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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
b. Serious difficulty walking or climbing
stairs
A. This Child’s Health
c. Difficulty dressing or bathing
A1 In general, how would you describe this child’s health
d. Difficulty doing errands alone, such
as visiting a doctor’s office or
shopping, because of a physical,
mental, or emotional condition
(the one named above)?
Excellent
Very good
e. Deafness or problems with hearing
Good
f. Blindness or problems with seeing,
even when wearing glasses
Fair
Has a doctor or other health care provider EVER told
you that this child has...
Poor
A5
A2 How would you describe the condition of this child’s
Allergies (including food, drug, insect, or other)?
Yes
teeth?
No
If yes, does this child CURRENTLY have the
condition?
Excellent
Yes
Very good
Good
Fair
No
If yes, is it:
Mild
A6
Poor
Moderate
Severe
Arthritis?
Yes
No
If yes, does this child CURRENTLY have the
condition?
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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Moderate
Severe
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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
Was this child born more than 3 weeks before their
due date?
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
Yes
10-20 minutes
No
More than 20 minutes
B2
What month and year was this child born?
Birth Month / 4-Digit Birth Year
/
C5
What is this child’s CURRENT height?
Your best estimate is fine.
2 0
feet AND
B3
How much did they weigh when born? Answer in pounds
and ounces OR kilograms and grams. Your best estimate is
fine.
inches
OR
meters AND
pounds AND
ounces
C6
OR
kilograms AND
B4
centimeters
How much does this child CURRENTLY weigh?
Your best estimate is fine.
grams
pounds
OR
What was the age of the mother when this child was
born? Your best estimate is fine.
kilograms
Age in years
C7
C. Health Care Services
Yes, it’s too high
C1 DURING THE PAST 12 MONTHS, did this child see a
Yes, it’s too low
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, I am not concerned
C8
No ➔ SKIP to question C5
Has a doctor or other health care provider ever told
you that this child is overweight?
Yes
C2 If yes, at their LAST medical care visit, did this child
have a chance to speak with a doctor or other health
care provider privately, without you or another
caregiver in the room?
Are you concerned about this child’s weight?
No
C9
Yes
No
Is there a place you or another caregiver USUALLY
take this child when they are sick or you need advice
about their health?
Yes
C3 DURING THE PAST 12 MONTHS, how many times did
No ➔ SKIP to question C11 on page 7
this child visit a doctor, nurse, or other health care
professional to receive a PREVENTIVE check-up? A
preventive check-up is when this child was not sick or injured,
such as an annual or sports physical, or well-child visit.
0 visits
1 visit
2 or more visits
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C10 If yes, where does this child USUALLY go first?
C15 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?
Mark (X) ONE box.
Doctor’s Office
Yes, saw a dentist
Hospital Emergency Room
Yes, saw other oral health care provider
Hospital Outpatient Department
Clinic or Health Center
No ➔ SKIP to question C18
C16 If yes, DURING THE PAST 12 MONTHS, did this child
see a dentist or other oral health care provider for
PREVENTIVE dental care, such as check-ups, dental
cleanings, dental sealants, or fluoride treatments?
Retail Store Clinic or “Minute Clinic”
School (Nurse’s Office, Athletic Trainer’s Office)
No preventive visits in the past
12 months ➔ SKIP to question C18
Some other place
Yes, 1 visit
C11 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?
Yes
Yes, 2 or more visits
C17 If yes, DURING THE PAST 12 MONTHS, what
PREVENTIVE dental service(s) did this child receive?
Mark (X) ALL that apply.
No ➔ SKIP to question C13
Check-up
C12 If yes, is this the same place this child goes when they
are sick?
Cleaning
Yes
Instruction on tooth brushing and oral health care
No
X-Rays
C13 DURING THE PAST 2 YEARS, has this child received a
Fluoride treatment
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
No ➔ SKIP to question C14
Sealant (plastic coatings on back teeth)
Don’t know
C18 DURING THE PAST 12 MONTHS, has this child
received any treatment or counseling from a mental
health professional? Mental health professionals include
psychiatrists, psychologists, psychiatric nurses, and clinical
social workers.
