2020 NSCH Screener and Topical Questionnaires

Appendix D_2020 NSCH Screener and Topical Questionnaires_FINAL.pdf

National Survey of Children's Health

2020 NSCH Screener and Topical Questionnaires

OMB: 0607-0990

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Appendix D

2020 National Survey of Children’s Health
Screener and Topical Questionnaires

26000083

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.

NSCH-S1
(03/02/2020)

§;!!t¤

26000075

Start Here
Respond online today at: https://respond.census.gov/nsch
OR complete this form and mail it back as soon as possible.
Thank you for helping us learn about the health and well-being of America’s children.
If your household has children 0 - 17 years old, the questions on this form should be answered by an adult who is familiar with
their health and health care. If your household does not have any children, please answer question 1 below AND return the
questionnaire.
For help or questions about completing this form, please call 1-800-845-8241. The telephone call is free.
For Telephone Device for the Deaf (TDD) assistance, please call: 1-800-582-8330. The telephone call is free.
Si necesita ayuda o tiene preguntas sobre cómo completar este formulario, llame al 1-800-845-8241. La llamada es gratuita.
Para recibir ayuda relacionada con el Dispositivo Telefónico para Personas Sordas (TDD), llame al 1-800-582-8330. La llamada
es gratuita.

In Your Home
1

Are there any children 0-17 years old who usually live or stay at this address?
Yes
No – STOP HERE after marking “No” and return this survey to us in the enclosed envelope. It is important that we
receive a response from every household selected for this study.

2

How many children 0-17 years old usually live or stay at this address?

Number of children living or staying at this address
3

What is the primary language spoken in the household?
English
Spanish
Other Language, specify:

4

C

Is this house, apartment, or mobile home –
Mark (X) ONE box.
Owned by you or someone in this household with a mortgage or loan? Include home equity loans.
Owned by you or someone in this household free and clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?

➜

Answer the remaining questions for each of the children 0-17 years old who usually live or stay at this address.
Start with the YOUNGEST CHILD, who we will call “Child 1” and continue with the next youngest until you have
answered the questions for all children who usually live or stay at this address.

NSCH-S1

2

§;!!l¤

26000067

CHILD 1

7

(Youngest)
1

First name, initials, or nickname of the youngest child

2

How old is this child? If the child is less than one month
old, round age in months to 1.

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?
Yes

No

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?
Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

Years OR
3

Months

8

What is this child’s sex?
Male

No

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

➜ NOTE: Answer BOTH question

4 about Hispanic
origin and question 5 about race.
For this survey, Hispanic origins are not races.

4

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Female

Yes

No, not of Hispanic, Latino, or Spanish origin

Yes
9

Yes, Puerto Rican

5

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Is this child of Hispanic, Latino, or Spanish origin?

Yes, Mexican, Mexican American, Chicano

No

No

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?

Yes, Cuban

Yes

Yes, another Hispanic, Latino, or Spanish origin

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

What is this child’s race? Mark (X) one or more boxes.
White

Korean

Black or
African American

Vietnamese

American Indian or
Alaska Native

Other Asian

No

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

No

10 Does this child need or get special therapy, such as
physical, occupational, or speech therapy?

Native Hawaiian

Yes

Chinese

Guamanian or
Chamorro

If yes, is this because of ANY medical, behavioral,
or other health condition?

Filipino

Samoan

Japanese

Other Pacific Islander

Asian Indian

No

Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

6

Answer the following question only if this child is at
least 4 years old. Otherwise, SKIP to question 7 .
How well does this child speak English?

No

11 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?

Very well

Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

No

Not well
Yes

No

Not at all
NSCH-S1

3

§;!!d¤

26000059

CHILD 2

7

(Next youngest)
1

First name, initials, or nickname of the next youngest
child

2

How old is this child? If the child is less than one month
old, round age in months to 1.

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?
Yes

No

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?
Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

Years OR
3

Months

8

What is this child’s sex?
Male

No

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

➜ NOTE: Answer BOTH question

4 about Hispanic
origin and question 5 about race.
For this survey, Hispanic origins are not races.

4

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Female

Yes

No, not of Hispanic, Latino, or Spanish origin

Yes
9

Yes, Puerto Rican

5

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Is this child of Hispanic, Latino, or Spanish origin?

Yes, Mexican, Mexican American, Chicano

No

No

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?

Yes, Cuban

Yes

Yes, another Hispanic, Latino, or Spanish origin

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

What is this child’s race? Mark (X) one or more boxes.
White

Korean

Black or
African American

Vietnamese

American Indian or
Alaska Native

Other Asian

No

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

No

10 Does this child need or get special therapy, such as
physical, occupational, or speech therapy?

Native Hawaiian

Yes

Chinese

Guamanian or
Chamorro

If yes, is this because of ANY medical, behavioral,
or other health condition?

Filipino

Samoan

Japanese

Other Pacific Islander

Asian Indian

No

Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

6

Answer the following question only if this child is at
least 4 years old. Otherwise, SKIP to question 7 .
How well does this child speak English?

No

11 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?

Very well

Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

No

Not well
Yes

No

Not at all
NSCH-S1

4

§;!!\¤

26000042

CHILD 3

7

(Next youngest)
1

First name, initials, or nickname of the next youngest
child

2

How old is this child? If the child is less than one month
old, round age in months to 1.

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?
Yes

No

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?
Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

Years OR
3

Months

8

What is this child’s sex?
Male

No

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

➜ NOTE: Answer BOTH question

4 about Hispanic
origin and question 5 about race.
For this survey, Hispanic origins are not races.

4

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Female

Yes

No, not of Hispanic, Latino, or Spanish origin

Yes
9

Yes, Puerto Rican

5

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Is this child of Hispanic, Latino, or Spanish origin?

Yes, Mexican, Mexican American, Chicano

No

No

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?

