
happen in any family, but some people may feel
uncomfortable with these questions. You may skip
any questions you do not want to answer.
To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated
I14
Has this child had any health care visits by video or
phone because of the Coronavirus pandemic?
Yes
No
I15
Did this child miss or skip any PREVENTIVE check-ups
because of the Coronavirus pandemic?
b. Parent or guardian died
Yes
c. Parent or guardian served time in jail
No ➔ SKIP to question I17 on page 19
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home
I16
e. Was a victim of violence or
witnessed violence in their
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
b. Health care provider’s location was
open but had limited appointments
due to the Coronavirus pandemic
h. Treated or judged unfairly because
of their race or ethnic group
i.
c. Parent, adult caregiver, or child was
concerned about going to the health
care provider’s location due to the
Coronavirus pandemic
Treated or judged unfairly because
of a health condition or disability
I10 When your family faces problems, how often are you
likely to do each of the following?
All of
the time
Most of
the time
If yes, did any of the following reasons contribute to
this child missing any PREVENTIVE check-ups?
Mark yes or no for each item.
Yes
No
a. Health care provider’s location
was closed due to the Coronavirus
pandemic
Some of
the time
d. This child no longer had health
insurance or had a change in
health insurance
None of
the time
a. Talk together
about what to do
e. Someone in the household was ill
f. Someone in the household had been
in contact with someone who was ill
b. Work together to
solve our problems
c. Know we have
strengths to draw on
d. Stay hopeful
even in difficult
times
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I17
Did any of the following events happen in your
household as a result of the Coronavirus pandemic?
Mark yes or no for each item.
Yes
No
a. At least one adult in the household
lost a job or was unable to work
b. At least one adult in the household
worked outside the home
J2
Male
Female
J3
c. A household member was
hospitalized due to the Coronavirus
d. A household member died from the
Coronavirus
I18
No ➔ SKIP to question I19
What is your age?
Age in years
J4
Where were you born?
In the United States ➔ SKIP to question J6
Has this child’s school, daycare, or other child care
arrangement been closed or unavailable at any time as
a result of the Coronavirus pandemic?
Yes
What is your sex?
Outside of the United States
J5
If yes, for how long?
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.
weeks
I19
Was this child separated from a parent or adult
caregiver as a result of the Coronavirus pandemic?
Yes
4-Digit Year
J6
No ➔ SKIP to section J
What is the highest grade or level of school you have
completed?
Mark (X) ONE box.
8th grade or less
If yes, for how long?
9th-12th grade; No diploma
weeks
High School Graduate or GED Completed
J. Child’s Caregivers
Completed a vocational, trade, or business school
program
About You
J1
Some College Credit, but no Degree
How are you related to this child?
Associate Degree (AA, AS)
Biological or Adoptive Parent
Bachelor’s Degree (BA, BS, AB)
Step-parent
Master’s Degree (MA, MS, MSW, MBA)
Grandparent
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
Foster Parent
J7
Other: Relative
What is your marital status?
Married
Other: Non-Relative
Not married, but living with a partner
Never Married
Divorced
Separated
Widowed
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J8
Other Parent or Caregiver
in the Household
In general, how is your physical health?
Excellent
Very good
J14 How is this other caregiver related to this child?
Biological or Adoptive Parent
Good
Step-parent
Fair
Grandparent
Poor
Foster Parent
J9
In general, how is your mental or emotional health?
Other: Relative
Excellent
Other: Non-Relative
Very good
J15 What is this caregiver’s sex?
Good
Male
Fair
Female
Poor
J16 What is this caregiver’s age?
J10 Which of the following best describes your current
employment status?
Mark (X) ONE box.
Employed full-time
Age in years
J17 Where was this caregiver born?
In the United States ➔ SKIP to question J19
Employed part-time
Outside of the United States
Working WITHOUT pay
Not employed but looking for work
J18 When did this caregiver come to live in the United
States? Indicate the 4-digit year in which this caregiver
came to live in the United States.
Not employed and not looking for work
4-Digit Year
J11 Have you ever served on active duty in the
U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
J19 What is the highest grade or level of school this
caregiver has completed?
Mark (X) ONE box.
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
8th grade or less
9th-12th grade; No diploma
Now on active duty
High School Graduate or GED Completed
On active duty in the past, but not now
Completed a vocational, trade, or business school
program
J12 Were you deployed at any time during this child’s life?
Some College Credit, but no Degree
Yes
Associate Degree (AA, AS)
No
Bachelor’s Degree (BA, BS, AB)
J13 Does this child have another parent or adult caregiver
Master’s Degree (MA, MS, MSW, MBA)
who lives in this household?
Yes ➔ Complete questions J14 - J25 for this other
parent or adult caregiver
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
No ➔ SKIP to question K1 on page 22
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J20 What is this caregiver’s marital status?
J24 Has this caregiver ever served on active duty in the
U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
Married
Not married, but living with a partner
Never served in the
military ➔ SKIP to question K1 on page 22
Never Married
Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question K1 on page 22
Divorced
Now on active duty
Separated
On active duty in the past, but not now
Widowed
J25 Was this caregiver deployed at any time during this
child’s life?
J21 In general, how is this caregiver’s physical health?
Excellent
Yes
Very good
No
Good
Fair
Poor
J22 In general, how is this caregiver’s mental or emotional
health?
Excellent
Very good
Good
Fair
Poor
J23 Which of the following best describes this caregiver’s
current employment status?
Mark (X) ONE box.
Employed full-time
Employed part-time
Working WITHOUT pay
Not employed but looking for work
Not employed and not looking for work
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K. Household Information
K1
K4
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.
Number of people
K3
$
Income in 2019
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.
,
,
.00
TOTAL AMOUNT
in the last calendar year
No
K4
Number of people
K2
f. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support, or alimony.
The following question is about your 2019 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
a. Wages, salary, commissions, bonuses, or tips for
all jobs.
Yes ➔
$
,
,
.00
TOTAL AMOUNT
in the last calendar year
No
b. Self-employment income from own nonfarm
businesses or farm business, including
proprietorships and partnerships.
Yes ➔
$
,
,
.00
Loss
TOTAL AMOUNT
in the last calendar year
No
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Yes ➔
$
,
,
.00
Loss
TOTAL AMOUNT
in the last calendar year
No
d. Social security or railroad retirement; retirement,
survivor, or disability pensions.
Yes ➔
$
,
,
.00
TOTAL AMOUNT
in the last calendar year
No
e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office.
Yes ➔
No
$
,
,
.00
TOTAL AMOUNT
in the last calendar year
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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
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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| File Type | application/pdf |
| Author | OneFormUser |
| File Modified | 2020-07-11 |
| File Created | 2020-07-11 |