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
Yes
No
No, but this child needed to see a mental health
professional
C14 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
No
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 C20
on page 8
C19 How difficult was it to get the mental health treatment
or counseling that this child needed?
Not difficult
Received eye examination
Somewhat difficult
Prescribed eyeglasses or contact lenses
Very difficult
Diagnosis of a vision disorder other than
nearsighted, farsighted, or astigmatism
It was not possible to obtain care
Other
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C20 DURING THE PAST 12 MONTHS, has this child taken
any medication because of difficulties with their
emotions, concentration, or behavior?
C26 Did any of the following reasons contribute to this child
not receiving needed health services?
Mark (X) Yes or No for EACH item.
Yes
a. This child was not eligible for the
services
No
b. The services this child needed were
not available in your area
C21 DURING THE PAST 12 MONTHS, did this child see a
Yes
d. There were problems with getting
transportation or child care
No, but this child needed to see a specialist
e. The clinic or doctor’s office wasn’t
open when this child needed care
f. There were issues related to cost
No, this child did not need to
see a specialist ➔ SKIP to question C23
C27 DURING THE PAST 12 MONTHS, how often were you
frustrated in your efforts to get services for this child?
child needed?
Not difficult
Never
Somewhat difficult
Sometimes
Very difficult
Usually
It was not possible to obtain care
Always
C23 DURING THE PAST 12 MONTHS, did this child use any
type of alternative health care or treatment? Alternative
health care can include acupuncture, chiropractic care,
relaxation therapies, herbal supplements, and others.
Some therapies involve seeing a health care provider,
while others can be done on your own.
No
c. There were problems getting an
appointment when this child needed
one
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.
C22 How difficult was it to get the specialist care that this
Yes
C28 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
C24 DURING THE PAST 12 MONTHS, was there any time
when this child needed health care but it was not
received? By health care, we mean medical care as well
as other kinds of care like dental care, vision care, and
mental health services.
C29 DURING THE PAST 12 MONTHS, was this child admitted
to the hospital to stay for at least one night?
Yes
No
Yes
No ➔ SKIP to question C27
C30 Has this child EVER had a special education or early
intervention plan? Children receiving these services often
have an Individualized Family Service Plan (IFSP) or
Individualized Education Plan (IEP).
C25 If yes, which types of care were not received?
Mark (X) ALL that apply.
Medical Care
Yes
Dental Care
No ➔ SKIP to question C33 on page 9
Vision Care
C31 If yes, how old was this child at the time of the FIRST
plan?
Hearing Care
Mental Health Services
Other, specify:
years AND
months
C
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C32 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?
C34 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?
C35 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?
C33 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 D13 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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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?
D14 If yes, have they talked with you about when this child
will need to see doctors or other health care providers
who treat adults?
Yes
Yes
No
No ➔ SKIP to question D10
D15 Has this child’s doctor or other health care provider
actively worked with this child to:
D9 If yes, DURING THE PAST 12 MONTHS, how often
did you get as much help as you wanted with
arranging or coordinating this child’s health care?
Yes
Sometimes
Never
b. Gain skills to manage their
health and health care. For example, by understanding current
health needs, knowing what to do
in a medical emergency, or taking
medications they may need?
D10 DURING THE PAST 12 MONTHS, how satisfied were
you with the communication between this child’s
doctors and other health care providers?
c. Understand the changes in
health care that happen at
age 18. For example, by
understanding changes in privacy,
consent, access to information, or
decision-making?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
D16 Did you and this child receive a summary of your
child’s medical history (for example, medical conditions,
allergies, medications, immunizations)?
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?
Yes
Yes
No ➔ SKIP to question D13
No
D17 Have this child’s doctors or other health care providers
worked with you and this child to create a plan of care
to meet their health goals and needs?
Did not need health care
provider to communicate
with these providers ➔ SKIP to question D13
Yes
D12 If yes, during this time, how satisfied were you with the
No ➔ SKIP to question D20 on page 11
health care provider’s communication with the school,
child care provider, or special education program?