Yes, Cuban

Yes

Yes, another Hispanic, Latino, or Spanish origin

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

What is this child’s race? Mark (X) one or more boxes.
White

Korean

Black or
African American

Vietnamese

American Indian or
Alaska Native

Other Asian

Yes

Filipino

Samoan

Japanese

Other Pacific Islander

No

10 Does this child need or get special therapy, such as
physical, occupational, or speech therapy?
Yes

Native Hawaiian
Guamanian or
Chamorro

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Asian Indian
Chinese

No

No

If yes, is this because of ANY medical, behavioral,
or other health condition?
Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

6

Answer the following question only if this child is at
least 4 years old. Otherwise, SKIP to question 7 .
How well does this child speak English?

No

11 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?

Very well

Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

No

Not well
Yes

No

Not at all
NSCH-S1

5

§;!!K¤

26000034

CHILD 4

7

(Next youngest)
1

First name, initials, or nickname of the next youngest
child

2

How old is this child? If the child is less than one month
old, round age in months to 1.

Does this child CURRENTLY need or use medicine
prescribed by a doctor, other than vitamins?
Yes

No

If yes, is this child’s need for prescription medicine
because of ANY medical, behavioral, or other health
condition?
Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

Years OR
3

Months

8

What is this child’s sex?
Male

No

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?

➜ NOTE: Answer BOTH question

4 about Hispanic
origin and question 5 about race.
For this survey, Hispanic origins are not races.

4

Does this child need or use more medical care, mental
health, or educational services than is usual for most
children of the same age?
Yes

Female

Yes

No, not of Hispanic, Latino, or Spanish origin

Yes
9

Yes, Puerto Rican

5

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?

Is this child of Hispanic, Latino, or Spanish origin?

Yes, Mexican, Mexican American, Chicano

No

No

Is this child limited or prevented in any way in his or her
ability to do the things most children of the same age
can do?

Yes, Cuban

Yes

Yes, another Hispanic, Latino, or Spanish origin

If yes, is this child’s limitation in abilities because of
ANY medical, behavioral, or other health condition?
Yes

What is this child’s race? Mark (X) one or more boxes.
White

Korean

Black or
African American

Vietnamese

American Indian or
Alaska Native

Other Asian

No

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

No

10 Does this child need or get special therapy, such as
physical, occupational, or speech therapy?

Native Hawaiian

Yes

Chinese

Guamanian or
Chamorro

If yes, is this because of ANY medical, behavioral,
or other health condition?

Filipino

Samoan

Japanese

Other Pacific Islander

Asian Indian

No

Yes

No

If yes, is this a condition that has lasted or
is expected to last 12 months or longer?
Yes

6

Answer the following question only if this child is at
least 4 years old. Otherwise, SKIP to question 7 .
How well does this child speak English?

No

11 Does this child have any kind of emotional,
developmental, or behavioral problem for which he or
she needs treatment or counseling?

Very well

Yes

Well

If yes, has his or her emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

No

Not well
Yes

No

Not at all
NSCH-S1

6

§;!!C¤

26000026

➜

If there are more than four children 0-17 years old who usually live or stay at this address, list the first name, initials,
or nickname for each child as well as their age and sex.
Do not repeat information for children already included for Child 1 through Child 4.

First name, initials, or nickname

CHILD 5
▲

(Next youngest)

Age

Years OR

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

Months

Sex

Male

Female

First name, initials, or nickname

CHILD 6
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

CHILD 7
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

CHILD 8
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

CHILD 9
▲

(Next youngest)

Age

Years OR

First name, initials, or nickname

CHILD 10
▲

(Next youngest)

Age

Years OR

NSCH-S1

7

§;!!;¤

26000018

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 your household and the children of this household.
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.

➜ Make sure you have:
• Listed all first names, initials, or nicknames of children 0-17 years old in the household
• Answered all questions for each child reported

➜ Place the completed questionnaire in the postage-paid return envelope. If the envelope has been
misplaced, please 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 5 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.

NSCH-S1

8

§;!!3¤

26010249

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.

NSCH-T1
(03/18/2020)

§;"#R¤

26010231

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

Decayed teeth or cavities

Does this child have any of the following?
a. Deafness or problems with hearing

A. This Child’s Health

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

NSCH-T1

2

§;"#@¤

26010223

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

Yes

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

A9 Diabetes?

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

NSCH-T1

3

§;"#8¤

26010215

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

No

If yes, does this child CURRENTLY have the
condition?

If yes, is it:
Mild

Moderate

Severe
Yes

Was this child diagnosed with:

No

If yes, is it:
Sickle Cell Disease?

Yes

No

Thalassemia?

Yes

No

Hemophilia?

Yes

No

Other Blood
Disorders?

Yes

No

Mild

Moderate

Severe

A21 Developmental Delay?

Yes

No

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

If yes, is it:
Yes

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

NSCH-T1

4

Moderate

Severe

§;"#0¤

26010207

A25 Has a doctor or other health care provider EVER told

A30 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).

you that this child has Attention Deficit Disorder or
Attention Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?

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

No ➔ SKIP to question A33

Yes

No ➔ SKIP to question A30

Yes

Moderate

Mild

Severe

Moderate

Severe

A31 Is this child CURRENTLY taking medication for ADD or
A26 How old was this child when a doctor or other health

ADHD?

care provider FIRST told you that they had Autism, ASD,
Asperger’s Disorder or PDD?
Age in years

Don’t know

Yes

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?

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.

No

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)

If yes, did you seek medical care from a doctor or
other health care provider?

Psychiatrist
Other, specify:

No

Yes
C

If yes, did a doctor or other health care
provider tell you that your child had a
concussion or brain injury?

Don’t know

Yes

A28 Is this child CURRENTLY taking medication for Autism,

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

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
NSCH-T1

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26010199

B. This Child as an Infant
B1

B7

Was this child born more than 3 weeks before their
due date?

How old was this child when they were FIRST fed
formula? Your best estimate is fine.
This child has never been fed formula
OR

Yes

At birth

No
B2

OR

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
and ounces OR kilograms and grams. Your best estimate
is fine.

OR
months

pounds AND

ounces
B8

OR
kilograms AND
B4

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

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

weeks
B6

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
C3

Words and phrases this child uses and
understands?

