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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.
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. Toothaches
f. Bleeding gums
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.
Your participation is important. Thank you.
DURING THE PAST 12 MONTHS, has this child had
FREQUENT or CHRONIC difficulty with any of the
following?
g. Decayed teeth or cavities
A4
Does this child have any of the following?
a. Serious difficulty concentrating,
remembering, or making decisions
because of a physical, mental, or
emotional condition
A. This Child’s Health
b. Serious difficulty walking or climbing
stairs
c. Difficulty dressing or bathing
A1 In general, how would you describe this child’s health
(the one named above)?
d. Deafness or problems with hearing
Excellent
e. Blindness or problems with seeing,
even when wearing glasses
Very good
Has a doctor or other health care provider EVER told
you that this child has...
Good
Fair
A5
Poor
Allergies (including food, drug, insect, or other)?
Yes
No
If yes, does this child CURRENTLY have the
condition?
A2 How would you describe the condition of this child’s
teeth?
Yes
Mild
Very good
Good
No
If yes, is it:
Excellent
A6
Severe
Arthritis?
Yes
Fair
Moderate
No
If yes, does this child CURRENTLY have the
condition?
Poor
Yes
No
If yes, is it:
Mild
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Moderate
Severe
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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?
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
No
If yes, is it:
No
If yes, is it:
Mild
Moderate
Severe
A8 Cerebral Palsy?
Yes
No
Mild
Moderate
Severe
A13 Tourette Syndrome?
Yes
No
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
A9 Diabetes?
Moderate
Severe
A14 Anxiety Problems?
Yes
No
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
If yes, does this child CURRENTLY have the
condition?
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?
Yes
No
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?
No ➔ SKIP to question A30
Yes
If yes, does this child CURRENTLY have the
condition?
Yes
If yes, does this child CURRENTLY have the
condition?
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
Yes
Other, specify: C
Yes
child’s health conditions or problems affected their
ability to do things other children their age do?
This child does not have any
health conditions ➔ SKIP to question B1 on page 6
No
Never
A29 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 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
B1
C4
What is this child’s CURRENT height?
Your best estimate is fine.
Was this child born more than 3 weeks before their
due date?
feet AND
OR
Yes
No
B2
meters AND
What month and year was this child born?
Birth Month / 4-Digit Birth Year
/
B3
C5
centimeters
How much does this child CURRENTLY weigh?
Your best estimate is fine.
2 0
pounds
OR
How much did they weigh when born? Answer in pounds
and ounces OR kilograms and grams. Your best estimate is
fine.
pounds AND
ounces
kilograms
C6
Are you concerned about this child’s weight?
Yes, it’s too high
OR
kilograms AND
B4
inches
Yes, it’s too low
grams
What was the age of the mother when this child was
born? Your best estimate is fine.
No, I am not concerned
C7
Age in years
Yes
C. Health Care Services
C1 DURING THE PAST 12 MONTHS, did this child see a
No
C8
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?
Is there a place you or another caregiver USUALLY
take this child when they are sick or you need advice
about their health?
Yes
Yes
No ➔ SKIP to question C10 on page 7
No ➔ SKIP to question C4
C2 If yes, DURING THE PAST 12 MONTHS, how many times
Has a doctor or other health care provider ever told
you that this child is overweight?
C9
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, where does this child USUALLY go first?
Mark (X) ONE box.
Doctor’s Office
Hospital Emergency Room
0 visits
Hospital Outpatient Department
1 visit
Clinic or Health Center
2 or more visits
C3
Retail Store Clinic or “Minute Clinic”
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.
School (Nurse’s Office, Athletic Trainer’s Office)
Some other place
Less than 10 minutes
10-20 minutes
More than 20 minutes
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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?
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?
Yes
No preventive visits in
the past 12 months ➔ SKIP to question C17
No ➔ SKIP to question C12
Yes, 1 visit
C11 If yes, is this the same place this child goes when they
are sick?
Yes
Yes, 2 or more visits
C16 If yes, DURING THE PAST 12 MONTHS, what
PREVENTIVE dental service(s) did this child receive?
Mark (X) ALL that apply.
No
Check-up
C12 DURING THE PAST 2 YEARS, has this child received a
vision screening from a care 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
Cleaning
Instruction on tooth brushing and oral health care
X-Rays
No ➔ SKIP to question C13
Fluoride treatment
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
No
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.