Very satisfied
D18 If yes, do you and this child have access to this plan of
care?
Somewhat satisfied
Yes
Somewhat dissatisfied
No
Very dissatisfied
Don’t
know
a. Make positive choices about
their health. For example, by
eating healthy, getting regular
exercise, not using tobacco,
alcohol or other drugs, or
delaying sexual activity?
Usually
Very dissatisfied
No
D19 Does this plan of care address transition to doctors and
other health care providers who treat adults?
D13 Do any of this child’s doctors or other health care
Yes
providers treat only children?
Yes
No
No ➔ SKIP to question D15
No, child already sees providers who treat adults
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D20 Eligibility for health insurance often changes in young
adulthood. Do you know how this child will be insured
as they become an adult?
E4
Is this child CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark (X) Yes or No for EACH item.
Yes
Yes ➔ SKIP to question E1
a. Insurance through a current or
former employer or union
No
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
D21 If no, has anyone discussed with you how to obtain or
keep some type of health insurance coverage as this
child becomes an adult?
Yes
No
d. TRICARE or other military
health care
No
e. Indian Health Service
E. This Child’s Health
Insurance Coverage
E1
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
Yes, this child was covered
all 12 months ➔ SKIP to question E4
E2
How often does this child’s health insurance offer
benefits or cover services that meet this child’s needs?
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
No
Never
E6
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
e. Dropped coverage because choice
of health care providers was
inadequate
How often does this child’s health insurance allow
them to see the health care providers they need?
Never
E7
f. Problems with application or
renewal process
g. Other, specify: C
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?
Always
Usually
E3
Sometimes
Is this child CURRENTLY covered by ANY kind of
health insurance or health coverage plan?
Never
Yes
This child does not use mental or behavioral
health services
No ➔ SKIP to question F1 on page 12
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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
$1,000-$5,000
This child does not need health care coordinated
on a weekly basis
More than $5,000
Less than 1 hour per week
1-4 hours per week
How often are these costs reasonable?
Always
5-10 hours per week
Usually
11 or more hours per week
Sometimes
G. This Child’s Schooling
and Activities
Never
F3
F4
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?
DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?
G1
DURING THE PAST 12 MONTHS, about how many days
did this child miss school because of illness or injury?
Include days missed from any formal home schooling.
Yes
No missed school days
No
1-3 days
DURING THE PAST 12 MONTHS, have you or other
family members...
Yes
4-6 days
No
7-10 days
a. Left a job or taken a leave of
absence because of this child’s
health or health conditions?
b. Cut down on the hours you work
because of this child’s health or
health conditions?
11 or more days
This child was not enrolled in school
G2
c. Avoided changing jobs because of
concerns about maintaining health
insurance for this child?
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?
None
1 time
2 or more times
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G3 SINCE STARTING KINDERGARTEN, has this child
G8 DURING THE PAST 12 MONTHS, how often was this
repeated any grades?
child bullied, picked on, or excluded by other children?
If the frequency changed throughout the year, report the
highest frequency.
Yes
Never (in the past 12 months)
No
1-2 times (in the past 12 months)
G4 DURING THE PAST 12 MONTHS, how often did you
attend events or activities that this child participated in?
1-2 times per month
Always
1-2 times per week
Usually
Almost every day
Sometimes
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.
Rarely
Never
Never (in the past 12 months)
G5 DURING THE PAST 12 MONTHS, did this child
participate in...
Yes
1-2 times (in the past 12 months)
No
a. A sports team or did they take
sports lessons after school or
on weekends?
1-2 times per month
1-2 times per week
b. Any clubs or organizations after
school or on weekends?
c. Any other organized activities or
lessons, such as music, dance,
language, or other arts?
d. Any type of community service or
volunteer work at school, place of
worship, or in the community?
Almost every day
G10 How often does this child...
Always
Usually Sometimes
a. Show interest and
curiosity in learning
new things?
e. Any paid work, including regular
jobs as well as babysitting, cutting
grass, or other occasional work?
b. Work to finish tasks
they start?
c. Stay calm and in
control when faced
with a challenge?