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 on page 8

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?

Some other place

Yes
No

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26010173

C10 Is there a place that this child USUALLY goes when

C16 If yes, DURING THE PAST 12 MONTHS, what

PREVENTIVE dental service(s) did this child receive?
Mark (X) ALL that apply.

they need routine preventive care, such as a physical
examination or well-child check-up?
Yes

Check-up

No ➔ SKIP to question C12

Cleaning
Instruction on tooth brushing and oral health care

C11 If yes, is this the same place this child goes when they

are sick?

X-Rays

Yes

Fluoride treatment

No

Sealant (plastic coatings on back teeth)

C12 DURING THE PAST 12 MONTHS, has this child had

Don’t know

their vision tested, such as with pictures, shapes, or
letters?

C17 DURING THE PAST 12 MONTHS, has this child

Yes

received any treatment or counseling from a mental
health professional? Mental health professionals include
psychiatrists, psychologists, psychiatric nurses, and clinical
social workers.

No ➔ SKIP to question C14
C13 If yes, where was this child’s vision tested?

Yes

Mark (X) ALL that apply.
Eye doctor or eye specialist (ophthalmologist,
optometrist) office

No, but this child needed to see a mental health
professional

Pediatrician or other general doctor’s office

No, this child did not need to see a
mental health professional ➔ SKIP to question C19

Clinic or health center

C18 How difficult was it to get the mental health treatment

or counseling that this child needed?

School
Other, specify:

Not difficult
C

Somewhat difficult
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
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?

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.

No preventive visits in
the past 12 months ➔ SKIP to question C17
Yes, 1 visit

Yes

Yes, 2 or more visits

No, but this child needed to see a specialist
No, this child did not need to see
a specialist ➔ SKIP to question C22 on page 9

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26010165

C21 How difficult was it to get the specialist care that this

C26 DURING THE PAST 12 MONTHS, how often were you

child needed?

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

C27 DURING THE PAST 12 MONTHS, how many times did

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.

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.

No ➔ SKIP to question C32

Medical Care
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

meet their developmental needs such as speech,
occupational, or behavioral therapy?

not receiving needed health services?
Mark (X) Yes or No for EACH item.
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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26010157

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

Usually Sometimes Never

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

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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26010140

D11 DURING THE PAST 12 MONTHS, did this child’s health

E3

care provider communicate with the child’s school, child
care provider, or special education program?

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
E7

e. Dropped coverage because choice
of health care providers was
inadequate

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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26010132

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

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?
This child does not need health care coordinated
on a weekly basis

$1,000-$5,000

Less than 1 hour per week

More than $5,000
F2

1-4 hours per week

How often are these costs reasonable?

5-10 hours per week

Always

11 or more hours per week

Usually

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...
Yes

Yes

c. Use 3 words together in a sentence,
such as, "Mommy come now."?

No

a. Left a job or taken a leave of
absence because of this child’s
health or health conditions?

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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26010124

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

G9 How often can this child explain things they have seen

home schooling.

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?
G10 How often can this child write their first name, even if

No

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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26010116

G13 Can this child identify the colors red, yellow, blue,

G19 How often does this child become angry or anxious

and green by name?

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

Sometimes

follow instructions to complete a simple task?
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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26010108

G24 Compared to other children their age, how often is

H5

this child able to sit still?
Always

DURING THE PAST WEEK, how many hours of sleep
did this child get during an average day (count both
nighttime sleep and naps)?
Less than 7 hours

Most of the time

7 hours

About half the time

8 hours

Sometimes

9 hours

Never

10 hours

G25 How often...
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?

On their side
On their back

d. Does this child
smile and laugh?

On their stomach

H. About You and This
Child

H7 ON MOST WEEKDAYS, about how much time did 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.

H1 Was this child born in the United States?

Yes ➔ SKIP to question

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.

Less than 1 hour

H3

1 hour

No

2 hours

H2 If no, how long has this child been living in the

3 hours

United States?

4 or more hours
years AND

months
H8 DURING THE PAST WEEK, how many days did you or

other family members read to this child?

H3 How many times has this child moved to a new address

since they were born?
0 days
Number of times

1-3 days
4-6 days

H4 How often does this child go to bed at about the same

time on weeknights?
Every day
Always
Usually
Sometimes
Rarely
Never
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H9 DURING THE PAST WEEK, how many days did you or

H14 Does this child receive care for at least 10 hours per

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.

other family members tell stories or sing songs to this
child?
0 days
1-3 days

Yes

4-6 days

No

Every day

H15 DURING THE PAST 12 MONTHS, did you or anyone in

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?

H10 How well do you think you are handling the day-to-day

demands of raising children?
Very well

Yes

Somewhat well

No

Not very well

I. About Your Family and
Household

Not well at all
H11 DURING THE PAST MONTH, how often have you felt...
Never

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?

I1

DURING THE PAST WEEK, on how many days did all
the family members who live in the household eat a
meal together?
0 days
1-3 days
4-6 days
Every day

H12 DURING THE PAST 12 MONTHS, was there someone

that you could turn to for day-to-day emotional support
with parenting or raising children?

I2

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

Yes

Yes

No ➔ SKIP to question H14

No ➔ SKIP to question I4

H13 If yes, did you receive emotional support from...
Yes

No

I3

If yes, does anyone smoke inside your home?

a. Spouse or domestic partner?

Yes

b. Other family member or close friend?

No

c. Health care provider?

I4

d. Place of worship or religious leader?

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?

e. Support or advocacy group related
to specific health condition?

Never

f. Peer support group?

Rarely

g. Counselor or other mental health
professional?

Somewhat often

h. Other person, specify:

Very often

C

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I5

I9

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.

Sometimes we could not afford enough to eat.

To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated

Often we could not afford enough to eat.

b. Parent or guardian died

We could always afford enough to eat but not always
the kinds of food we should eat.