C13 DURING THE PAST 2 YEARS, has this child seen an
eye doctor? An eye doctor may be referred to as an
optometrist or ophthalmologist.
Yes
Yes
No
No, but this child needed to see a mental health
professional
If yes, what care did this child receive from the
eye doctor?
Mark (X) ALL that apply.
No, this child did not need to see a
mental health professional ➔ SKIP to question C19
Received eye examination
Prescribed eyeglasses or contact lenses
C18 How difficult was it to get the mental health treatment
or counseling that this child needed?
Diagnosis of a vision disorder other than
nearsighted, farsighted, or astigmatism
Not difficult
Somewhat difficult
Other
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?
Yes, saw a dentist
C19 DURING THE PAST 12 MONTHS, has this child taken
any medication because of difficulties with their
emotions, concentration, or behavior?
Yes, saw other oral health care provider
Yes
No ➔ SKIP to question C17
No
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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.
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
No
a. This child was not eligible for the
services
Yes
No, but this child needed to see a specialist
b. The services this child needed were
not available in your area
No, this child did not need to see
a specialist ➔ SKIP to question C22
c. There were problems getting an
appointment when this child needed
one
d. There were problems with getting
transportation or child care
C21 How difficult was it to get the specialist care that this
child needed?
Not difficult
e. The clinic or doctor’s office wasn’t
open when this child needed care
Somewhat difficult
f. There were issues related to cost
C26 DURING THE PAST 12 MONTHS, how often were you
Very difficult
frustrated in your efforts to get services for this child?
It was not possible to obtain care
Never
C22 DURING THE PAST 12 MONTHS, did this child use any
Sometimes
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.
Yes
Usually
Always
C27 DURING THE PAST 12 MONTHS, how many times did
this child visit a hospital emergency room?
No
None
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
1 time
2 or more times
C28 DURING THE PAST 12 MONTHS, was this child admitted
to the hospital to stay for at least one night?
No ➔ SKIP to question C26
Yes
C24 If yes, which types of care were not received?
No
Mark (X) ALL that apply.
C29 Has this child EVER had a special education or early
Medical Care
intervention plan? Children receiving these services often
have an Individualized Family Service Plan (IFSP) or
Individualized Education Plan (IEP).
Dental Care
Vision Care
Yes
Hearing Care
No ➔ SKIP to question C32 on page 9
Mental Health Services
C30 If yes, how old was this child at the time of the FIRST
Other, specify:
plan?
C
years AND
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C31 Is this child CURRENTLY receiving services under
one of these plans?
D4
Yes
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers...
No
Always
meet their developmental needs such as speech,
occupational, or behavioral therapy?
c. Show sensitivity to
your family’s values
and customs?
No ➔ SKIP to question D1
d. Provide the specific
information you
needed concerning
this child?
C33 If yes, how old was this child when they began
receiving these special services?
months
e. Help you feel like a
partner in this
child’s care?
C34 Is this child CURRENTLY receiving these special
services?
D5
Yes
No
D. Experience with This
Child’s Health Care
Providers
No ➔ SKIP to question D7
D6
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.
Always
Usually Sometimes Never
b. Make it easy for you
to raise concerns or
disagree with
recommendations
for this child’s health
care?
No
c. Work with you to
decide together which
health care and
treatment choices would
be best for this child?
DURING THE PAST 12 MONTHS, did this child need a
referral to see any doctors or receive any services?
Yes
D3
If yes, DURING THE PAST 12 MONTHS, how often did
this child’s doctors or other health care providers...
a. Discuss with you the
range of options to
consider for their health
care or treatment?
Yes, more than one person
No ➔ SKIP to question D4
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?
Yes
Yes, one person
D2
Never
b. Listen carefully to
you?
Yes
years AND
Usually Sometimes
a. Spend enough time
with this child?
C32 Has this child EVER received special services to
D1
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 10.
D7
How difficult was it to get referrals?
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
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 10
Very difficult
It was not possible to get a referral
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E. This Child’s Health
Insurance Coverage
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
E1
No ➔ SKIP to question D10
DURING THE PAST 12 MONTHS, was this child EVER
covered by ANY kind of health insurance or health
coverage plan?