G6 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?
d. Care about doing
well in school?
e. Do all required
homework?
0 days
1-3 days
f. Argue too much?
4-6 days
H. About You and This
Child
Every day
G7 Compared to other children their age, how much
difficulty does this child have making or keeping
friends?
H1 Was this child born in the United States?
No difficulty
Yes ➔ SKIP to question H3 on page 14
A little difficulty
No
A lot of difficulty
H2 If no, how long has this child been living in the
United States?
years AND
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H3
How many times has this child moved to a new address H8 How well do you think you are handling the day-to-day
since they were born?
demands of raising children?
Very well
Number of times
Somewhat well
H4 How often does this child go to bed at about the same
time on weeknights?
Not very well
Always
Usually
Not well at all
H9 DURING THE PAST MONTH, how often have you felt...
Never
Sometimes
Rarely
Never
Less than 6 hours
b. That this child
does things
that really
bother you
a lot?
6 hours
c. Angry with
this child?
H5 DURING THE PAST WEEK, how many hours of sleep
did this child get on most weeknights?
7 hours
Rarely Sometimes Usually Always
a. That this child
is much harder
to care for than
most children
their age?
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?
8 hours
9 hours
Yes
10 hours
No ➔ SKIP to question I1 on page 15
11 or more hours
H11 If yes, did you receive emotional support from...
Yes
H6 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.
a. Spouse or domestic partner?
b. Other family member or close friend?
Less than 1 hour
c. Health care provider?
1 hour
d. Place of worship or religious leader?
2 hours
e. Support or advocacy group related
to specific health condition?
3 hours
f. Peer support group?
4 or more hours
g. Counselor or other mental health
professional?
h. Other person, specify:
H7 How well can you and this child share ideas or talk
C
about things that really matter?
Very well
Somewhat well
Not very well
Not well at all
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I. About Your Family and
Household
I1
I6
At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive...
Yes
No
Yes
No
a. Cash assistance from a government
welfare program?
DURING THE PAST WEEK, on how many days did all the
family members who live in the household eat a meal
together?
b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?
0 days
c. Free or reduced-cost breakfasts or
lunches at school?
1-3 days
d. Benefits from the Women, Infants,
and Children (WIC) Program?
4-6 days
I7
Every day
In your neighborhood, is/are there...
a. Sidewalks or walking paths?
I2
Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?
b. A park or playground?
c. A recreation center, community
center, or boys’ and girls’ club?
Yes
No ➔ SKIP to question
I3
I4
I4
d. A library or bookmobile?
e. Litter or garbage on the street
or sidewalk?
If yes, does anyone smoke inside your home?
Yes
f. Poorly kept or rundown housing?
No
g. Vandalism such as broken
windows or graffiti?
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?
I8
Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree
Never
a. People in this
neighborhood help
each other out
Rarely
Somewhat often
b. We watch out for
each other’s
children in this
neighborhood
Very often
I5
To what extent do you agree with these statements
about your neighborhood or community?
c. This child is
safe in our
neighborhood
Which of these statements best describes your
household’s ability to afford the food you need
DURING THE PAST 12 MONTHS?
d. When we
encounter
difficulties, we
know where to
go for help in
our community
We could always afford to eat good nutritious meals.
We could always afford enough to eat but not always
the kinds of food we should eat.
Sometimes we could not afford enough to eat.
e. This child is safe
at school
Often we could not afford enough to eat.
I9
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?
Yes
No
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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.
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 anyone living in your household EVER been tested
for COVID-19?
Yes
No
I15
Has this child had any health care visits by video or
phone because of the Coronavirus pandemic?
b. Parent or guardian died
Yes
c. Parent or guardian served time in jail
No
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home
I16
Yes
e. Was a victim of violence or
witnessed violence in their
neighborhood
No ➔ SKIP to question I18
f. Lived with anyone who was mentally
ill, suicidal, or severely depressed
I17
g. Lived with anyone who had a problem
with alcohol or drugs
h. Treated or judged unfairly because
of their race or ethnic group
i.
Treated or judged unfairly because
of a health condition or disability
j.