I6

c. Parent or guardian served time in jail

At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive...
Yes

d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home

No

a. Cash assistance from a government
welfare program?

e. Was a victim of violence or
witnessed violence in their
neighborhood

b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?

f. Lived with anyone who was mentally
ill, suicidal, or severely depressed

c. Free or reduced-cost breakfasts or
lunches at school?

g. Lived with anyone who had a problem
with alcohol or drugs

d. Benefits from the Women, Infants,
and Children (WIC) Program?
I7

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.

In your neighborhood, is/are there...

h. Treated or judged unfairly because
of their race or ethnic group
Yes

No
I10

a. Sidewalks or walking paths?

When your family faces problems, how often are you
likely to do each of the following?
All of
the time

b. A park or playground?

d. A library or bookmobile?

b. Work together to
solve our problems

e. Litter or garbage on the street
or sidewalk?

c. Know we have
strengths to draw on

f. Poorly kept or rundown housing?

d. Stay hopeful
even in difficult
times

g. Vandalism such as broken
windows or graffiti?

None of
the time

J. Child’s Caregivers

To what extent do you agree with these statements
about your neighborhood or community?

About You

Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

a. People in this
neighborhood
help each other
out

Some of
the time

a. Talk together
about what to do

c. A recreation center, community
center, or boys’ and girls’ club?

I8

Most of
the time

J1

How are you related to this child?
Biological or Adoptive Parent

b. We watch out for
each other’s
children in this
neighborhood

Step-parent

c. This child is
safe in our
neighborhood

Foster Parent

d. When we
encounter
difficulties, we
know where to
go for help in
our community

Other: Non-Relative

Grandparent

Other: Relative

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J2

J3

What is your sex?

J8

In general, how is your physical health?

Male

Excellent

Female

Very good
Good

What is your age?

Fair
Age in years
Poor
J4

Where were you born?
J9

In general, how is your mental or emotional health?

In the United States ➔ SKIP to question J6
Excellent
Outside of the United States
Very good
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.

Good
Fair

4-Digit Year
J6

What is the highest grade or level of school you have
completed?
Mark (X) ONE box.

Poor
J10 Which of the following best describes your current

employment status?
Mark (X) ONE box.

8th grade or less

Employed full-time

9th-12th grade; No diploma

Employed part-time

High School Graduate or GED Completed

Working WITHOUT pay

Completed a vocational, trade, or business school
program

Not employed but looking for work
Not employed and not looking for work

Some College Credit, but no Degree
Associate Degree (AA, AS)

J11 Have you ever served on active duty in the

U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.

Bachelor’s Degree (BA, BS, AB)

Never served in the
military ➔ SKIP to question J13

Master’s Degree (MA, MS, MSW, MBA)

Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question J13

Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)
J7

Now on active duty

What is your marital status?

On active duty in the past, but not now

Married
Not married, but living with a partner

J12 Were you deployed at any time during this child’s life?

Never Married

Yes

Divorced

No

Separated

J13 Does this child have another parent or adult caregiver

who lives in this household?
Widowed

Yes ➔ Complete questions J14 - J25 for this other
parent or adult caregiver
No ➔ SKIP to question K1 on page 20

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26010066

Other Parent or Caregiver
in the Household

J20 What is this caregiver’s marital status?

Married

J14 How is this other caregiver related to this child?

Not married, but living with a partner

Biological or Adoptive Parent

Never Married

Step-parent

Divorced

Grandparent

Separated

Foster Parent
Other: Relative

Widowed
J21 In general, how is this caregiver’s physical health?

Other: Non-Relative

Excellent

J15 What is this caregiver’s sex?

Very good

Male

Good

Female

Fair

J16 What is this caregiver’s age?

Age in years

Poor
J22 In general, how is this caregiver’s mental or emotional

health?
J17 Where was this caregiver born?

Excellent
In the United States ➔ SKIP to question J19
Very good
Outside of the United States
Good
J18 When did this caregiver come to live in the United

Fair

States? Indicate the 4-digit year in which this caregiver
came to live in the United States.

Poor
4-Digit Year

J23 Which of the following best describes this caregiver’s

current employment status?
Mark (X) ONE box.

J19 What is the highest grade or level of school this

caregiver has completed?
Mark (X) ONE box.

Employed full-time

8th grade or less

Employed part-time

9th-12th grade; No diploma

Working WITHOUT pay

High School Graduate or GED Completed

Not employed but looking for work

Completed a vocational, trade, or business school
program

Not employed and not looking for work

Some College Credit, but no Degree

J24 Has this caregiver ever served on active duty in the

U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.

Associate Degree (AA, AS)
Bachelor’s Degree (BA, BS, AB)

Never served in the
military ➔ SKIP to question K1 on page 20

Master’s Degree (MA, MS, MSW, MBA)

Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question K1 on page 20

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

Now on active duty
On active duty in the past, but not now

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26010058

J25 Was this caregiver deployed at any time during this

e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office.

child’s life?
Yes

Yes ➔

$

No

K1
K4

K2

Yes ➔

$

K4

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.

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

Number of people
K3

.00

f. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support, or alimony.

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.
Number of people

,

TOTAL AMOUNT
in the last calendar year

No

K. Household Information

,

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 ➔
No

$

,

,

.00

TOTAL AMOUNT
in the last calendar year

NSCH-T1

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26010017

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.

NSCH-T1

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26020206

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.

NSCH-T2
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26020198

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. 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.

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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2

Moderate

Severe

§;#"¥¤

26020180

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

No

If yes, is it:

If yes, is it:
Mild

Moderate

Severe

Mild

Moderate

Severe

A13 Tourette Syndrome?

A8 Cerebral Palsy?

Yes

No

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

Moderate

Severe

A16 Down Syndrome?

A11 Heart Condition?

Yes

Moderate

A15 Depression?

No

Yes

No

If yes, is it:

If yes, is it:

Yes

No

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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26020172

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

No

If yes, does this child CURRENTLY have the
condition?

If yes, is it:
Mild

Moderate

Severe
Yes

Was this child diagnosed with:

No

If yes, is it:
Sickle Cell Disease?

Yes

No

Thalassemia?