Yes, this child was covered
all 12 months ➔ SKIP to question E4
D9 If yes, DURING THE PAST 12 MONTHS, how often
Yes, but this child had a gap in coverage
did you get as much help as you wanted with
arranging or coordinating this child’s health care?
No
Usually
E2
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
No
a. Change in employer or employment
status
D10 DURING THE PAST 12 MONTHS, how satisfied were
b. Cancellation due to overdue
premiums
you with the communication between this child’s
doctors and other health care providers?
Very satisfied
c. Dropped coverage because it was
unaffordable
Somewhat satisfied
d. Dropped coverage because benefits
were inadequate
e. Dropped coverage because choice
of health care providers was
inadequate
Somewhat dissatisfied
Very dissatisfied
f. Problems with application or
renewal process
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?
g. Other, specify: C
Yes
No ➔ SKIP to question E1
E3
Did not need health care provider to communicate
with these providers ➔ SKIP to question E1
Is this child CURRENTLY covered by ANY kind of
health insurance or health coverage plan?
Yes
D12 If yes, during this time, how satisfied were you with the
No ➔ SKIP to question F1 on page 11
health care provider’s communication with the school,
child care provider, or special education program?
E4
Very satisfied
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
Somewhat satisfied
a. Insurance through a current or
former employer or union
Somewhat dissatisfied
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 dissatisfied
d. TRICARE or other military
health care
e. Indian Health Service
f. Other, specify: C
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E5
How often does this child’s health insurance offer
benefits or cover services that meet this child’s needs?
F2
Always
Always
Usually
Usually
Sometimes
Sometimes
Never
Never
E6
How often does this child’s health insurance allow
them to see the health care providers they need?
How often are these costs reasonable?
F3
Always
DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?
Yes
Usually
No
Sometimes
Never
E7
F4
Yes
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
F5
This child does not use mental or behavioral
health services
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
F. Providing for This
Child’s Health
F1
No
a. Left a job or taken a leave of
absence because of this child’s
health or health conditions?
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?
Never
DURING THE PAST 12 MONTHS, have you or other
family members...
Less than 1 hour per week
1-4 hours per week
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
F6
insurance or another source.
$0 (No medical or health-related
expenses) ➔ SKIP to question F4
5-10 hours per week
11 or more hours per week
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-$249
This child does not need health care coordinated
on a weekly basis
$250-$499
Less than 1 hour per week
$500-$999
1-4 hours per week
$1,000-$5,000
5-10 hours per week
More than $5,000
11 or more hours per week
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G. This Child’s Schooling
and Activities
G5
Yes
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
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 they are 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
No
a. A sports team or did they take
sports lessons after school or
on weekends?
G1 DURING THE PAST 12 MONTHS, about how many days
G2
DURING THE PAST 12 MONTHS, did this child
participate in...
G7
repeated any grades?
Compared to other children their age, how much
difficulty does this child have making or keeping
friends?
Yes
No difficulty
No
A little difficulty
A lot of difficulty
G4 DURING THE PAST 12 MONTHS, how often did you
attend events or activities that this child participated in?
Always
G8 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.
Usually
Sometimes
Never (in the past 12 months)
Rarely
1-2 times (in the past 12 months)
Never
1-2 times per month
1-2 times per week
Almost every day
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G9 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.
H4
How often does this child go to bed at about the same
time on weeknights?
Always
Never (in the past 12 months)
Usually
1-2 times (in the past 12 months)
Sometimes
1-2 times per month
Rarely
1-2 times per week
Never
Almost every day
H5
G10 How often does this child...
Always
Usually Sometimes
Never
DURING THE PAST WEEK, how many hours of sleep
did this child get on most weeknights?
Less than 6 hours
a. Show interest and
curiosity in learning
new things?
6 hours
b. Work to finish tasks
they start?
7 hours
c. Stay calm and in
control when faced
with a challenge?
8 hours
9 hours
d. Care about doing
well in school?
10 hours
e. Do all required
homework?
11 or more hours
f. Argue too much?
H6
H. About You and This
Child
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.
Less than 1 hour
H1 Was this child born in the United States?
1 hour
Yes ➔ SKIP to question H3
2 hours
No
3 hours
4 or more hours
H2 If no, how long has this child been living in the United
States?
H7
years AND
months
How well can you and this child share ideas or talk
about things that really matter?
