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pdfAppendix 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.
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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
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3
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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
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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
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§;"#@¤
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
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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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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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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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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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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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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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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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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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26010074
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
NSCH-T1
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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
(04/06/2020)
§;##’¤
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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§;#"q¤
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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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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6
§;#"Y¤
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
NSCH-T2
7
§;#"R¤
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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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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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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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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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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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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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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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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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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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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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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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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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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National Survey of Children’s Health
A study by the U.S. Department of Health and Human Services
to better understand the health issues faced by children in the
United States today.
The U.S. Census Bureau is required by law to protect your information and is not permitted to publicly release your responses in a way
that could identify you or your household. The U.S. Census Bureau is conducting the National Survey of Children’s Health on the behalf
of the Department of Health and Human Services (HHS) under Title 13, United States Code, Section 8(b), which allows the Census Bureau
to conduct surveys on behalf of other agencies. Title 42 U.S.C. Section 701(a)(2) allows HHS to collect information for the purpose of
understanding the health and well-being of children in the United States. Federal law protects your privacy and keeps your answers
confidential under 13 U.S.C. Section 9. Per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity
risks through screening of the systems that transmit your data.
Access to records maintained in the system is restricted to Census Bureau employees and certain individuals authorized by Title 13, U.S.
Code (designated as Special Sworn Status individuals). These individuals are subject to the same confidentiality requirements as regular
Census Bureau employees identified above and as permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a) and SORN
COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame).
Participation in this survey is voluntary and there are no penalties for refusing to answer questions. However, your cooperation in obtaining
this much needed information is extremely important in order to ensure complete and accurate results.
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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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Moderate
Severe
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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
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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
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Moderate
Severe
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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
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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
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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
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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
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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
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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
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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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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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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
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H3
How many times has this child moved to a new address H8 How well do you think you are handling the day-to-day
since they were born?
demands of raising children?
Very well
Number of times
Somewhat well
H4
How often does this child go to bed at about the same
time on weeknights?
Not very well
Always
Usually
Not well at all
H9
DURING THE PAST MONTH, how often have you felt...
Never
Sometimes
Rarely
Never
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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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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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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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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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 Type | application/pdf |
| Author | Leah Meyer (CENSUS/ADDP FED) |
| File Modified | 2020-05-13 |
| File Created | 2020-01-17 |