Treated or judged unfairly because
of their sexual orientation or gender
identity
c. Parent, adult caregiver, or child was
concerned about going to the health
care provider’s location due to the
Coronavirus pandemic
likely to do each of the following?
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
b. Health care provider’s location was
open but had limited appointments
due to the Coronavirus pandemic
I11 When your family faces problems, how often are you
All of
the time
Did this child miss or skip any PREVENTIVE check-ups
because of the Coronavirus pandemic?
Some of
the time
None of
the time
d. This child no longer had health
insurance or had a change in health
insurance
a. Talk together
about what to do
e. Someone in the household was ill
b. Work together to
solve our problems
c. Know we have
strengths to draw on
f. Someone in the household had been
in contact with someone who was ill
I18
d. Stay hopeful even
in difficult times
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?
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
Yes
c. A household member was
hospitalized due to the Coronavirus
No
d. A household member died from the
Coronavirus
I13 Has anyone living in your household EVER tried to get
tested for COVID-19?
Yes
No
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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
J6
8th grade or less
No ➔ SKIP to question I20
9th-12th grade; No diploma
If yes, for how long?
High School Graduate or GED Completed
weeks
Completed a vocational, trade, or business school
program
I20 Was this child separated from a parent or adult
caregiver as a result of the Coronavirus pandemic?
Yes
What is the highest grade or level of school you have
completed?
Mark (X) ONE box.
Some College Credit, but no Degree
No ➔ SKIP to section J
Associate Degree (AA, AS)
If yes, for how long?
Bachelor’s Degree (BA, BS, AB)
weeks
Master’s Degree (MA, MS, MSW, MBA)
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
J. Child’s Caregivers
About You
J1
J7
What is your marital status?
Married
How are you related to this child?
Not married, but living with a partner
Biological or Adoptive Parent
Never Married
Step-parent
Divorced
Grandparent
Separated
Foster Parent
Widowed
Other: Relative
J8
In general, how is your physical health?
Other: Non-Relative
J2
Excellent
What is your sex?
Very good
Male
Good
Female
J3
Fair
What is your age?
Poor
Age in years
J4
Where were you born?
J9
Excellent
In the United States ➔ SKIP to question J6
Very good
Outside of the United States
J5
In general, how is your mental or emotional health?
Good
When did you come to live in the United States?
Indicate the 4-digit year in which you came to live in the
United States.
Fair
Poor
4-Digit Year
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J10 Which of the following best describes your current
employment status?
Mark (X) ONE box.
J16 What is this caregiver’s age?
Age in years
Employed full-time
Employed part-time
J17 Where was this caregiver born?
In the United States ➔ SKIP to question J19
Working WITHOUT pay
Outside of the United States
Not employed but looking for work
Not employed and not 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.
J11 Have you ever served on active duty in the
U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question J13
4-Digit Year
J19 What is the highest grade or level of school this
caregiver has completed?
Mark (X) ONE box.
Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question J13
8th grade or less
Now on active duty
9th-12th grade; No diploma
On active duty in the past, but not now
High School Graduate or GED Completed
J12 Were you deployed at any time during this child’s life?
Yes
Completed a vocational, trade, or business school
program
No
Some College Credit, but no Degree
Associate Degree (AA, AS)
J13 Does this child have another parent or adult caregiver
who lives in this household?
Bachelor’s Degree (BA, BS, AB)
Yes ➔ Complete questions J14 - J25 for this other
parent or adult caregiver
Master’s Degree (MA, MS, MSW, MBA)
No ➔ SKIP to question K1 on page 19
Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
Other Parent or Caregiver
in the Household
J20 What is this caregiver’s marital status?
J14 How is this other caregiver related to this child?
Not married, but living with a partner
Married
Biological or Adoptive Parent
Never Married
Step-parent
Divorced
Grandparent
Separated
Foster Parent
Widowed
Other: Relative
J21 In general, how is this caregiver’s physical health?
Excellent
Other: Non-Relative
Very good
J15 What is this caregiver’s sex?
Good
Male
Fair
Female
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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26031013
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 |