Very well
H3 How many times has this child moved to a new address
since they were born?
Somewhat well
Not very well
Number of times
Not well at all
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I. About Your Family and
Household
H8 How well do you think you are handling the day-to-day
demands of raising children?
Very well
I1
Somewhat well
DURING THE PAST WEEK, on how many days did all the
family members who live in the household eat a meal
together?
Not very well
0 days
Not well at all
1-3 days
H9 DURING THE PAST MONTH, how often have you felt...
Never
4-6 days
Rarely Sometimes Usually Always
a. That this child
is much harder
to care for than
most children
their age?
Every day
I2
b. That this child
does things
that really
bother you
a lot?
Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?
Yes
No ➔ SKIP to question
c. Angry with
this child?
I3
If yes, does anyone smoke inside your home?
Yes
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?
Yes
I4
No
I4
No ➔ SKIP to question 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
H11 If yes, did you receive emotional support from...
Yes
Rarely
No
a. Spouse or domestic partner?
Somewhat often
b. Other family member or close friend?
Very often
c. Health care provider?
I5
d. Place of worship or religious leader?
e. Support or advocacy group related
to specific health condition?
We could always afford to eat good nutritious meals.
f. Peer support group?
We could always afford enough to eat but not always
the kinds of food we should eat.
g. Counselor or other mental health
professional?
h. Other person, specify:
Which of these statements best describes your
household’s ability to afford the food you need
DURING THE PAST 12 MONTHS?
Sometimes we could not afford enough to eat.
C
Often we could not afford enough to eat.
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I6
At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive...
Yes
I10 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 Women, Infants,
and Children (WIC) Program?
c. Parent or guardian served time in jail
I7
In your neighborhood, is/are there...
Yes
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home
No
a. Sidewalks or walking paths?
e. Was a victim of violence or
witnessed violence in their
neighborhood
b. A park or playground?
c. A recreation center, community
center, or boys’ and girls’ club?
f. Lived with anyone who was mentally
ill, suicidal, or severely depressed
d. A library or bookmobile?
g. Lived with anyone who had a problem
with alcohol or drugs
e. Litter or garbage on the street
or sidewalk?
h. Treated or judged unfairly because
of their race or ethnic group
f. Poorly kept or rundown housing?
g. Vandalism such as broken
windows or graffiti?
I8
To what extent do you agree with these statements
about your neighborhood or community?
Treated or judged unfairly because
of a health condition or disability
j.
Treated or judged unfairly because
of their sexual orientation or gender
identity
I11 When your family faces problems, how often are you
likely to do each of the following?
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree
All of
the time
a. People in this
neighborhood help
each other out
Most of
the time
Some of
the time
None of
the time
a. Talk together
about what to do
b. We watch out for
each other’s
children in this
neighborhood
b. Work together to
solve our problems
c. This child is
safe in our
neighborhood
d. Stay hopeful even
in difficult times
d. When we
encounter
difficulties, we
know where to
go for help in
our community
c. Know we have
strengths to draw on
I12
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?
Yes
No
e. This child is safe
at school
I13
I9
i.
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 they
can rely on for advice or guidance?
Has anyone living in your household EVER tried to get
tested for COVID-19?
Yes
No
Yes
No
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I14
Has anyone living in your household EVER been tested
for COVID-19?
I19
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
Yes
No
I15
If yes, for how long?
Has this child had any health care visits by video or
phone because of the Coronavirus pandemic?
Yes
weeks
I20
No
I16
No ➔ SKIP to question I20
Was this child separated from a parent or adult
caregiver as a result of the Coronavirus pandemic?
Yes
Did this child miss or skip any PREVENTIVE check-ups
because of the Coronavirus pandemic?
No ➔ SKIP to section J
If yes, for how long?
Yes
weeks
No ➔ SKIP to question I18
I17
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
J. Child’s Caregivers
About You
J1
How are you related to this child?
Biological or Adoptive Parent
b. Health care provider’s location was
open but had limited appointments
due to the Coronavirus pandemic
Step-parent
c. Parent, adult caregiver, or child was
concerned about going to the health
care provider’s location due to the
Coronavirus pandemic
Grandparent
Foster Parent
d. This child no longer had health
insurance or had a change in health
insurance
Other: Relative
Other: Non-Relative
e. Someone in the household was ill
f. Someone in the household had been
in contact with someone who was ill
J2
What is your sex?