Yes

No

Hemophilia?

Yes

No

Other Blood
Disorders?

Yes

No

Mild

Moderate

Severe

A21 Developmental Delay?

Yes

No

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

If yes, is it:
Yes

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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4

Moderate

Severe

§;#"i¤

26020164

A25 Has a doctor or other health care provider EVER told

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?

you that this child has Autism or Autism Spectrum
Disorder (ASD)? Include diagnoses of Asperger’s Disorder
or Pervasive Developmental Disorder (PDD).
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

Severe

ADHD?
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?

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

Yes

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

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

Yes

No

A34 DURING THE PAST 12 MONTHS, how often have this
A28 Is this child CURRENTLY taking medication for Autism,

child’s health conditions or problems affected their
ability to do things other children their age do?

ASD, Asperger’s Disorder or PDD?
Yes

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

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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§;#"a¤

26020156

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?

C5

Birth Month / 4-Digit Birth Year

/
B3

inches

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

centimeters

ounces

kilograms
C6

Are you concerned about this child’s weight?
Yes, it’s too high

OR
kilograms AND

Yes, it’s too low

grams

No, I am not concerned
B4

What was the age of the mother when this child was
born? Your best estimate is fine.

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
Retail Store Clinic or “Minute Clinic”
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.

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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26020149

C10 Is there a place that this child USUALLY goes when

C16 If yes, DURING THE PAST 12 MONTHS, what

PREVENTIVE dental service(s) did this child receive?
Mark (X) ALL that apply.

they need routine preventive care, such as a physical
examination or well-child check-up?
Yes

Check-up

No ➔ SKIP to question C12

Cleaning
Instruction on tooth brushing and oral health care

C11 If yes, is this the same place this child goes when they

are sick?

X-Rays

Yes

Fluoride treatment

No

Sealant (plastic coatings on back teeth)

C12 DURING THE PAST 12 MONTHS, has this child had

Don’t know

their vision tested, such as with pictures, shapes, or
letters?

C17 DURING THE PAST 12 MONTHS, has this child

Yes

received any treatment or counseling from a mental
health professional? Mental health professionals include
psychiatrists, psychologists, psychiatric nurses, and clinical
social workers.

No ➔ SKIP to question C14
C13 If yes, where was this child’s vision tested?

Yes

Mark (X) ALL that apply.
Eye doctor or eye specialist (ophthalmologist,
optometrist) office

No, but this child needed to see a mental health
professional

Pediatrician or other general doctor’s office

No, this child did not need to see a
mental health professional ➔ SKIP to question C19

Clinic or health center

C18 How difficult was it to get the mental health treatment

or counseling that this child needed?

School
Other, specify:

Not difficult
C

Somewhat difficult
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
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?

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.

No preventive visits in
the past 12 months ➔ SKIP to question C17
Yes, 1 visit

Yes

Yes, 2 or more visits

No, but this child needed to see a specialist
No, this child did not need to see
a specialist ➔ SKIP to question C22 on page 8

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26020131

C21 How difficult was it to get the specialist care that this

C25 Did any of the following reasons contribute to this child

not receiving needed health services?
Mark (X) Yes or No for EACH item.

child needed?

Yes

Not difficult
Somewhat difficult

a. This child was not eligible for the
services

Very difficult

b. The services this child needed were
not available in your area

No

c. There were problems getting an
appointment when this child needed
one

It was not possible to obtain care
C22 DURING THE PAST 12 MONTHS, did this child use any

d. There were problems with getting
transportation or child care

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.

e. The clinic or doctor’s office wasn’t
open when this child needed care
f. There were issues related to cost

Yes
C26 DURING THE PAST 12 MONTHS, how often were you

No

frustrated in your efforts to get services for this child?
Never

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.

Sometimes
Usually

Yes

Always

No ➔ SKIP to question C26
C27 DURING THE PAST 12 MONTHS, how many times did

this child visit a hospital emergency room?
C24 If yes, which types of care were not received?

Mark (X) ALL that apply.

None

Medical Care

1 time

Dental Care

2 or more times

Vision Care
C28 DURING THE PAST 12 MONTHS, was this child admitted

to the hospital to stay for at least one night?

Hearing Care
Mental Health Services

Yes

Other, specify:

No

C

C29 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).
Yes
No ➔ SKIP to question C32 on page 9
C30 If yes, how old was this child at the time of the FIRST

plan?
years AND

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26020123

C31 Is this child CURRENTLY receiving services under

D4

one of these plans?
Yes

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.
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers...

No

Always
C32 Has this child EVER received special services to

meet their developmental needs such as speech,
occupational, or behavioral therapy?

Never

b. Listen carefully to
you?

Yes

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?
years AND

Usually Sometimes

a. Spend enough time
with this child?

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

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

D. Experience with This
Child’s Health Care
Providers
D1

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.

If yes, DURING THE PAST 12 MONTHS, how often did
this child’s doctors or other health care providers...
Always

Usually Sometimes Never

a. Discuss with you the
range of options to
consider for their health
care or treatment?
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

No
D2

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
No ➔ SKIP to question D4

D3

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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26020115

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?
E1

Yes
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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26020107

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
F4

Never

DURING THE PAST 12 MONTHS, have you or other
family members...
Yes

E7

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?

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
Never

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

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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26020099

G. This Child’s Schooling
and Activities

G5

DURING THE PAST 12 MONTHS, did this child
participate in...
Yes

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

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
G2

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

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?
G8 DURING THE PAST 12 MONTHS, how often was this

Always

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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26020081

G9 DURING THE PAST 12 MONTHS, how often did this

H4

child bully others, pick on them, or exclude them?
If the frequency changed throughout the year, report the
highest frequency.

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

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
H6

f. Argue too much?

H. About You and This
Child
H1

H2

DURING THE PAST WEEK, how many hours of sleep
did this child get on most weeknights?

ON MOST WEEKDAYS, about how much time did 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

Was this child born in the United States?

1 hour

Yes ➔ SKIP to question H3

2 hours

No

3 hours
4 or more hours

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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26020073

H8

I. About Your Family and
Household

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 I4

c. Angry with
this child?

I3

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

If yes, does anyone smoke inside your home?

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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26020065

I6

At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive...
Yes

I9

No

a. Cash assistance from a government
welfare program?

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

b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?

No

c. Free or reduced-cost breakfasts or
lunches at school?

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.

d. Benefits from the Women, Infants,
and Children (WIC) Program?
I7

In your neighborhood, is/are there...
Yes

To the best of your knowledge, has this child EVER
experienced any of the following?
No
Yes
a. Parent or guardian divorced or
separated

No

a. Sidewalks or walking paths?
b. A park or playground?

b. Parent or guardian died

c. A recreation center, community
center, or boys’ and girls’ club?

c. Parent or guardian served time in jail
d. A library or bookmobile?
d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home

e. Litter or garbage on the street
or sidewalk?

e. Was a victim of violence or
witnessed violence in their
neighborhood

f. Poorly kept or rundown housing?
g. Vandalism such as broken
windows or graffiti?
I8

f. Lived with anyone who was mentally
ill, suicidal, or severely depressed

To what extent do you agree with these statements
about your neighborhood or community?

g. Lived with anyone who had a problem
with alcohol or drugs

Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

h. Treated or judged unfairly because
of their race or ethnic group

a. People in this
neighborhood help
each other out
b. We watch out for
each other’s
children in this
neighborhood

i.

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?
All of
the time

c. This child is
safe in our
neighborhood

Most of
the time

Some of
the time

None of
the time

a. Talk together
about what to do

d. When we
encounter
difficulties, we
know where to
go for help in
our community

b. Work together to
solve our problems
c. Know we have
strengths to draw on
d. Stay hopeful even
in difficult times

e. This child is safe
at school

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26020057

J. Child’s Caregivers

J6

About You
J1

What is the highest grade or level of school you have
completed?
Mark (X) ONE box.
8th grade or less

How are you related to this child?

9th-12th grade; No diploma

Biological or Adoptive Parent

High School Graduate or GED Completed

Step-parent

Completed a vocational, trade, or business school
program

Grandparent
Some College Credit, but no Degree
Foster Parent
Associate Degree (AA, AS)
Other: Relative
Bachelor’s Degree (BA, BS, AB)
Other: Non-Relative
Master’s Degree (MA, MS, MSW, MBA)
J2

What is your sex?

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

Male
J7

What is your marital status?

Female
Married
J3

Not married, but living with a partner

What is your age?

Never Married

Age in years

Divorced
J4

Where were you born?

Separated

In the United States ➔ SKIP to question J6
Outside of the United States

J5

Widowed
J8

In general, how is your physical health?
Excellent

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.

Very good
Good

4-Digit Year

Fair
Poor
J9

In general, how is your mental or emotional health?
Excellent
Very good
Good
Fair
Poor

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26020040

Other Parent or Caregiver
in the Household

J10 Which of the following best describes your current

employment status?
Mark (X) ONE box.
Employed full-time

J14 How is this other caregiver related to this child?

Employed part-time

Biological or Adoptive Parent

Working WITHOUT pay

Step-parent

Not employed but looking for work

Grandparent

Not employed and not looking for work

Foster Parent
Other: Relative

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

Other: Non-Relative
J15 What is this caregiver’s sex?

Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question J13

Male

Now on active duty

Female

On active duty in the past, but not now

J16 What is this caregiver’s age?

J12 Were you deployed at any time during this child’s life?

Age in years

Yes
J17 Where was this caregiver born?

No
In the United States ➔ SKIP to question J19
on page 18
J13 Does this child have another parent or adult caregiver

Outside of the United States

who lives in this household?

Yes ➔ Complete questions J14 - J25 for this other
parent or adult caregiver
J18 When did this caregiver come to live in the United
States? Indicate the 4-digit year in which this caregiver
No ➔ SKIP to question K1 on page 19
came to live in the United States.
4-Digit Year

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26020032

J19 What is the highest grade or level of school this

J22 In general, how is this caregiver’s mental or emotional

health?

caregiver has completed?
Mark (X) ONE box.

Excellent
8th grade or less
Very good
9th-12th grade; No diploma
Good
High School Graduate or GED Completed
Fair
Completed a vocational, trade, or business school
program

Poor

Some College Credit, but no Degree
J23 Which of the following best describes this caregiver’s

current employment status?
Mark (X) ONE box.

Associate Degree (AA, AS)
Bachelor’s Degree (BA, BS, AB)

Employed full-time

Master’s Degree (MA, MS, MSW, MBA)

Employed part-time

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

Working WITHOUT pay
Not employed but looking for work

J20 What is this caregiver’s marital status?

Not employed and not looking for work

Married
Not married, but living with a partner

J24 Has this caregiver ever served on active duty in the U.S.

Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.

Never Married

Never served in the military ➔ SKIP to question K1
on page 19
Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question K1 on page 19

Divorced
Separated
Widowed

Now on active duty
On active duty in the past, but not now

J21 In general, how is this caregiver’s physical health?

Excellent

J25 Was this caregiver deployed at any time during this

child’s life?

Very good

Yes

Good

No

Fair
Poor

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26020024

K. Household Information

K3

K1 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.

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.
Yes ➔

$

Number of people

,

,

.00

TOTAL AMOUNT
in the last calendar year

No
K2 How many of these people in your household are family

b. Self-employment income from own nonfarm
businesses or farm business, including
proprietorships and partnerships.

members? Family is defined as anyone related to this child
by blood, marriage, adoption, or through foster care.
Number of people

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 ➔

$

,

,

.00

TOTAL AMOUNT
in the last calendar year

No

f. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support, or alimony.
Yes ➔

$

,

.00

TOTAL AMOUNT
in the last calendar year

No
K4

,

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
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26020016

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 atthe upper left of the form confirms this approval. If this number
were not displayed, we could not conduct this survey.

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26030205

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.