Male
I18
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
Female
J3
Age in years
b. At least one adult in the household
worked outside the home
c. A household member was
hospitalized due to the Coronavirus
What is your age?
J4
Where were you born?
In the United States ➔ SKIP to question J6
on page 17
d. A household member died from the
Coronavirus
Outside of the United States
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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.
J9
Excellent
Very good
4-Digit Year
J6
Good
What is the highest grade or level of school you have
completed?
Mark (X) ONE box.
Fair
Poor
8th grade or less
9th-12th grade; No diploma
J10 Which of the following best describes your current
employment status?
Mark (X) ONE box.
High School Graduate or GED Completed
Employed full-time
Completed a vocational, trade, or business school
program
Employed part-time
Some College Credit, but no Degree
Working WITHOUT pay
Associate Degree (AA, AS)
Not employed but looking for work
Bachelor’s Degree (BA, BS, AB)
Master’s Degree (MA, MS, MSW, MBA)
Not employed and not looking for work
J11 Have you ever served on active duty in the
U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
J7
What is your marital status?
Never served in the military ➔ SKIP to question J13
Married
Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question J13
Not married, but living with a partner
Now on active duty
Never Married
On active duty in the past, but not now
Divorced
J8
In general, how is your mental or emotional health?
J12 Were you deployed at any time during this child’s life?
Separated
Yes
Widowed
No
In general, how is your physical health?
J13 Does this child have another parent or adult caregiver
who lives in this household?
Excellent
Yes ➔ Complete questions J14 - J25 for this other
parent or adult caregiver
Very good
No ➔ SKIP to question K1 on page 19
Good
Fair
Poor
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Other Parent or Caregiver
in the Household
J19 What is the highest grade or level of school this
caregiver has completed?
Mark (X) ONE box.
J14 How is this other caregiver related to this child?
8th grade or less
Biological or Adoptive Parent
9th-12th grade; No diploma
Step-parent
High School Graduate or GED Completed
Grandparent
Completed a vocational, trade, or business school
program
Foster Parent
Some College Credit, but no Degree
Other: Relative
Associate Degree (AA, AS)
Other: Non-Relative
Bachelor’s Degree (BA, BS, AB)
J15 What is this caregiver’s sex?
Master’s Degree (MA, MS, MSW, MBA)
Male
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
Female
J20 What is this caregiver’s marital status?
J16 What is this caregiver’s age?
Married
Age in years
Not married, but living with a partner
Never Married
J17 Where was this caregiver born?
Divorced
In the United States ➔ SKIP to question J19
on page 18
Separated
Outside of the United States
Widowed
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.
J21 In general, how is this caregiver’s physical health?
Excellent
4-Digit Year
Very good
Good
Fair
Poor
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J22 In general, how is this caregiver’s mental or emotional
health?
K3
Excellent
Very good
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.
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.
J23 Which of the following best describes this caregiver’s
current employment status?
Mark (X) ONE box.
Employed full-time
Yes ➔
Employed part-time
No
$
,
,
.00
Loss
TOTAL AMOUNT
in the last calendar year
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Working WITHOUT pay
Not employed but looking for work
Yes ➔
Not employed and not looking for work
$
,
.00
Loss
TOTAL AMOUNT
in the last calendar year
No
J24 Has this caregiver ever served on active duty in the U.S.
Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
,
d. Social security or railroad retirement; retirement,
survivor, or disability pensions.
Never served in the military ➔ SKIP to question K1
Yes ➔
Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question K1
No
$
,
,
.00
TOTAL AMOUNT
in the last calendar year
e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office.
Now on active duty
On active duty in the past, but not now
Yes ➔
J25 Was this caregiver deployed at any time during this
$
child’s life?
,
,
.00
TOTAL AMOUNT
in the last calendar year
No
Yes
f. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support, or alimony.
No
K. Household Information
Yes ➔
$
Include everyone who usually lives or stays at this address.
Do NOT include anyone who is living somewhere else for
K4
more than two months, such as a college student living away
or someone in the Armed Forces on deployment.
Number of people
K2 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.
.00
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.
$
Number of people
,
TOTAL AMOUNT
in the last calendar year
No
K1 How many people are living or staying at this address?
,
,
.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 |