NSCH-T3
(04/06/2020)

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26030197

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. 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.

g. Decayed teeth or cavities
A4

Does this child have any of the following?

Your participation is important. Thank you.
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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2

Moderate

Severe

§;$"¿¤

26030189

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

No

If yes, is it:

If yes, is it:
Mild

Moderate

Severe

Mild

Moderate

Severe

A13 Tourette Syndrome?

A8 Cerebral Palsy?

Yes

No

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

NSCH-T3

3

§;$"z¤

26030171

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

No

If yes, does this child CURRENTLY have the
condition?

If yes, is it:
Mild

Moderate

Severe
Yes

Was this child diagnosed with:

No

If yes, is it:
Sickle Cell Disease?

Yes

No

Thalassemia?

Yes

No

Hemophilia?

Yes

No

Other Blood
Disorders?

Yes

No

Mild

Moderate

Severe

A21 Developmental Delay?

Yes

No

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

If yes, is it:
Yes

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

NSCH-T3

4

Moderate

Severe

§;$"h¤

26030163

A25 Has a doctor or other health care provider EVER told

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?

you that this child has Autism or Autism Spectrum
Disorder (ASD)? Include diagnoses of Asperger’s Disorder
or Pervasive Developmental Disorder (PDD).
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

Severe

ADHD?
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?

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

Yes

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

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

Yes

No

A34 DURING THE PAST 12 MONTHS, how often have this
A28 Is this child CURRENTLY taking medication for Autism,

child’s health conditions or problems affected their
ability to do things other children their age do?

ASD, Asperger’s Disorder or PDD?
Yes

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

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

NSCH-T3

5

§;$"‘¤

26030155

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
C1

Yes, it’s too high

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

Yes, it’s too low
No, I am not concerned
C8

No ➔ SKIP to question C5
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?

Has a doctor or other health care provider ever told
you that this child is overweight?
Yes
No

C9

Yes
No
C3

Are you concerned about this child’s weight?

Is there a place you or another caregiver USUALLY
take this child when they are sick or you need advice
about their health?
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.

No ➔ SKIP to question C11 on page 7

0 visits
1 visit
2 or more visits

NSCH-T3

6

§;$"X¤

26030148

C10 If yes, where does this child USUALLY go first?

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?

Mark (X) ONE box.
Doctor’s Office
Hospital Emergency Room

No preventive visits in the past
12 months ➔ SKIP to question C18

Hospital Outpatient Department

Yes, 1 visit

Clinic or Health Center

Yes, 2 or more visits

Retail Store Clinic or “Minute Clinic”

C17 If yes, DURING THE PAST 12 MONTHS, what

PREVENTIVE dental service(s) did this child receive?
Mark (X) ALL that apply.

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

Check-up

Some other place

Cleaning

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?

Instruction on tooth brushing and oral health care

Yes

X-Rays

No ➔ SKIP to question C13

Fluoride treatment
Sealant (plastic coatings on back teeth)

C12 If yes, is this the same place this child goes when they

are sick?

Don’t know

Yes
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.

No
C13 DURING THE PAST 12 MONTHS, has this child had

their vision tested, such as with pictures, shapes, or
letters?

Yes

Yes

No, but this child needed to see a mental health
professional

No ➔ SKIP to question C15

No, this child did not need to see a
mental health professional ➔ SKIP to question C20

C14 If yes, where was this child’s vision tested?

Mark (X) ALL that apply.
Eye doctor or eye specialist (ophthalmologist,
optometrist) office

C19 How difficult was it to get the mental health treatment

or counseling that this child needed?

Pediatrician or other general doctor’s office

Not difficult

Clinic or health center

Somewhat difficult

School

Very difficult

Other, specify:

It was not possible to obtain care

C

C20 DURING THE PAST 12 MONTHS, has this child taken

any medication because of difficulties with their
emotions, concentration, or behavior?
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?

Yes
No

Yes, saw a dentist
Yes, saw other oral health care provider
No ➔ SKIP to question C18
NSCH-T3

7

§;$"Q¤

26030130

C21 DURING THE PAST 12 MONTHS, did this child see a

C26 Did any of the following reasons contribute to this child

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.

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

b. The services this child needed were
not available in your area

No, but this child needed to see a specialist

c. There were problems getting an
appointment when this child needed
one

No, this child did not need to
see a specialist ➔ SKIP to question C23

d. There were problems with getting
transportation or child care

C22 How difficult was it to get the specialist care that this

child needed?

e. The clinic or doctor’s office wasn’t
open when this child needed care

Not difficult

f. There were issues related to cost
Somewhat difficult
C27 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
Sometimes

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.

Usually
Always
C28 DURING THE PAST 12 MONTHS, how many times did

Yes

this child visit a hospital emergency room?

No

None

C24 DURING THE PAST 12 MONTHS, was there any time

1 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.

2 or more times
C29 DURING THE PAST 12 MONTHS, was this child admitted

Yes

to the hospital to stay for at least one night?

No ➔ SKIP to question C27

Yes
No

C25 If yes, which types of care were not received?

Mark (X) ALL that apply.
C30 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 C33 on page 9

Mental Health Services

C31 If yes, how old was this child at the time of the FIRST

plan?
Other, specify:

C

years AND

NSCH-T3

8

months

§;$"?¤

26030122

C32 Is this child CURRENTLY receiving services under

D4

one of these plans?
Yes

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.
DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers...

No

Always
C33 Has this child EVER received special services to

meet their developmental needs such as speech,
occupational, or behavioral therapy?

Never

b. Listen carefully to
you?

Yes

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?
years AND

Usually Sometimes

a. Spend enough time
with this child?

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

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

D. Experience with This
Child’s Health Care
Providers
D1

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.

If yes, DURING THE PAST 12 MONTHS, how often did
this child’s doctors or other health care providers...
Always

Usually Sometimes Never

a. Discuss with you the
range of options to
consider for their health
care or treatment?
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

No
D2

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
No ➔ SKIP to question D4

D3

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

NSCH-T3

9

§;$"7¤

26030114

D8 DURING THE PAST 12 MONTHS, have you felt that you

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?

could have used extra help arranging or coordinating
this child’s care among the different health care
providers or services?

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

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

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?

D18 If yes, do you and this child have access to this plan of

Very satisfied

care?

Somewhat satisfied

Yes

Somewhat dissatisfied

No

Very dissatisfied

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

NSCH-T3

10

§;$"/¤

26030105

D20 Eligibility for health insurance often changes in young

E4

adulthood. Do you know how this child will be insured
as they become an adult?

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

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

No

Never
E6

a. Change in employer or employment
status

How often does this child’s health insurance allow
them to see the health care providers they need?
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

f. Problems with application or
renewal process

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

g. Other, specify: C

Usually
Sometimes
E3

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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11

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26030098

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
4-6 days

DURING THE PAST 12 MONTHS, have you or other
family members...
Yes

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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26030080

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?

Almost every day
G10 How often does this child...
Always

d. Any type of community service or
volunteer work at school, place of
worship, or in the community?

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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Never

26030072

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
H5

Less than 6 hours

b. That this child
does things
that really
bother you
a lot?

6 hours

c. Angry with
this child?

DURING THE PAST WEEK, how many hours of sleep
did this child get on most weeknights?

7 hours

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
H6

H11 If yes, did you receive emotional support from...
Yes

ON MOST WEEKDAYS, about how much time did 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

Rarely Sometimes Usually Always

a. That this child
is much harder
to care for than
most children
their age?

How well can you and this child share ideas or talk
about things that really matter?

C

Very well
Somewhat well
Not very well
Not well at all

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No

26030064

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 I4

I3

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

To what extent do you agree with these statements
about your neighborhood or community?
Definitely Somewhat Somewhat Definitely
agree
disagree disagree
agree

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

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.

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26030056

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

J. Child’s Caregivers
About You
J1

No

How are you related to this child?
Biological or Adoptive Parent
Step-parent

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.

Grandparent
Foster Parent

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. Parent or guardian died

Other: Relative
Other: Non-Relative

J2

What is your sex?

c. Parent or guardian served time in jail

Male

d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home

Female

e. Was a victim of violence or
witnessed violence in their
neighborhood

J3

What is your age?
Age in years

f. Lived with anyone who was mentally
ill, suicidal, or severely depressed
g. Lived with anyone who had a problem
with alcohol or drugs

J4

Where were you born?

h. Treated or judged unfairly because
of their race or ethnic group

In the United States ➔ SKIP to question J6
on page 17

i.

Outside of the United States

Treated or judged unfairly because
of their sexual orientation or gender
identity
J5

I11 When your family faces problems, how often are you

likely to do each of the following?
All of
the time

Most of
the time

Some of
the time

None of
the time

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.
4-Digit Year

a. Talk together
about what to do
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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26030049

J6

What is the highest grade or level of school you have
completed?
Mark (X) ONE box.

J10 Which of the following best describes your current

employment status?
Mark (X) ONE box.

8th grade or less

Employed full-time

9th-12th grade; No diploma

Employed part-time

High School Graduate or GED Completed

Working WITHOUT pay

Completed a vocational, trade, or business school
program

Not employed but looking for work
Not employed and not looking for work

Some College Credit, but no Degree
Associate Degree (AA, AS)

J11 Have you ever served on active duty in the

U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.

Bachelor’s Degree (BA, BS, AB)

Never served in the military ➔ SKIP to question J13

Master’s Degree (MA, MS, MSW, MBA)

Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question J13

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

Now on active duty
J7

What is your marital status?
On active duty in the past, but not now
Married
Not married, but living with a partner

J12 Were you deployed at any time during this child’s life?

Yes

Never Married

No

Divorced
Separated

J13 Does this child have another parent or adult caregiver

who lives in this household?
Yes ➔ Complete questions J14 - J25 for this other
parent or adult caregiver

Widowed
J8

In general, how is your physical health?

No ➔ SKIP to question K1 on page 19

Excellent
Very good
Good
Fair
Poor
J9

In general, how is your mental or emotional health?
Excellent
Very good
Good
Fair
Poor

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26030031

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?

In the United States ➔ SKIP to question J19

Divorced

Outside of the United States

Separated
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
J22 In general, how is this caregiver’s mental or emotional

health?
Excellent
Very good
Good
Fair
Poor

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26030023

Employed full-time

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.

Employed part-time

a. Wages, salary, commissions, bonuses, or tips for
all jobs.

J23 Which of the following best describes this caregiver’s

K3

current employment status?
Mark (X) ONE box.

Working WITHOUT pay

Yes ➔

Not employed but looking for work

$

,

.00

TOTAL AMOUNT
in the last calendar year

No

Not employed and not looking for work

,

b. Self-employment income from own nonfarm
businesses or farm business, including
proprietorships and partnerships.

J24 Has this caregiver ever served on active duty in the U.S.

Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.

Yes ➔

$

Never served in the military ➔ SKIP to question K1

,

.00

Loss

TOTAL AMOUNT
in the last calendar year

No
Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question K1

,

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.

Now on active duty

Yes ➔

On active duty in the past, but not now

$

,

.00

Loss

TOTAL AMOUNT
in the last calendar year

No
J25 Was this caregiver deployed at any time during this

child’s life?

,

d. Social security or railroad retirement; retirement,
survivor, or disability pensions.

Yes

Yes ➔

No

$

,

.00

TOTAL AMOUNT
in the last calendar year

No

K. Household Information

,

e. Supplemental security income (SSI); any public
assistance or welfare payments from the state or
local welfare office.

K1 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 ➔

$

,

.00

TOTAL AMOUNT
in the last calendar year

No

Number of people

,

f. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support, or alimony.

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.

Yes ➔

$

K4

,

.00

TOTAL AMOUNT
in the last calendar year

No

Number of people

,

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
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26030015

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 Typeapplication/pdf
AuthorLeah Meyer (CENSUS/ADDP FED)
File Modified2020-05-13
File Created2020-01-17

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